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Management of Pain Related to Metastatic Breast Cancer

     

 

Metastatic Breast Cancer
Fact Sheet

This section discusses pain management for metastatic (also called advanced or stage IV) breast cancer.  

Learn more about the management of pain related to the treatment of early breast cancer.

What is pain management?

Controlling pain should be a standard part of treatment for all people with breast cancer. For those with metastatic cancer, it is crucial. If you are living with metastatic breast cancer, let your health care provider(s) know about any pain or discomfort you have.  

Although metastatic cancer cannot be cured, treatment may extend life. Pain related to treatment or the cancer itself, however, can affect your quality of life. The goal of pain management is to have the most pain control with the least amount of therapy (to limit side effects). This allows you to get the most benefit from the treatments aimed at reducing your cancer.

Pain control and palliation for metastatic breast cancer

With metastatic breast cancer, pain can be related to treatment or the cancer itself. Pain is not the same for everyone. Even among people at a similar stage of disease, pain can vary. Some people have more intense and more frequent pain than others.  

You may feel pain is simply a part of your treatment and you should be strong and endure it, but you shouldn’t. Even when pain is mild, it can interfere with daily life and make other side effects, such as fatigue, seem worse.  

Pain is usually easier to treat when you first have it. Waiting until the pain is severe before getting relief can make it harder to control and require more medication. That is why it is so important to talk to your health care provider about any pain you have. Sometimes, treatment plans can be changed to reduce painful side effects. 

Komen Perspectives 

 Read our perspective on palliative care, hospice and end-of-life decision-making
(April 2011).*
 

Health care providers and palliative care or pain specialists

Every visit with your health care provider should include a discussion of your pain. Your provider will likely change the type and dose of pain medication throughout your care. He/she may also suggest other types of pain control as your needs change. This ensures you are getting the most benefit from available therapies and are as comfortable as possible.

Some health care providers are more experienced at treating pain than others. If your provider is unable to control your pain, ask him/her for a referral to consult with a specialist in palliative (PAY-lee-uh-tiv) care or pain. Your provider can usually follow the specialist’s recommendations. If the treatment is effective, you shouldn’t need to see the specialist again.

Palliative care specialists (physicians, nurse practitioners and nurses) treat pain from cancer or other causes. They can treat people with early breast cancer as well as those with advanced cancer. Palliative medicine is a medical specialty, just like oncology. Most palliative care specialists are anesthesiologists (physicians who have had special training in pain management) and are experts in procedures (such as injections) to relieve pain.

You may have a palliative care specialist on your treatment team. If not, your oncologist will likely know of a palliative care specialist in your area. Be sure to ask your oncologist for a referral if your pain is not controlled or you have side effects from the pain medications.

For a list of pain management centers and programs in your area, call the National Cancer Institute's Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237) or the American Cancer Society toll-free at 1-800-ACS-2345 (1-800-227-2345).

Describing your pain

Everyone's pain is different so it is important to describe exactly what you are feeling to your health care provider. This ensures she/he can offer you the best pain management possible. Certain types of pain respond better to certain types of treatment.

Providers will often ask questions to learn more about your pain so they can choose the best treatment (see below). Pain may change as time goes on and it is important to let your provider know about these changes so she/he can change your treatment plan to fit your needs.

Questions your health care provider may ask you about pain

  1. Where is the pain?
  2. When did the pain start?
  3. How long has the pain lasted?
  4. Has the pain changed in any way?
  5. Is there anything that makes the pain worse or better?
  6. How intense is the pain (mild, moderate, severe, etc. or, on a scale from 1-10, with 10 being the worst, how would you describe your pain)?
  7. What is your pain level now? Most of the time? Is that level OK to you?
  8. Describe the pain (throbbing, burning, tingling, pressure, etc.).
  9. Does the pain come and go or do you feel it all the time?
  10. Does the pain affect your ability to perform or enjoy daily activities?
  11. Does the pain interfere with your sleep? Your appetite? Does it affect your mood?
  12. What do you think is causing the pain?
  13. How do you feel about pain control?

Questions to ask your provider about your pain

  1. What can be done to relieve my pain?
  2. What can we do if the pain medications do not work?
  3. What side effects may occur with the pain medications?
  4. What can be done to prevent or manage these side effects?
  5. What side effects do I need to report to you?
  6. What other options do I have for pain control?

(Adapted from National Comprehensive Cancer Network, American Cancer Society and National Cancer Institute materials [44-46].)

