Managing Pain Related to Metastatic Breast Cancer
Read our blog, Improving Quality of Life: Using Palliative Care for Metastatic Breast Cancer Patients.
What is pain management?
Pain can affect your quality of life. So, controlling pain is an important part of your breast cancer 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 your cancer treatment.
Let your health care team know about any pain or discomfort you have. The National Comprehensive Cancer Network (NCCN) recommends your health care provider determine your palliative care needs before treatment begins and throughout your treatment [102]. Palliative care includes all the care that affects your quality of life including pain and other physical side effects, as well as emotional, social and spiritual needs.
Learn about managing pain related to early breast cancer treatment.
Pain
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.
Tell your health care team as soon as you have pain
Let your health care team 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 a member of your health care team as soon as you notice any pain.
Your health care provider may prescribe medications or change your treatment plan to reduce painful side effects.
Pam Kohl, living with metastatic breast cancer
“Start with palliative care as soon as you can so that you’re getting the help you need to manage the symptoms.”
Susan G. Komen® Metastatic Breast Cancer (MBC) Impact Series |
|
Susan G. Komen’s MBC Impact Series provides people living with metastatic breast cancer and their loved ones a safe, collaborative space to gather information related to metastatic breast cancer and discover practical resources to help make decisions for improved physical and emotional health. During the free events, you can participate in sessions with leading experts, hear from individuals living with metastatic breast cancer and gather information from wellness experts. You’ll also have the opportunity to ask our speakers questions. To stay up to date about event topics and timing, sign up for our MBC Newsletter here. You can also learn more and register for events by visiting www.komen.org/mbcseries. |
Talk with your health care provider
Every visit with your health care provider should include a discussion of pain. The NCCN recommends your health care provider determine your palliative care needs (such as pain control) before treatment begins and throughout your treatment [102].
Your health care provider can change the type and dose of pain medication throughout your care in response to your needs.
Your health care provider may suggest different types of pain control as your needs change. This makes sure you get the most benefit from available therapies and are as comfortable as possible.
Palliative care specialists and pain specialists
What is palliative care?
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 [103].
Specialists in palliative care help people and their families identify and manage physical, emotional, social and spiritual sources of distress. They can help you and your family identify your hopes and worries. They can also help you decide whether the burden of any specific cancer treatment outweighs its benefits.
Palliative care is a standard part of metastatic breast cancer care. It becomes the main focus of care when treatment for the cancer ends.
Palliative care and pain specialists
Palliative care and pain specialists (doctors, nurse practitioners and physician assistants) 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, including fatigue, anxiety and depression. They work with your oncology team to help you maintain the best quality of life possible.
Palliative care specialists can also help with advance care planning. This planning helps you identify your personal values and goals that should guide your 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
Anesthesia pain experts are anesthesiologists with special training in pain management. They are experts in procedures, such as injections, to relieve pain.
Seeing a palliative care or anesthesia pain specialist
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:
- Your pain is not controlled
- You have side effects from pain medications
- You’re worried about becoming addicted to pain medications
- You’d like to discuss more options to manage your pain
- You’d like to discuss other sources of distress
- You have concerns about the benefits versus the burdens of your breast cancer treatments
Your oncologist may 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. Or your oncologist may recommend you follow up with the specialist for any ongoing pain management.
Palliative care resources
American Academy of Hospice and Palliative Medicine
Find information on palliative care and a list of palliative care programs in your area.
www.palliativedoctors.org/
American Cancer Society (ACS)
Find information on palliative care.
https://www.cancer.org/cancer/managing-cancer/palliative-care.html
Describing your pain
Everyone’s pain is different. So, describe exactly what you’re feeling to your health care provider. This makes sure they give you the best treatment for your pain.
Certain types of pain respond better to certain types of treatment. Health care 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 health care 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 health care provider if you’re worried that an increase in pain means your cancer has gotten worse.
Questions your health care provider may ask you about your pain
- Where is the pain?
- When did the pain start?
- How long has the pain lasted?
- Has the pain changed in any way?
- Is there anything that makes the pain worse?
- Is there anything that makes the pain better?
- How intense is the pain? Is it mild, moderate or severe? Or, on a scale from 1-10, with 10 being the worst, how would you describe your pain?
- What is your pain level now? Most of the time? Is that level OK to you?
- Describe the pain (throbbing, burning, tingling, pressure, etc.).
- Does the pain come and go, or do you feel it all the time?
