Pain management in metastatic breast cancer

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Pain – no matter how severe – can almost always be at least partly relieved through treatment. Well-coordinated pain management with regular adjustments is crucial for maintaining quality of life. It is one of the main medical treatments used in metastatic breast cancer.

Metastatic breast cancer treatment targets not only the cancer cells, but also the related symptoms such as pain and any possible side effects of more aggressive treatments.

The symptoms caused by breast cancer will depend on various factors, including the size of the tumor and the rate at which it is growing. A growing tumor can cause pain if the cells press against nearby nerves or damage healthy tissue. Large tumors may prevent organs from working properly if they grow deeper into the chest wall or the skin. The location of metastatic tumors also influences the kind of symptoms they cause. If your lungs are affected, you may have trouble breathing. Metastases in the bones can be painful and make the bones more brittle.

Pain often makes you feel tired and anxious, and can get you down. But medication can almost always help.

Describing pain

Pain can often be treated effectively. But the treatment is more likely to work if you tell your doctor when you experience the pain and describe it as accurately as you can. You also need to let them know how well the medication is working and whether you are experiencing any side effects. Only then can you find the right medication and dose for you.

There are questionnaires to help you better describe and compare the severity and extent of the pain. The scale they use typically rates pain severity from zero (no pain) to ten (worst pain imaginable). Sometimes the scales use words or symbols instead.

The type of pain can help doctors to identify what is causing it. Hard-to-pinpoint pain that tends to be dull and pressing typically comes from internal organs. Pain in the skin, on the other hand, is often described as sharp, pulling or piercing, and it is usually possible to specify where it is. Pain in or around bones, joints or muscles is often perceived as dull, pulling, piercing or cramping, but may be hard to describe. It also sometimes radiates into surrounding tissue. Burning and shooting pain is often a sign of nerve damage.

Medications and dosage

The type and dose of medication used in pain management – and how long the pain is treated – depend on factors such as the cause and severity of the pain, the type of cancer treatment and your overall health. It is important that you talk to your doctor regularly about how you feel and about the aim of the pain-relief treatment.

There are two main classes of painkillers (analgesics):

  • Non-opioid drugs
  • Opioid drugs

Non-opioid substances affect the outer (peripheral) nerves of the skin, muscles and organs. They are used to treat mild to moderate pain. Most of them also have an anti-inflammatory effect, and some of them lower fever. In Germany and other countries, many of them are available without a prescription, including ibuprofen, acetylsalicylic acid (the drug found in Aspirin), and acetaminophen (paracetamol). But you shouldn't take them all the time without talking to the doctor about it first. One commonly used drug is called metamizole.

Opioid drugs mainly affect the central nervous system (the brain and the spinal cord), where incoming pain signals are processed. Opioids are only used to treat moderate to very severe pain. Weak opioids include drugs like codeine and tramadol; strong opioids include fentanyl, morphine and oxycodone. Medication can be used in various forms, including tablets, a patch, or an infusion (drip). Patches may be more suitable in certain situations, for instance if you have trouble swallowing, have to vomit or are exhausted.

The risk of becoming dependent on opioids is low – as long as you use them as prescribed by the doctor.

The World Health Organization (WHO) has developed a three-step approach for treating pain according to its severity:

  • Step 1 (mild pain): Non-opioid drugs
  • Step 2 (moderate pain): Weak opioids and non-opioid painkillers (analgesics)
  • Step 3 (severe to very severe pain): Strong opioids and non-opioid painkillers

If you are still in pain despite treatment, let someone know. The same goes for bothersome side effects. You can also turn to a pain management specialist. Some cities have their own pain center or pain clinic too.

Side effects of opioids

Opioids usually relieve the pain, but can lead to side effects such as constipation, nausea or drowsiness. Constipation is particularly common.

So women who use opioids are also given other medications, such as anticonvulsants or antidepressants, to avoid or weaken the side effects. The doctor will monitor the dose and combination of drugs used in order to prevent side effects as much as possible. It's important to let the doctor know if new and unusual symptoms occur, or existing symptoms get worse, after starting treatment with painkillers.

Can you become dependent on opioids?

Many patients and their loved ones are worried that they will become dependent on strong painkillers if they use them. Sometimes they are so worried about this that they refuse to use strong painkillers even if it would help to relieve their pain. But you are unlikely to become dependent on strong painkillers if you take them for less than four weeks.

Taking them for longer than that can cause your body to get used to them. That's normal and happens with a lot of medications. If you then suddenly stop using the medication, it could cause various problems such as trouble sleeping, restlessness, diarrhea or vomiting. If you stop using the medication gradually, following your doctor's instructions, these problems can be avoided, reduced or treated.

To achieve the best pain relief, it's important to take the medication as recommended by your doctor. This sometimes also includes trying to reduce the dose. That way you can find out whether the pain has improved. If it has, you might be able to generally reduce the dose of the opioid medication or even stop using it altogether.

Things you can try on your own

Individual perception of pain varies widely and is influenced by a number of factors, including the time of day and your general mindset. Stress and fear – including fear of pain – can make you more sensitive to pain.

Because pain perception takes place in the brain, you can influence it yourself to some degree. Pain management strategies like relaxation techniques can help here. They give you a way to relieve the pain yourself, besides taking medication.

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Deutsche Krebsgesellschaft (DKG), Deutsche Krebs-Hilfe (DKH), Deutsche Gesellschaft für Palliativmedizin (DGP). S3-Leitlinie Palliativmedizin für Patienten mit einer nicht heilbaren Krebserkrankung. AWMF-Registernr.: 128-001OL. August 2019. (Leitlinienprogramm Onkologie).

Handwerker HO. Nozizeption und Schmerz.In: Schmidt RF, Schaible HG (Ed). Neuro- und Sinnesphysiologie. Berlin: Springer. 2000: S. 257-271.

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World Health Organization (WHO). WHO's cancer pain ladder for adults 2019.

World Health Organization (WHO). WHO guidelines for the pharmacological and radiotherapeutic management of cancer pain in adults and adolescents. Geneva: WHO; 2018.

IQWiG health information is written with the aim of helping people understand the advantages and disadvantages of the main treatment options and health care services.

Because IQWiG is a German institute, some of the information provided here is specific to the German health care system. The suitability of any of the described options in an individual case can be determined by talking to a doctor. informedhealth.org can provide support for talks with doctors and other medical professionals, but cannot replace them. We do not offer individual consultations.

Our information is based on the results of good-quality studies. It is written by a team of health care professionals, scientists and editors, and reviewed by external experts. You can find a detailed description of how our health information is produced and updated in our methods.

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Updated on March 18, 2021
Next planned update: 2024

Authors/Publishers:

Institute for Quality and Efficiency in Health Care (IQWiG, Germany)

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