Types of pain

Health care providers may use the terms neuropathic (NOOR-oh-PATH-ik), visceral (VIH-suh-rul) and somatic (soh-MA-tik) to describe different types of pain (see Figure 5.12).  

Figure 5.12. Types of pain  

Type of pain 

Description 

Neuropathic

  • Sharp, tingling, burning or shooting feeling
  • Often related to pain caused by pressure on nerves or the spinal cord
  • Can be caused by chemotherapy
 

Visceral

  • Sharp, aching, cramping or gnawing feeling
  • Often related to pain caused when tumors spread to organs (such as the liver) or other tissues
 

Somatic

  • Stabbing, aching, pressure or throbbing feeling
  • Pain most often involves skin, muscle or bone
 

Other

  • Headaches, muscle strain and other types of pain that occur in daily life and may or may not be caused by breast cancer or treatment
 

 

Pain related to a tumor 

Much of the pain related to metastatic breast cancer is due to the cancer itself. A tumor can put pressure on nerves or the spinal cord, causing injury and pain. This pain is often described as a sharp, tingling, burning or shooting feeling (neuropathic pain).  

Tumors can also cause pain if they spread to organs (such as the liver) or other tissues. This pain may feel sharp, aching, cramping or gnawing (visceral pain).  

When pain is caused by pressure from a tumor, the tumor itself is often treated. Surgery, chemotherapy or hormone therapy may be used to shrink the tumor so it no longer presses against nerves, the spinal cord or other organs or tissues. Surgery can also be used to prevent or control problems such as a blockage in the bowel.  

If neuropathic pain resists the first drug treatments (see below), an anesthesia pain specialist can inject a drug combination that has an anesthetic (to relieve pain) and a steroid (to reduce swelling) into or around a nerve to block pain. In some cases, this drug combination is injected into the fluid around the spinal cord to block the pain.

Bone pain

When cancer spreads to the bones (bone metastases), it can greatly affect quality of life. This somatic pain often responds to heat, or to mild pain relievers such as ibuprofen (Advil or Motrin) or acetaminophen (Tylenol). Opioids (such as morphine or oxycodone) can be added if the ibuprofen or acetaminophen alone does not relieve the pain.

Bone-strengthening drug therapy

Part of standard treatment for bone metastases is bone-strengthening therapy. Two types of drugs that can help strengthen bones are:

  • Bisphosphonates (zoledronic acid (Zometa) or pamidronate (Aredia))
  • RANK ligand (RANKL) inhibitor (denosumab (Xgeva))

Use of bisphosphonates or denosumab once a month can lower the risk of fractures related to bone metastases and can help reduce pain caused by bone metastases. These drugs can also reduce the need for radiation therapy and surgery related to bone fractures and bone pain [28].  

In some people, bisphosphonates and denosumab can cause severe bone, joint or muscle pain [29-30]. Any of these side effects should be reported to a health care provider right away.  

Some people taking bisphosphonates need to increase their intake of vitamin D and calcium. If you develop muscle twitching or increased anxiety, ask your health care provider if you should take supplements to keep your calcium levels up.  

In rare cases, with either type of drug, a jawbone disorder called osteonecrosis of the jaw may occur [29-30]. Having a full dental exam before starting treatment with bisphosphonates or denosumab may reduce the risk of osteonecrosis of the jaw [31]. Talk with your oncologist before getting any dental procedure while you are being treated with bisphosphonates or denosumab.

Radiation therapy and surgery

Radiation therapy and surgery can be used to ease the pain of bone metastases. Radiation therapy to the bone can relieve pain and prevent fractures.  

Radiopharmaceuticals are drugs attached to sources of radiation. They are given through an IV and go to the site of the cancer in the bone where they act to decrease bone pain. These drugs are helpful in some people.

Surgery is used to prevent or repair bone fractures.

Pain related to lymphedema

Pain related to lymphedema can be relieved through treatment of the lymphedema itself.  

Learn more about treating lymphedema.  

Non-opioid and opioid medications used to treat metastatic breast cancer pain

Non-opioid drugs

When pain is mild to moderate, the first choice for pain relief is usually a non-opioid drug. Examples of these drugs include ibuprofen (such as Advil or Motrin) and acetaminophen (Tylenol).  

If pain persists or becomes more severe, opioid drugs in combination with or instead of non-opioid drugs give added pain relief. In general, the more pain medication you take, the more side effects you have. Health care providers try to treat pain with the least amount of medication to limit side effects.  

Although you can get most non-opioid drugs without a prescription, check with your provider before taking them.

