Controlling pain is an important part of metastatic breast cancer care.
Learn about managing pain related to early breast cancer treatment.
Pain can affect your quality of life. So, controlling pain is a crucial part of your care.
Everyone experiences pain differently. Pain management decreases pain to a level that’s tolerable for you. The goal of treating pain is to give the most pain control with the least amount of medication (to limit side effects). This allows you to get the most benefit from the treatments aimed at reducing your cancer.
Let your health care providers know about any pain or discomfort you have.
Pain isn't the same for everyone. Even among people at the same stage of disease, pain can vary. Some people have more intense and more frequent pain than others.
You should never feel you have to endure pain. Even when pain is mild, it can interfere with daily life and make other side effects, such as fatigue, seem worse.
Pain can be related to treatment or the cancer itself.
Let your health care provider(s) know about any pain or discomfort you have.
Pain is usually easier to treat when you first notice it. Waiting until the pain is severe before getting relief can make it harder to control. It may also require more medication. So, it’s important to talk with your provider as soon as you notice any pain.
Your provider may prescribe medications or change your treatment plan to reduce painful side effects.
Every visit with your health care provider should include a discussion of pain.
Your provider can change the type and dose of pain medication throughout your care in response to your needs.
Your provider may suggest different 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.
Palliative care focuses on relieving or preventing symptoms (such as pain and other sources of distress) rather than treating disease. It’s an extra layer of care that can be given along with treatments for the breast cancer. Palliative care can improve quality of life for patients and caregivers [84-85].
Palliative care specialists help people and their families identify and manage physical, emotional, social and spiritual sources of distress .
Palliative care is a standard part of metastatic breast cancer care. It becomes the focus of care when treatment for the cancer ends.
Palliative care and pain specialists (physicians, nurse practitioners and nurses) treat pain from cancer or other causes. They treat people with metastatic breast cancer as well as those with early breast cancer.
Palliative care specialists have special training in treating pain and other symptoms, such as fatigue, anxiety and depression. They work with the oncology team to help people maintain the best quality of life possible.
Palliative care specialists also help people weigh the burdens and benefits of different cancer treatments.
They can also help with advance care planning. This means helping people identify their personal values and goals that should guide their care.
With metastatic breast cancer, these discussions are especially important. Your oncologist will often be a part of the discussion with you and the palliative care specialist.
Anesthesia pain experts are anesthesiologists with special training in pain management. They are experts in procedures (such as injections) to relieve pain.
You may have a palliative care or anesthesia pain specialist on your treatment team. If not, your oncologist may know of a specialist in your area.
Be sure to ask your oncologist for a referral if:
You may only need to see the specialist once. Your provider should be able to carry out the pain management plan recommended by the specialist. If the treatment is effective, you may not need to see the specialist again.
American Academy of Hospice and Palliative MedicineFind information on palliative care and a list of palliative care programs in your area.www.palliativedoctors.org/
American Cancer SocietyFind palliative care programs in your area.1-800-ACS-2345 (1-800-227-2345)www.cancer.org
American Society of Clinical Oncology (ASCO)Find information on palliative care.www.cancer.net/navigating-cancer-care/how-cancer-treated/palliative-care
National Cancer InstituteFind palliative care programs in your area.1-800-4-CANCER (1-800-422-6237)www.cancer.gov
Everyone's pain is different. So, describe exactly what you're feeling to your health care provider. This ensures your provider gives you the best treatment for your pain.
Certain types of pain respond better to certain types of treatment.
Providers will often ask questions (see below) to learn more about your pain so they can choose the best treatment.
Pain may change over time. Tell your provider about any changes. Your provider can change your treatment plan to fit your needs.
A change in pain doesn’t always mean there's a change in the cancer. Talk with your provider if you are worried that an increase in pain means your cancer has gotten worse.
(Adapted from National Cancer Institute, American Cancer Society and National Comprehensive Cancer Network materials [87-89].)
Health care providers may use the terms neuropathic, visceral and somatic to describe different types of pain (see Figure 5.12).
Type of pain
Much of the pain related to metastatic breast cancer is due to the cancer itself.
A tumor can injure nerves or put pressure on the spinal cord, causing 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 block the bowel, and cause swelling. This pain may feel sharp, aching, cramping or gnawing (visceral pain).