- Does the pain affect your ability to perform or enjoy daily activities?
- Does the pain interfere with your sleep? Your appetite? Does it affect your mood?
- What do you think is causing the pain?
- How do you feel about pain control?
Questions to ask your health care provider about your pain
- What can be done to relieve my pain?
- If my pain doesn’t go away, can I take more pain medication?
- What can we do if the pain medications don’t work?
- How long does the pain medication take to start working? How long does it last?
- What side effects may occur with the pain medications? What can be done to prevent or manage these side effects? What side effects should I report to you?
- Do I need to avoid taking any other medications while taking pain medication?
- Do I need to avoid drinking alcohol or driving while taking pain medication? Are there other things I should avoid?
- Will I become addicted to the pain medication?
- What other options do I have for pain control?
(Adapted from National Cancer Institute, American Cancer Society and National Comprehensive Cancer Network materials [104-106].)
Ashley Fernandez, living with metastatic breast cancer
“Palliative care is life-changing. They treat the symptoms and the person. It’s not end-of-life care, it’s there to make sure your day-to-day life gets better.”
Types of pain
Health care providers may use the terms neuropathic, visceral and somatic to describe different types of pain (see table below).
Type of pain |
Description |
Neuropathic |
|
Visceral |
|
Somatic |
|
Other |
|
Pain related to a tumor
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 pain that starts from the back and spreads around to the front or goes down an arm, buttock or leg (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).
Tumors that invade bones or muscles, or that spread to the skin can also cause pain (somatic 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.
Managing pain related to a tumor
Surgery, radiation therapy and breast cancer drug therapies (such as chemotherapy and hormone therapy) 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’re 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 a drug that combines an anesthetic (to relieve pain) and a steroid (to reduce swelling) 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).
Nerve pain (neuropathic pain)
Neuropathic pain is pain that comes from an injured nerve. Nerves can be injured by surgery, chemotherapy or radiation therapy. Nerves can also be injured by infections, such as shingles (which can affect anyone).
Surgery-related nerve pain
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, the higher the chance of injury tends to be. For example, a mastectomy is a more extensive surgery than a lumpectomy.
This nerve damage can lead to a persistent burning or shooting pain around the surgical scar and/or the underarm area on the treated side. This is called post-mastectomy pain syndrome. However, women who’ve had a lumpectomy can also get this syndrome.
People who have a port-a-cath inserted for chemotherapy may develop pain around the insertion site.
Learn about surgery-related pain just after breast surgery.
Treating surgery-related nerve pain
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. Up to 3 patches can stay in place for 12-24 hours each day. This is usually enough time to control the pain.
- Place the patch in the daytime if putting clothing on over the area is difficult.
- Place the patch in the evening if the pain keeps you up at night.
Chemotherapy-related nerve pain
Some chemotherapy drugs can cause nerve damage. These include:
- Cisplatin (Platinol) and carboplatin (Paraplatin)
- Vinorelbine (Navelbine)
- Taxanes, such as paclitaxel (Taxol) and docetaxel (Taxotere)
Nerve damage from chemotherapy may cause a burning or shooting pain, tingling or numbness, most often in your fingers or toes. This is called chemotherapy-induced peripheral neuropathy (CIPN).
About 30% to 40% of people who get paclitaxel as part of their early breast cancer treatment have lingering nerve issues (numbness and/or pain) caused by chemotherapy [107-109].
Using a cooling system that has special mittens and socks (called cryotherapy) while getting paclitaxel or other taxane-based chemotherapy may help reduce the risk of neuropathy in the hands and feet [4].
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. They may want to change your chemotherapy plan to ease these symptoms.
Your health care 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 health care provider may refer you to a palliative care or anesthesia pain specialist.
Tumor-related nerve pain
Cancer itself can injure nerves and cause symptoms. 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’re 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 antidepressants, anti-seizure medications, corticosteroids and local anesthetics (see table below). These drugs are only available by prescription. Before taking any of these medications, discuss their possible side effects with your health care provider.
