Treating pain with metastatic breast cancer

Many people fear that having metastatic breast cancer means they will experience pain that cannot be managed.

It can help to know that some people experience very little pain, and others no pain at all.

You should be able to achieve good control of your pain.

Many different drugs and treatments aim to reduce or remove cancer pain. It’s important you let your team know if your pain is not under control as they can change the dose or use different drugs to help.

Causes of pain in metastatic breast cancer

In metastatic breast cancer, tumours in other parts of the body such as the liver or bones can cause pain. 

Treating the cancer will help treat the pain.

Tell your treating team about any discomfort or pain. They can assess you to identify the cause (where possible) and treat it more effectively. They may need a number of strategies, as pain may be caused by multiple things.

Pain can also affect your sleep, so let your specialist know if you are having trouble sleeping.

How to describe your pain

It can be hard to describe your pain to your treating team or to other people.

The more accurately you can describe the pain, the easier it is for doctors to prescribe effective treatment. It may be helpful to keep a diary to record the following:

• If 0 is no pain at all and 10 is the worst pain you could imagine, what number is yours?
• What does the pain feel like: a dull ache or more like stabbing or burning?
• Is it constant or does it come and go (intermittent)?
• When is it at its worst (if it comes and goes) and how long does it last?
• Is it easy to pinpoint where the pain is or is it more general?
• Does anything provide relief or make it worse?
• If you have tried medications, did any work better than others?

Pain medications

Many different pain-relieving drugs (‘analgesics’) can be used on their own or with others.

For mild pain

Paracetamol (Panadol) is effective for mild pain. It works best if you take it regularly. Don’t wait for pain to come back or get worse before you take the next dose.

Anti-inflammatory medications such as aspirin and ibuprofen (Nurofen) are also effective for mild pain.

These are available without a prescription (‘over the counter’). Always check with your doctor to make sure the over-the-counter drugs are safe for you to take.

For moderate pain

Painkillers that contain codeine, such as Panadeine and Panadeine Forte, are effective for moderate to strong pain. You need a prescription from your medical oncologist or GP.

For severe pain

Your doctor may prescribe opioid-based drugs to control moderate or more severe pain. Opiate painkillers include:

• Oxycontin, Targin, Endone (contain oxycodone)
• Kapanol and MS Contin  (contain morphine)
• Jurnista and Dilaudid (contains hydromorphone)
• Durogesic (fentanyl) patches.

For strong pain, the usual approach is to use a slow-release opioid, either:

• tablets such as Oxycontin, Targin, MS Contin or Jurnista, or
• patches such as Fentanyl/Durogesic. You put these on the skin and replace them every few days.

You may also be able to use 'fast-acting'  pain medication for ‘breakthrough pain’. This is pain that happens despite the slow-release pain medication. Examples are:

• Endone, Dilaudid (tablets)
• morphine mixture (liquid)
• Actiq, Abstral (fentanyl lozenge).

The steroid dexamethasone can sometimes help for pain associated with bone, brain or liver metastases. Steroids work by reducing inflammation, which can be causing the pain.

Nerve blocking drugs (‘anaesthetics’) can ease pain by reducing feeling.

Some medications have side effects, so tell your treating team if you experience any. They can help prevent or manage the impact of pain treatment.

Common concerns about pain medication

Some people worry they may become dependent on painkillers. The risk of becoming addicted to pain medication taken for cancer pain is low.

Others worry that increasing the dose means their cancer is getting worse. If your medication isn’t working as well as it was, speak to your doctor. You may need:

• a higher dose because you have developed a tolerance for the medication
• a different pain medication.

It is important you take your pain medication regularly as ordered, to control your pain well.

If your pain improves, tell your treating team. They may recommend you reduce some medications.

Myths around morphine

There are many myths about pain-relieving agents and cancer, particularly morphine.

Myth 1 – If I take morphine I will get addicted. 

Using morphine for pain relief does not cause people to become addicted.

Myth 2 – If I take morphine now, it won’t work if my pain gets worse.

This is not true. If your pain becomes more severe, morphine dosage can be adjusted.

Myth 3 – If my doctor recommends morphine it means that my cancer is getting worse.

If your doctor recommends morphine, they want you to feel as well and as pain-free as possible. They don’t think another medication will achieve that. Morphine is not a ‘last resort’ drug. Many people use varying doses of morphine over several years.

Myth 4 – If I take morphine I will be too ‘out of it’ to do anything.

Like any other drug, morphine can have side effects. You need to balance these against the benefits. At first, it can have a sedative effect. In most cases, the body adjusts quickly, so feeling sedated is not a major problem for most people.

Myth 5 – Morphine is too strong if I’m also taking other medication.

While morphine can be effective on its own, it’s commonly used with other pain medication such as paracetamol. Some antidepressants increase the pain-relieving benefits of morphine and are often used as an effective combination.

Radiotherapy

Radiation therapy can be an effective way to reduce pain from metastatic breast cancer. It can:

• shrink tumours where the breast cancer has spread
• reduce bone pain when you have 1 or only a few bone metastases
• reduce the risk of bone fracture

Treatment is generally well tolerated and has few side effects.

Generally, it takes 2 to 4 weeks to get the maximum benefit from radiotherapy.

Read about Radiotherapy for metastatic breast cancer.

Surgery

Sometimes surgery is needed to treat pain. Doctors may recommend this to treat fractures caused by bone metastases or spinal cord compression.

Pain management specialist

Your oncologist may suggest input from someone who specialises in cancer pain management. This may be through a pain clinic or with a palliative care physician as part of your cancer treatment team.

Read about palliative care physicians at:

• Your metastatic treatment and care team
• The role of palliative care.

Complementary therapies

Many different complementary therapies can help to manage pain including:

• acupuncture​
• Cognitive Behavioural Therapy (CBT)​
• gentle massage ​
• mindfulness meditation (mindfulness stress reduction); guided imagery, hypnosis​
• music therapy​
• nutrition​
• physical therapy – exercise, yoga, Tai Chi​
• reflexology​
• relaxation therapy, breathing techniques
• cold packs (but not heat packs due to the risk of burns if the affected area is numb).

Always talk to your doctor before you start any complementary therapies, to make sure they are safe for you. They may interfere with your treatments or the management of your side effects.

Read about Complementary therapies.

For non-medical ways of reducing or controlling pain read Non-medical pain relief for metastatic breast cancer.