When pain is caused by the tumor, the pain usually decreases when the tumor itself is treated. Even when the tumor can't be treated, the pain can be treated.
Surgery, radiation therapy and breast cancer drug therapies (chemotherapy, hormone therapy and other drug therapies) may be used to shrink the tumor so it no longer injures nerves, presses against the spinal cord or causes injury to other organs or tissues.
Surgery can also be used to prevent or control problems such as a blockage in the bowel and the pain the blockage causes.
While you are waiting for the drug therapies to work, or if no treatments are shrinking your tumor, your pain can still be treated with medications (see below).
If needed, an anesthesia pain specialist can sometimes inject an anesthetic (to relieve pain) and steroid (to reduce swelling) drug combination into or around a nerve to block pain.
In some cases, the specialist injects this drug combination or a combination of anesthetics and opioids into the fluid around the coverings of your spinal cord or into the spinal fluid itself to block the pain (see below).
Neuropathic pain is pain that comes from an injured nerve. Nerves can be injured by surgery, chemotherapy or radiation therapy. They can also be injured by the cancer itself.
Many people with metastatic breast cancer had breast surgery in the past to treat early breast cancer.
Breast surgery (lumpectomy, mastectomy or breast reconstruction) can injure nerves in nearby tissues. The more extensive the surgery (for example, mastectomy is more extensive than lumpectomy), the higher the chance of injury tends to be.
This nerve damage can lead to a persistent burning or shooting pain in the area of the surgical scar and/or the underarm area on the affected side. This may be called post-mastectomy pain syndrome. However, women who had lumpectomy can also get this syndrome.
People who have a port-a-cath or a Hickman catheter inserted for chemotherapy may develop pain around the insertion site.
Learn about surgery-related pain just after breast surgery.
Blocking the nerves with a local anesthetic injection can ease nerve pain after surgery.
A lidocaine (Lidoderm) patch placed over the area can also ease nerve pain. The patch can stay in place for 12-24 hours each day, which is usually enough time to control the pain.
Some chemotherapy drugs can cause nerve damage. These include:
Nerve damage from chemotherapy may cause a burning or shooting pain, or numbness, usually in your fingers or toes (called chemotherapy-induced peripheral neuropathy).
About 30-40 percent of people who get paclitaxel as part of their adjuvant breast cancer treatment have lingering pain caused by the chemotherapy injury to the nerves [90-91].
Even among people who have no lingering pain from chemotherapy, many have some numbness in their fingers and toes from nerve damage.
Tell your health care provider if you have burning or shooting pain, or numbness. Your provider may want to change your chemotherapy plan to ease these symptoms.
Your provider may also prescribe mild pain relievers or other medications to ease the pain or numbness. If you still have pain, let your provider know. They may need to adjust your prescription.
Duloxetine (Cymbalta) is the only medication helpful for the burning or shooting pain caused by cisplatin or taxane chemotherapy drugs. However, it doesn’t relieve the numbness caused by these drugs.
If your pain doesn’t respond to these measures, your provider may refer you to a palliative care or anesthesia pain specialist.
Cancer itself can injure nerves. The cancer can grow into nerves or their blood supply. Often, this pain can be relieved by radiation therapy or drug therapies that shrink the tumor.
While you are waiting for the radiation therapy or drug therapies to work, or if no treatments are shrinking your tumor, nerve pain can be treated with medications.
Drugs specific for neuropathic pain include anti-depressants, anti-seizure medications, steroids and local anesthetics (see Figure 5.13).These drugs are only available by prescription. Before taking any of these medications, discuss their potential side effects with your health care provider.
Pain relief benefit
Potential side effects
Can relieve some neuropathic pain, but not chemotherapy-induced peripheral neuropathy
Dry mouth, nausea, constipation and diarrhea
Less often, sleepiness, dizziness or fainting when standing and increased sweating
SNRIs (serotonin/norepinephrine reuptake inhibitors) anti-depressants
Duloxetine can relieve chemotherapy-induced peripheral neuropathy
Venlafaxine must be stopped gradually (cannot be stopped suddenly)
Liver problems and reduced red and white blood cell counts
Sleepiness, dizziness and leg swelling
Can relieve nerve swelling and pain, and bone pain, but side effects limit how long they can be used
Puffiness due to fluid buildup in the body
Intolerance of sugar (diabetes-like condition)
Lidoderm patch(Lidocaine patch)
Can relieve some neuropathic pain in the area under the patch
Skin rash or irritation
Adapted from National Cancer Institute materials .