Medications for Neuropathic Pain | |||
Medication |
Examples |
Pain relief benefit |
Potential side effects |
Tricyclic antidepressants | Amitriptyline Nortriptyline | 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 |
SNRI (serotonin/ | Duloxetine Venlafaxine | Duloxetine can relieve peripheral neuropathy caused by cisplatin (Platinol) or taxane chemotherapy drugs, such as paclitaxel (Taxol) and docetaxel (Taxotere) | Venlafaxine must be stopped gradually (can’t be stopped suddenly) |
Anti-seizure medications | Gabapentin Pregabalin | Can relieve some neuropathic pain, but not chemotherapy-induced peripheral neuropathy | Liver problems, reduced red blood cell and white blood cell counts Sleepiness, dizziness and leg swelling |
Corticosteroids | Dexamethasone | 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 Stomach irritation Intolerance of sugar (diabetes-like condition) Mood changes |
Local anesthetics | Lidoderm patch | Can relieve some neuropathic pain in the area under the patch | Skin rash or irritation |
Adapted from National Cancer Institute materials [104]. | |||
Bone pain
When breast cancer spreads to the bones (bone metastases), it can cause pain and possibly bone fractures, which can greatly affect your quality of life.
Learn more about bone metastases.
Medications for mild bone pain
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 platelet count, or if you have kidney problems or heart failure, your health care provider may advise you not to take ibuprofen or naproxen.
Medications for more severe bone pain
Tramadol, tapentadol or opioids (such as morphine or oxycodone) can be added if the ibuprofen, naproxen or acetaminophen alone don’t relieve your pain.
Side effects of tramadol, tapentadol and opioids include sleepiness and nausea. Most often, these side effects go away after about a week. If they don’t, tell your health care provider. These side effects can be treated.
Tramadol, tapentadol and opioids 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 you:
- Increase your liquid intake (warm or hot liquids may be helpful)
- Use a mild laxative, such as Senna, or a stronger laxative, such as polyethylene glycol (Miralax), or both, if recommended by your health care provider
If you’re already taking a non-soluble fiber supplement (such as Metamucil), your health care provider may recommend replacing it with a soluble fiber supplement (such as Benefiber) to manage constipation.
If you don’t have a bowel movement within 4 days of taking the recommended laxatives, tell your health care provider.
If you’re prescribed opioid medications, your health care 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) that can also relieve bone pain.
Learn more about opioids.
Bone-strengthening drug therapy
Bone-strengthening therapy helps reduce the pain caused by bone metastases and is part of the standard of care for bone metastases.
The 2 types of these drugs are:
- Bisphosphonates (zoledronic acid (Zometa) or pamidronate (Aredia))
- RANK ligand (RANKL) inhibitor (denosumab (Xgeva or Prolia))
Bisphosphonates are given by vein (through an IV). Denosumab is given by an injection under the skin.
Learn more about bone-strengthening therapy.
Radiation therapy to relieve bone pain
Radiation therapy to the bone can relieve pain at the site of the tumor(s) and prevent fractures. This is most often given in 1, 5 or 10 treatment sessions.
Drugs called radiopharmaceuticals (samarium (Quadramet), alpharadin (Xofigo) or lutetium Lu 177 dotatate (Lutathera)) are outpatient infusions that can relieve pain from bone metastases. If you’re likely to benefit from this therapy, your oncologist can refer you to a doctor who specializes in nuclear medicine.
Surgery to relieve bone pain
Surgery can be used to prevent or repair bone fractures related to bone metastases.
Pain related to lymphedema
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 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 platelet count, or if you have kidney problems or heart failure, your health care provider may advise you not to take ibuprofen or naproxen.
Learn about treating lymphedema.
Non-opioid and opioid pain medications
Non-steroidal anti-inflammatory drugs (NSAIDs)
When pain is mild to moderate, the first choice for pain relief is usually a non-steroidal anti-inflammatory drug (NSAID), such as ibuprofen (Advil or Motrin) or 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 platelet count, or you have kidney problems or heart failure, your health care provider may advise you not to take ibuprofen or naproxen.
If the pain persists or gets worse, your health care 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 (such as ibuprofen or naproxen) or acetaminophen.
In general, the more pain medication you take, the more side effects you’ll have. To limit these side effects, your health care team will try to treat your pain with a combination of effective non-opioid medications, along with the lowest amount of opioid medication that will relieve your pain.
Opioid drugs
Common Opioid Drugs |
|
Drug |
How is the drug given? |
Morphine |
IV (given by vein through an IV), liquid or pill |
Oxycodone |
Liquid or pill |
Hydromorphone |
IV or pill |
Fentanyl |
IV, patch on the skin, or tablet, film or spray that dissolves in the mouth |
Methadone |
IV, liquid or pill |
Oxymorphone |
IV or pill |
Buprenorphine |
Patch on the skin, or tablet or film that dissolves in the mouth |
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.