Opioid drugs

Opioid drugs include (in order of the most commonly used):

  • Morphine 
  • Oxycodone 
  • Hydromorphone
  • Fentanyl
  • Methadone
  • Oxymorphone
  • Buprenorphine

Opioids are only available by prescription. These medications tend to have more side effects than non-opioid drugs, so they are only given after non-opioid drugs can no longer control pain. While being treated with opioids, alcohol, sleep aids and other medications that cause drowsiness should be avoided as they can have a harmful interaction.  

Some opioid medications contain both opioid and non-opioid drugs. For example, Percocet contains oxycodone (an opioid) and acetaminophen. To ensure you do not take too much of the non-opioid drug, talk to your health care provider before taking any over-the-counter medications, especially those containing acetaminophen or non-steroidal anti-inflammatory drugs (NSAID), such as ibuprofen.  

Figure 5.13. Non-opioid and opioid medications used to treat metastatic breast cancer pain

Type of drug 

Examples 

Use of the drug 

Possible side effects 

Non-opioids

Acetaminophen (Tylenol)

Non-steroidal anti-inflammatory drugs (NSAID), such as ibuprofen (Advil, Motrin)

First choice for mild to moderate pain

Often used with opioid medications for severe bone and muscle pain

 

In large amounts, acetaminophen can cause liver damage  

Side effects of other NSAIDs may include stomach and intestinal problems (such as ulcers and bleeding), problems with kidney function and worsening of heart problems  

NSAIDs can also slow blood clotting

Opioids

Morphine  

Oxycodone  

Hydromorphone  

Fentanyl  

Methadone  

Oxymorphone  

Buprenorphine  

Typically used when non-opioid drugs alone do not control pain  

Usually stopped gradually to avoid withdrawal symptoms  

Morphine, oxycodone, hydromorphone, fentanyl, oxymorphone and buprenorphine are available as immediate release for short-term pain relief  

Morphine, oxycodone, hydromorphone and oxymorphone are available as oral sustained release medications that pain control for eight to 12 hours  

Methadone takes about three days to achieve full pain relieving effect, but then has sustained high levels of pain relief if taken two to three times a day  

Fentanyl and buprenorphine are available in a patch form that delivers medication through the skin (patches are changed every 48 to 72 hours)  

Constipation, drowsiness, nausea, slowed breathing and itchiness

All but constipation may go away after a few days, but some of the side effects will need treatment

Methadone can be dangerous if not taken exactly as prescribed

Potential barriers to pain management with opioids

People may have concerns about some types of pain management, especially opioid medications, because of worry over side effects or addiction. However, when used as prescribed, these drugs can offer a great deal of pain relief and will not cause addiction.

Side effects

Regular use of opioids almost always causes side effects, especially constipation. Your health care provider can help you prevent or control these symptoms so you can continue these medications. If you are overly sleepy, you or your family should contact your provider right away.  

Nausea and vomiting can occur after starting opioids, but these side effects tend to go away after a few days. If you have itching or a rash, it may be a sign of an allergic reaction to opioids. Tell your provider and he/she can change your medication.  

If pain increases over time, a higher dose of opioid medication may be needed. Most people build up a tolerance to the side effects of these drugs, so they can handle the side effects of increased doses more easily [44].

Fear of addiction

Health care providers are careful to monitor the amount of opioids they prescribe so you do not take too much. If you abruptly stop taking an opioid medication or the dosage is suddenly reduced, you may go through withdrawal symptoms (such as pain, anxiety, nausea and diarrhea). A gradual reduction in the dose reduces the chance withdrawal symptoms will occur.  

Withdrawal symptoms are a sign of physical dependence and are not related to addiction. Physical dependence is a natural effect of regular opioid use, while addiction involves a loss of control over the drug and can be related to harmful behavior. Addiction among people taking opioids for cancer pain management who have not had a problem with addiction in the past is very rare [44].

Policy barriers

Because opioids have the potential to become addictive and can be sold illegally, some states have laws in place that restrict their use. Health care providers in these states may be hesitant to treat pain aggressively for fear of breaking these laws.  

The good news is that many states are adopting policies that improve access to pain management for people living with cancer, and steady progress continues towards these efforts.

Other medications used to treat metastatic breast cancer pain

Many drugs work with pain medications to reduce pain related to metastatic breast cancer. They include antidepressants, anticonvulsants, steroids and local anesthetics. These drugs are only available by prescription.  