When breast cancer spreads to the bones (bone metastases), it can greatly affect quality of life.
Learn about bone metastases.
Bone pain often responds to heat, or to mild pain relievers such as ibuprofen (Advil or Motrin), naproxen (Aleve or Naprosyn) or acetaminophen (Tylenol).
Although you can get these medications without a prescription, check with your health care provider before taking them. For example, if you have (or are expected to have) a low blood count, or your kidneys are not functioning normally, or you have heart failure, your provider may advise you not to take ibuprofen or naproxen.
Tramadol, tapentadol or opioids (such as morphine or oxycodone) can be added if the ibuprofen, naproxen or acetaminophen alone don't relieve the pain.
Side effects of tramadol, tapentadol or opioids include sleepiness and nausea. These usually go away after about a week. If they don’t go away, tell your provider. These side effects can be treated.
All of these drugs can cause constipation, so you may need to make some changes in your diet or take medications to promote regular bowel movements. To manage constipation, your health care provider may recommend:
If you don’t have a bowel movement within 4 days, despite taking the recommended laxatives, be sure to tell your provider.
If you’re prescribed opioid medications, your provider will carefully monitor the amount prescribed so you don't take too much.
You may also be given a bone-strengthening drug therapy (see more below) to relieve pain.
Learn more about opioids.
Bone-strengthening therapy helps reduce the pain caused by bone metastases and is a standard part of treatment for bone metastases.
The 2 types of these drugs are:
Bisphosponates are given by vein (through an IV) and denosumab is given by an injection under the skin.
Learn more about bone-strengthening therapy.
Radiation therapy to the bone can relieve pain at the site of the tumor(s) and prevent fractures.
Drugs called radiopharmaceuticals (samarium (Quadramet) or alpharadin (Xofigo)) can also treat pain from bone metastases. If you are likely to benefit from this therapy, your oncologist can refer you to a doctor who specializes in nuclear medicine.
Surgery is used to prevent or repair bone fractures related to bone metastases.
Pain from lymphedema can be relieved through treatment of the lymphedema itself.
If lymphedema pain persists, talk with your health care provider about taking mild pain relievers such as ibuprofen (Advil or Motrin), naproxen (Aleve or Naproxyn) or acetaminophen (Tylenol).
Although you can get these medications without a prescription, check with your provider before taking them. For example, if you have (or are expected to have) a low blood count, or if you have kidney problems or heart failure, your provider may advise you not to take ibuprofen or naproxen.
Learn about treating lymphedema.
When pain is mild to moderate, the first choice for pain relief is usually a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen (such as Advil or Motrin), naproxen (Aleve or Naprosyn) and acetaminophen (Tylenol).
Although you can get these medications without a prescription, check with your health care provider before taking them. For example, if you have (or are expected to have) a low blood count, or you have kidney problems or heart failure, your provider may advise you not to take ibuprofen or naproxen.
If pain persists or becomes worse, your provider may prescribe stronger non-opioid drugs (tramadol or tapentadol). If you need more pain relief than these drugs can give, your health care provider may prescribe opioid drugs in combination with or instead of NSAIDs (acetaminophen, ibuprofen or naproxen).
In general, the more pain medication you take, the more side effects you'll have. Health care providers try to treat pain with the least amount of medication to limit side effects.
Opioid drugs include (in order of the most commonly used):
Opioids are only available by prescription.
Opioids tend to have more side effects than non-opioid drugs, so they're only given after non-opioid drugs can no longer control pain.
While being treated with opioids, avoid alcohol, sleep aids, anti-anxiety medications such as lorazepam (for example, Ativan) and other medications that cause drowsiness because they can have a harmful interaction.
Some opioid medications contain both an opioid and an NSAID. For example, Percocet contains oxycodone (an opioid) and acetaminophen (an NSAID).
