Controlling pain is an important part of metastatic breast cancer care. Metastatic breast cancer is also called advanced or stage IV breast cancer.
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.
The goal of pain management is to have 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 provider(s) know about any pain or discomfort you have.
Pain is not 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 have it. Waiting until the pain is severe before getting relief can make it harder to control and may require more medication. So, it’s important to talk with your provider as soon as you have 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 (like pain) rather than treating disease and should be given throughout treatment for breast cancer. Palliative care is especially important for those with metastatic breast cancer.
Palliative care is an extra layer of care that can be given along with treatments for the breast cancer to maximize quality of life.
Palliative care specialists focus on symptom control, rather than control of the cancer. They treat physical, emotional, social and spiritual needs .
Palliative care is a standard part of metastatic breast cancer care and becomes the focus of care when treatment for the cancer ends. It can improve quality of life for patients and caregivers [68-69].
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 work with oncologists to give extra care to help people maintain the best quality of life possible. They have special training in treating pain and other symptoms, such as fatigue, anxiety and depression.
They can help people weigh the burdens and benefits of different treatments for symptoms as well as for medications or other therapies to treat the cancer.
Palliative care specialists can also help with advance care planning. They can help people identify their personal values and goals that will guide their care.
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 will likely 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 follow the specialist’s recommendations and carry out your pain management plan. If the treatment is effective, you shouldn’t need to see the specialist again.
For a list of pain management centers and palliative care programs in your area, call the National Cancer Institute 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).
For more information on palliative care, visit the American Academy of Hospice and Palliative Medicine website or the American Society of Clinical Oncology (ASCO) website.
Everyone's pain is different. So, it's important to describe exactly what you're feeling to your health care provider. This ensures your provider can give 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 so he or she can change your treatment plan to fit your needs.
A change in pain doesn’t always mean there's a change in your 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 [70-72].)
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 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, radiation therapy and breast cancer drug treatments (such as chemotherapy)
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.
Neuropathic pain can 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, this drug combination is injected into the fluid around the coverings of the spinal cord or into the spinal fluid itself to block the pain. It may also be given by vein (through an IV).
When breast 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), 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, 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.
All of these drugs can cause constipation, so you may need to make some changes in your diet or take medications to promote regularity. For example, your provider may recommend eating high-fiber foods and drinking plenty of liquids (warm or hot liquids may be helpful) to manage constipation.
Other side effects of these drugs 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.
If you are 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.
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:
These drugs are given once a month by vein (through an IV).
Learn more about bone-strengthening therapy.
Radiation therapy and surgery can be used to ease the pain of bone metastases.
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.
Pain from lymphedema can be relieved through treatment of the lymphedema itself.
Learn about treating lymphedema.
When pain is mild to moderate, the first choice for pain relief is usually a non-opioid drug, such as ibuprofen (such as Advil or Motrin), naproxen (Aleve or Naprosyn) and acetaminophen (Tylenol).
If pain persists or becomes worse, your provider may prescribe stronger non-opioid drugs (tramadol or tapentadol) or opioid drugs in combination with or instead of milder non-opioid drugs (acetaminophen, inbuprofen or naproxen) give added pain relief.
In general, the more pain medication you take, the more side effects you will 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 are only given after non-opioid drugs can no longer control pain.
While being treated with opioids, avoid alcohol, sleep aids and other medications that cause drowsiness because 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 don't take too much of the non-opioid drug, talk with 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.
Type of drug
Use of the drug
Possible side effects
Non-steroidal anti-inflammatory drugs (NSAID), such as ibuprofen (Advil, Motrin) or naproxen (Aleve or Naprosyn)
Acetaminophen or an NSAID is the first choice for mild to moderate pain
Acetaminophen and NSAIDs are often used with opioid medications for severe bone and muscle pain
Tapentadol and tramadol are often used with NSAIDs for moderate 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
Tapentadol and tramadol can cause constipation, drowsiness and nausea (if drowsiness and nausea do not go away after about a week, tell your provider so these side effects can be treated)
Typically used when non-opioid 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 1 hour (these may only be prescribed for people who are already taking a lot of sustained release 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 get the 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 through the skin (the patch doses 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
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 will not cause addiction.
If you are prescribed opioid medications, your health care provider will carefully monitor the amount prescribed so you don't take too much. Many providers will fill out a written opioid agreement with you if you are taking opioid medications regularly.
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.
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 are taking opioids, work closely with your health care team to monitor your prescriptions.
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 treated. You may need to make some changes in your diet or take medications to promote regularity.
Your provider may recommend eating high-fiber foods and drinking plenty of liquids (warm or hot liquids may be helpful) to manage constipation.
Drowsiness usually goes away after about a week. If it persists, tell your 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 provider. These side effects can be treated.
If you have itching or a rash, it may be a sign of an allergic reaction to opioids. Tell your provider and he or 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 (other than constipation) and they can handle the side effects of increased doses more easily .
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. 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 5.14.
Pain relief benefit
Potential side effects
Dry mouth, nausea, constipation and diarrhea
Less often, sleepiness, dizziness or fainting when standing and increased sweating
Venlafaxine must be stopped gradually (cannot be stopped suddenly)
Can relieve some neuropathic pain
Liver problems and reduced red and white blood cell counts
Sleepiness, dizziness and leg swelling
Can relieve nerve swelling and bone pain
Puffiness due to fluid buildup in the body
Intolerance of sugar (diabetes-like condition)
Lidoderm patch(Lidocaine patch)
Can relieve some neuropathic pain
Skin rash or irritation
Adapted from National Cancer Institute materials .
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. 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 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).
Medications can 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 rare cases, pain can't 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 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 difficult 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 ease some feelings of distress.
Learn more about support groups and other types of social support.
Pain can affect the whole family. It's upsetting for family and friends to know a loved one is in 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, 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 is stopped, palliative care becomes the main focus, rather than just a part of treatment.
Learn more about care after treatment for breast cancer ends.
When life expectancy is 6 months or less, your health care provider may suggest you enroll in a hospice home care program.
With your personal guidance, hospice can make the later stage of cancer care as comfortable as possible for you and your family.
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 hospice, counseling and other types of support, visit the Support section.
The National Institutes of Health (NIH) website has information on end-of-life planning and care, including questions to ask your provider.
The American Society for Clinical Oncology (ASCO) has a guide for patients and their families to help make decisions on end-of-life care.
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