The benefits of these medications are described in Figure 5.14. Before taking any of these medications for pain relief, it is important to discuss their potential side effects with your health care provider.

Figure 5.14. Other medications used to treat metastatic breast cancer pain 

 

Examples 

Pain relief benefit 

Potential side effects 

Antidepressants

Amitriptyline
(Elavil)  

Nortriptylin
(Pamelor)  

Duloxetine
(Cymbalta)  

Venlafaxine
(Effexor)

Can relieve some neuropathic pain 

Dry mouth, nausea, constipation and diarrhea

Less often, sleepiness, dizziness or fainting when standing and increased sweating

Venlafaxine must be weaned off (cannot be stopped suddenly)

Anticonvulsants

Gabapentin
(Neurontin)

Pregabalin
(Lyrica)

Can relieve some neuropathic pain

     
 

Liver problems and reduced red and white blood cell counts

Sleepiness, dizziness and leg swelling 

Steroids

Dexamethasone
(Decadron)

 

Can relieve nerve swelling and bone pain 

Puffiness due to fluid buildup in the body

Stomach irritation

Intolerance of sugar (diabetes-like condition)

Mood changes 

Local anesthetics

Lidoderm patch
(Lidocaine patch) 

Can relieve some neuropathic pain 

Skin rash or irritation

 

Adapted from National Cancer Institute materials [44].

How pain medications are given

There are many ways to take opioid and non-opioid pain medications. Most are pills taken by mouth. For people who have trouble swallowing pills, some are available in liquid form or a special tablet that dissolves inside the cheek. A few pain relievers can be taken in the form of rectal suppositories. Fentanyl and buprenorphine come in a patch form. This patch is placed on the skin and releases pain medication continuously over several days.

In cases of severe pain, when oral medications do not relieve the pain or when a person cannot take medications by mouth, many drugs can be given into a vein or underneath the skin with a small needle.

Medications can also be given into the vein through a port-a-cath or a peripherally inserted central catheter (PICC). These have a portable pump that delivers the medication. Some people get the medication continuously. Others can push a button to release an extra dose of medication for added relief (called patient-controlled analgesia). Still others have both continuous mediation and the option to give themselves extra doses.

In very rare cases, pain cannot be controlled by the medications described above or their side effects are too severe. In these cases, an implanted catheter can deliver the medications using a small computerized pump to the space directly above the spinal cord (epidural pump) or to the fluid around the spinal cord itself (intrathecal pump). The pump is carried in a backpack or "fanny pack" (for epidural pumps) or implanted under the skin (for intrathecal pumps). The pumps allow both continuous medication and patient-controlled extra doses for pain flares. The pumps are programmed to prevent an overdose.

Integrative and complementary therapies (non-drug therapies) for pain

There are many non-drug therapies you may choose to use along with pain medications. These include physical therapy, acupuncture, nutrition, relaxation techniques, massage therapy, hot and cold therapy, yoga and guided imagery. Learn more about these integrative and complementary therapies.

Joining a support group can ease some feelings of pain and provide other benefits. Learn more about support groups and other types of social support.

Issues for family members and other co-survivors

Pain can affect the whole family. It can be upsetting for family, friends and other co-survivors to know a loved one has pain.

In some cases, a person living with pain may become irritable and this may strain family relationships. Social support during this time is important for family members. Spouses and partners may be in special need of support.

Hospitals and other organizations offer support programs for spouses, partners, family members and other co-survivors. Learn more about these programs.

Find more information for co-survivors.   

Komen Support Resources 

 

 

Care after treatment ends  

 

End-of-Life Care
Fact Sheet

At some point, treatment for metastatic breast cancer may be stopped. This can happen when treatment stops showing any benefit or when it greatly affects quality of life. Once treatment is stopped, reducing any cancer-related symptoms (called palliative care) becomes the main focus, rather than just a part of treatment.

With your personal guidance, hospice can make the later stage of cancer care as comfortable as possible for you and your family. Your health care providers will continue to guide your care while you are in hospice and you can continue visits with them.

This can be a very difficult time for you and your family. Your provider or hospital can arrange for counseling or a support group to help you address and manage the feelings and emotions that come with this stage of cancer care.

For more on support groups, hospice and other types of support, visit the Support section.

Komen Support Resources 

 

 

Komen Perspectives 

 Read our perspective on end-of-life care (April 2011).*  

*Please note, the information provided within Komen Perspectives articles is only current as of the date of posting. Therefore, some information may be out of date at this time.   

Updated 03/28/14

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