To ensure you don't take too much of the NSAID, talk with your health care provider before taking any over-the-counter medications, especially NSAIDs, such as ibuprofen.
Type of drug
Use of the drug
Possible side effects
Acetaminophen is often the first choice for mild to moderate pain. It’s also used with opioids for severe bone or muscle pain.
In large amounts, acetaminophen can cause liver damage.
Ibuprofen (Advil, Motrin) or naproxen (Aleve or Naprosyn)
Ibuprofen and naproxen are often used with opioid medications for severe bone and muscle pain.
Side effects may include stomach and intestinal problems (such as ulcers and bleeding), problems with kidney function and worsening of heart problems.
Ibuprofen and naproxen can also slow blood clotting.
Other non-opioid drugs
Tapentadol and tramadol are often used with NSAIDs for moderate pain.
Tapentadol and tramadol can cause constipation, drowsiness and nausea (if drowsiness and nausea don’t go away after about a week, tell your health care provider so these side effects can be treated).
Typically used when non-opioid and neuropathic drugs alone don't control pain.
Usually stopped gradually to avoid withdrawal symptoms.
Morphine, oxycodone, hydromorphone and oxymorphone are available as immediate release for relief of pain for 2-3 hours.
Fentanyl tablets, films or spray can give immediate pain relief that controls pain for about one hour (these may only be prescribed for people who are already tolerant to opioid medication).
Morphine, oxycodone, hydromorphone and oxymorphone are available as oral sustained release medications that control pain for 8-12 hours.
Methadone takes about 3-5 days to reach its full pain-relieving effect, but then has sustained high levels of pain relief if taken 2-3 times a day.
Fentanyl and buprenorphine are available in a patch form that delivers medication continuously into the fat in the skin. They are absorbed there and provide pain relief.
The patch doses of buprenorphine available in the U.S. may be lower than many people need for pain relief.
Fentanyl patches are changed every 48-72 hours and buprenorphine patches are changed every 7 days.
Opioids can cause constipation, drowsiness, nausea, slowed breathing and itchiness.
Constipation always needs treatment.
Other side effects may go away after a few days but some will need treatment.
Methadone can be very dangerous if not taken exactly as prescribed.
People may worry about taking opioid medications, fearing side effects or addiction.
However, when used as prescribed, these drugs can offer a great deal of pain relief and most people who take them will not become addicted.
If you are prescribed opioid medications, your health care provider will assess your risk of using opioids for things that distress you other than pain. For example, if you have a history of using alcohol or other substances to excess, or you have a strong family history of that behavior, you may be at an increased risk .
Whatever your risk, your health care provider will carefully monitor the amount prescribed so you don't take too much. Many providers will ask you to complete a written opioid agreement with them if you’re taking opioid medications regularly.
Your provider will also explain how to store opioid medications safely so you’re the only one that can use them. They will also explain how to dispose safely of any unused medication.
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, not addiction.
Physical dependence is a natural effect of regular opioid use, while addiction involves a loss of control over personal decisions about using a drug and can be related to harmful behavior. Addiction means using the drug despite harm to yourself to “get out of” your life. If you have pain from cancer, you’ll use opioids to “get back into” your life.
It’s uncommon for addiction to develop among people taking opioids for cancer pain, especially for those who haven’t had a problem with addiction in the past .
Changing federal and state laws on opioid prescriptions have made it more difficult for providers to prescribe or renew opioid medications. If you’re taking opioids, work closely with your health care team to ensure you’re able to get the prescriptions you need.
Regular use of opioids almost always causes side effects. Your health care provider can help you prevent or control side effects so you can continue taking your medication.
Constipation is a common side effect of opioid medications and needs to be prevented and treated.
You may need to make some changes in your diet or take medications to promote regularity. To manage constipation, your health care provider may recommend:
If you don’t have a bowel movement within 4 days, despite taking the recommended laxatives, be sure to tell your provider.
Drowsiness usually goes away after about a week. If it persists, tell your health care provider so it can be treated.
If you become 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 they don’t go away, tell your health care provider. These side effects can be treated.
If you have itching or a rash, it may be a sign of an allergic reaction to the opioid you’re taking. Tell your health care provider and he or she can switch you to a different opioid.