Medications that contain an opioid and an NSAID or acetaminophen
Some opioid medications contain both an opioid and an NSAID, such as ibuprofen or naproxen, or acetaminophen (Tylenol). For example, Percocet contains oxycodone (an opioid) and acetaminophen. In these combination medications, the NSAID or acetaminophen can be toxic if too many pills are taken.
If you need more medication for your pain than the combination medication safely provides, your health care provider will stop the combination medication and give you a prescription for a higher dose of the opioid.
Your health care provider will let you know how much of the NSAID or acetaminophen you can safely take each day, along with the opioid. To make sure you don’t take too much of the NSAID or acetaminophen, talk with your health care provider before taking any over-the-counter medications, especially NSAIDs, such as ibuprofen.
Non-Opioid and Opioid Medications for Non-Neuropathic Pain Related to Metastatic Breast Cancer | |||
Type of drug | Examples | Use of the drug | Possible side effects |
Acetaminophen | Tylenol | 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. |
NSAIDs | Ibuprofen (Advil, Motrin) or naproxen (Aleve or Naprosyn) | Ibuprofen and naproxen are often used with opioid medications for severe bone or 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 Tramadol | 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. |
Opioids |
Morphine Oxycodone Hydromorphone Fentanyl Methadone Oxymorphone Buprenorphine |
Opioids are typically used when non-opioid and neuropathic drugs alone don’t control pain. Opioids are 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. They are also available as oral (by mouth) sustained-release medications that control pain for 8-12 hours. Oral 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. They are difficult to get because of federal regulations. 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. Pain relief occurs 12-18 hours after they are placed. 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. Buprenorphine patches are changed every 7 days. 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. | Opioids can cause constipation, drowsiness, nausea, slowed breathing and itchiness. Constipation continues as long as you’re taking an opioid. Other side effects lessen after about a week. Methadone can be especially dangerous if not taken exactly as prescribed because it can build up in the body and cause suppression of breathing (breathing too slowly). |
Potential barriers to pain management with opioids
People may worry about taking opioid medications, fearing side effects or addiction [110].
However, when used as prescribed, these drugs can offer a great deal of pain relief.
Fear of addiction
If you’re prescribed opioid medications, your health care provider will assess your risk of using opioids for things other than pain that distress you. 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 of addiction [111].
Whatever your risk, your health care provider will carefully monitor the amount of the opioid medication prescribed so you don’t take too much. Many health care providers will ask you to complete a written opioid agreement with them if you’re taking opioid medications regularly.
Your health care 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 safely get rid of any unused medication.
Withdrawal symptoms
If you abruptly stop taking an opioid medication or the dosage is suddenly reduced, you may have 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 versus addiction
Physical dependence is a natural effect of regular opioid use. Addiction involves a loss of control over personal decisions about using a drug. It 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 not common 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 [104].
Opioid prescriptions
Some recent federal and state laws on opioid prescriptions have made it more difficult for health care providers to prescribe or renew opioid medications.
If you’re taking opioids, work closely with your health care team to make sure you can get the prescriptions you need.
Side effects of opioids
Regular use of opioids almost always causes side effects. Your health care provider can help you prevent or control side effects so you can keep taking your medication.
Constipation
Constipation is a common side effect of opioid medications. It needs to be prevented and treated.
You may need to make changes to your diet or take medications to promote regularity. To manage constipation, your health care provider may recommend you:
- Increase intake of liquids (warm or hot liquids may be helpful)
- Use a mild laxative, such as Senna, or a stronger laxative, such as polyethylene glycol (Miralax), or both, if recommended by your health care provider
If you’re already taking a non-soluble fiber supplement (such as Metamucil), your health care provider may recommend replacing it with a soluble fiber supplement (such as Benefiber) to manage constipation.
If you don’t have a bowel movement within 4 days of taking the recommended laxatives, tell your health care provider.
Drowsiness
Drowsiness usually goes away after about a week. If it lasts longer, tell your health care provider. Drowsiness can be treated.
If you become overly sleepy, you or your family should contact your health care provider right away.
Nausea
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.
Itching or a rash (an allergic reaction)
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 they can switch you to a different opioid.
Increased doses of opioids and side effects
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) [104]. They stop having side effects from the lower doses of the drugs and can handle the side effects of increased doses more easily [104].
If you need a higher dose of an opioid, your health care provider will prescribe increased doses of laxatives or add stronger laxatives. Be sure to tell your health care provider if you haven’t had a bowel movement in 4 days.
Other pain medications
Many drugs work with pain medications to reduce pain related to metastatic breast cancer. They include antidepressants, anti-seizure medications, corticosteroids 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.
Learn about the benefits of these medications.
How pain medications are given
There are many ways to take opioid and non-opioid pain medications. Most are liquids or pills taken by mouth.
For people who have trouble swallowing pills, some medications are available in liquid form or a special tablet or strip (film) that dissolves inside the cheek. Liquid pain medications can also be put into feeding tubes. A few pain relievers can be taken in the form of rectal suppositories, or a liquid put through a rectal tube.
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 vein (through an IV).
Intravenous pain control at home and patient-controlled analgesia
Opioid medications can be given into a vein through a port-a-cath or a peripherally inserted central catheter (PICC).
If you need to manage your pain at home with opioid medications given by vein (through an IV), 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.
Patient-controlled analgesia allows you to control your pain relief. It’s programmed to prevent an overdose. The medication cassette is usually replaced weekly, but it can be replaced more often depending on how much medication you need.
Implanted spinal catheter
In rare cases, pain can’t be controlled by the medications described above or the side effects are so severe people can’t tolerate them.
In these cases, an implanted catheter can deliver the medications using a small, computerized pump to the fluid around the spinal cord itself. This is called an intrathecal pump and it’s implanted under the skin.
An intrathecal pump allows both continuous medication and patient-controlled extra doses for pain flares. It’s programmed to prevent an overdose. The pump is usually refilled monthly.
Complementary and integrative therapies (non-drug therapies) for pain
There are many non-drug therapies you may choose to use along with pain medications.
These include [112]:
- Acupressure
- Acupuncture
- Cognitive-behavioral therapy (a special type of mental health counseling that may combine techniques such as relaxation exercises)
- Hot and cold therapy
- Guided imagery
- Hypnosis
- Massage therapy
- Mindfulness meditation (mindfulness stress reduction)
- Music therapy
- Nutrition
- Physical therapy
- Reflexology
- Relaxation therapy
- Yoga
Learn more about complementary and integrative therapies.
Marijuana
Some studies show marijuana (cannabis) products, including cannabidiol (CBD) oil or cream, can help ease chronic neuropathic pain [71,113-117]. However, these studies did not include cancer patients [71,113-117]. (CBD comes from the cannabis plant but does not contain the chemical in the plant that causes a “high” feeling.)
The American Society of Clinical Oncology (ASCO) guidelines for cancer patients who have chronic pain say cannabinoids may be considered for those with neuropathic pain or chronic refractory pain syndromes [118].
Although data are limited, people who use marijuana don’t appear to have an increased risk of lung cancer [119]. However, if you use marijuana, you may develop cognitive changes, including declines in your memory and the ability to concentrate [120].
Marijuana isn’t legal in every state. Some states allow the use of medical marijuana and some further allow the use of recreational marijuana. If you’re considering using medical marijuana, check the laws in your state.
Learn more about marijuana products, including CBD.
Support
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.
For some, a metastatic 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.
Ashley Fernandez, living with metastatic breast cancer
“It’s important to find and meet people that understand what you’re going through with no judgment.”
SUSAN G. KOMEN® METASTATIC BREAST CANCER SUPPORT RESOURCES |
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Issues for family members and other loved ones
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.
Care after breast cancer treatment ends
At some point, you may decide to stop active treatment for the cancer. This can happen when treatment stops showing a benefit or when treatment greatly affects your quality of life.
Once treatment for the cancer ends, palliative care becomes the main focus of care, rather than a part of treatment.
Learn more about care after treatment for breast cancer ends.
Hospice programs
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) [121].
With your personal guidance, the hospice program can make this later stage of cancer care as comfortable as possible.
This can be a very hard time for you and your family.
If you’re not interested in enrolling in hospice care, your health care provider or hospital can arrange for ongoing palliative care. They can also help you find a counselor 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.
Hospice resources
American Academy of Hospice and Palliative Medicine
Offers 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.asco.org
National Hospice and Palliative Care Organization
Offers 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 health care provider.
www.nia.nih.gov/health/end-of-life
Komen Perspectives
Read our perspective on palliative care, hospice and end-of-life decision-making.*
* 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.
Updated 06/03/24