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 lower doses of these drugs (other than constipation) . They stop having side effects from the lower doses of the drugs and can handle the side effects of increased doses more easily .
If you need a higher dose of an opioids, your health care provider will prescribe increased doses of laxatives or add stronger laxatives. Be sure to tell your provider if you haven’t had a bowel movement in 4 days.
Many drugs work with pain medications to reduce pain related to metastatic breast cancer. They include anti-depressants, anti-seizure medications, steroids and local anesthetics.
These drugs are only available by prescription. Before taking any of these medications, it's important to discuss their potential side effects with your health care provider.
The benefits of these medications are described in Figure 5.13.
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 medications are available in liquid form or a special tablet or strip that dissolves inside the cheek. Pain medications can also be put into feeding tubes. 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 over an area of fat, and releases pain medication continuously into the fat over several days.
In cases of severe pain, when oral medications don't relieve the pain or when a person can't take medications by mouth, many drugs can be given by injection or by vein (through an IV).
Opioid medications can be given into the vein through a port-a-cath or a peripherally inserted central catheter (PICC).
If you need to continue the opioids at home, you can have a small portable pump that contains the medication attached to the port-a-cath or PICC. It will deliver the opioid medication continuously.
You can carry the pump in a special backpack or fanny pack, so it won’t limit your activities.
People who need an opioid continuously sometimes also need an extra dose of medication for added relief. The portable pump allows you to push a button to release the extra dose of medication. This system is called patient-controlled analgesia (PCA).
PCA allows you to control your pain relief. It’s programmed to prevent an overdose.
In rare cases, pain can't be controlled by the medications described above or the side effects are so severe that people can’t tolerate them.
In these cases, an implanted catheter can deliver the medications using a small, computerized pump to the space directly outside 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. They are programmed to prevent an overdose.
There are many non-drug therapies you may choose to use along with pain medications.
Learn more about complementary and integrative therapies.
Pain from breast cancer treatment can be hard to explain to family and friends. This can lead to feelings of frustration and isolation.
Emotional issues surrounding breast cancer or treatment may worsen pain and cause distress.
Talking one-on-one with a counselor or joining a support group may ease some feelings of pain and distress, as well as provide other benefits.
For some, a breast cancer diagnosis and treatment can cause a spiritual crisis. Counseling from a trusted spiritual advisor may be part of your pain management program.
Learn more about support.
SUSAN G. KOMEN® SUPPORT RESOURCES
Learn more about what Komen is doing to help people with metastatic breast cancer.
Pain can affect the whole family. It's upsetting for family and friends to know a loved one is in pain.
Sometimes, a person living with pain may become irritable and this may strain family relationships.
Social support during this time is important for family members, especially spouses and partners.
Hospitals and other organizations offer support programs for spouses, partners, family members and other loved ones.
Learn more about programs for family, friends and other loved ones.
Find more information for family, friends and other loved ones.
At some point, you may decide to stop treatments for the cancer. This can happen when treatment stops showing any benefit or when it greatly affects quality of life.
Once treatment for the cancer ends, palliative care becomes the main focus, rather than just a part of treatment.
Learn more about care after treatment for breast cancer ends.
Hospice care can begin when a person has a life expectancy of 6 months or less, if the disease takes its usual course (as estimated by the person’s doctor and confirmed by the hospice program’s medical director) .
With your personal guidance, the hospice program can make the later stage of cancer care as comfortable as possible.
This can be a very difficult time for you and your family.
If you’re not interested in enrolling in hospice care, your provider or hospital can arrange for ongoing palliative care. They can also 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 hospice care, counseling and other types of support, visit the Support section.
American Academy of Hospice and Palliative MedicineOffers information on end-of-life planning and hospice, including a list of questions to help you assess hospice care programs.www.palliativedoctors.org
American Society for Clinical Oncology (ASCO) Offers a guide for patients and their families to help make decisions on end-of-life care.www.cancer.net/
National Hospice and Palliative Care OrganizationOffers information on end-of-life planning and care for patients and families.www.nhpco.org/patients-and-caregivers
National Institutes of Health (NIH)Offers information on end-of-life planning and care, including questions to ask your provider. www.nia.nih.gov/health/end-of-life
* 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.
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