Questions and answers on breast cancer
GUIDELINE 10. THE MANAGEMENT OF PERSISTENT PAIN
AFTER BREAST CANCER TREATMENT |
I've had breast cancer treatment, and now I'm having pain. Does this mean the cancer has come back?
The cause of the pain will have to be investigated because the pain may be from some other source that has nothing to do with breast cancer or its treatment. Or it may be a result of the surgery, radiotherapy or chemotherapy you have had. A third possibility is that the cancer has returned.
What types of pain may come from surgery?
One cause of pain is the "postmastectomy syndrome." This occurs because removal of a lump can damage nerves in the area. This problem is more common after a total mastectomy (removal of the whole breast) but can also follow a lumpectomy (removal of just the cancer), especially if you've also had lymph nodes removed in the armpit area. Usually, this type of pain is not severe and will gradually improve.
Swelling of the arm (lymphedema) is another condition that can cause discomfort and pain. Removal of lymph nodes from the armpit during surgery can damage the channels which drain lymph from the arm. This leads to swelling and can be painful, especially if the arm becomes infected.
Could my pain be related to anticancer drugs?
Some drugs may cause painful conditions, including bladder inflammation (cystitis), numbness and tingling (peripheral neuropathy), mouth ulcers (mucositis) and aching joints. Taking drugs intravenously may also cause painful inflammation of the veins (phlebitis).
What about pain caused by cancer?
One type of pain is called "brachial plexopathy." A burning or stabbing pain is felt in the arm, shoulder or hand when these areas are touched, or they may feel "different" — either numb or very sensitive. There may also be weakness in the arm, especially if the pain has been going on for a long time. This pain usually means that cancer has come back in the lymph nodes behind the collarbone.
Rarely, this kind of pain may be just a side effect of radiotherapy or surgery. Careful investigation is necessary to rule out cancer, although your doctor may be able to provide some reassurance by pinpointing which nerves are involved. This is because cancer usually attacks some nerve branches and not others. Pain due to cancer is often centred around the shoulder and seems to spread to the elbow, the forearm and the fourth and fifth fingers.
Persistent pain in the bones is often a signal that the cancer has recurred and is spreading. If you have lasting pain at any time, you should consult your doctor immediately.
Although the bones are the most common site in which cancer returns (metastasizes), pain can also occur from cancer spreading to the nerves and other organs.
Should medication get rid of all my pain?
If the pain is caused by cancer, anticancer treatment such as radiotherapy or chemotherapy may give you the relief you need. Otherwise, anti-pain medications can usually provide good pain control.
The medication should be chosen in such a way that the pain is controlled rapidly and completely. This is done by increasing the amount you take in stages and changing the medication, if necessary, until the pain is under control.
The medication should also prevent the pain from coming back. This is done by adjusting the times you take your medication. Additional doses should be available to you in case of "breakthrough" pain between regular doses. If you often have breakthrough pain, your regular dosage schedule should be adjusted or another medication prescribed.
Above all, don't simply ignore the pain and hope you'll get used to it. People don't get used to pain. Sometimes, putting up with pain can make it even harder to control later with medication. Remember, you are in control of your pain and you need to let your doctors know if your pain is not controlled.
What kind of medication should I be taking to get rid of the pain?
If your pain is mild to moderate, it can often be controlled by painkillers you can buy without a prescription such as acetylsalicylic acid, acetaminophen and ibuprofen. You can choose the brand you are most familiar with, or ask your doctor or pharmacist to recommend one.
These painkillers can have toxic effects, which you should know about. They may aggravate asthma and cause stomach ulcers or kidney damage. If you have a history of stomach or duodenal ulcers, or if you're over 65 years old, use of medications such as misoprostol can help avoid such problems.
If these drugs alone don't control the pain, don't take more than the recommended dose. Higher doses won't help the pain but will increase your risk of having toxic side effects. Instead, your doctor can prescribe a more powerful medication, for example, an opioid such as codeine or oxycodone.
If these steps don't give you relief, you will need a more powerful opioid such as morphine. At the start, short-acting morphine is given in increasing doses until pain is controlled. Then you can switch to long-acting morphine, which is more convenient. Usually, short-acting morphine must be taken every 4 hours and long-acting morphine twice a day.
If I take opioids, what side effects should I watch out for?
Because opioids tend to cause constipation, laxatives should always be prescribed along with them.
Nausea and vomiting may occur when you start taking an opioid, but this problem goes away completely after a short time. In the meantime, there are many drugs that can control this side effect, such as dimenhydrinate (Gravol). You can buy these drugs without a prescription under several brand names.
Sedation (feeling sleepy) or confusion can be a problem, especially for elderly patients. No one should drive or use potentially dangerous equipment for 3 to 5 days after starting opioid therapy or after any change in dosage. The drowsy feeling usually disappears with time.
Although these are the most common side effects, individuals vary a great deal in their reactions to opioids. This means that a particular side effect may disappear entirely if you switch from one opioid drug to another. For example, if you have a bad reaction to morphine, your doctor can try other opioids such as hydromorphone, oxycodone, fentanyl, methadone or diamorphine.
The effectiveness of your medication should be re-evaluated after 24 hours every time you switch from one opioid to another, change your dosage, or change the way you take the drug — for example, if you switch from tablets to injections.
Can I take opioids by mouth?
All the drugs mentioned here can be taken by mouth. If for any reason this can't be done, most are also available as suppositories or skin patches. Some can also be injected under the skin.
Won't I get addicted to morphine or some of these other drugs?
True addiction ("psychological dependence") is extremely rare when opioids are taken for cancer pain. Much more commonly, people who are not receiving enough medication may seem addicted simply because their continuing pain forces them to demand more and more medication.
However, anyone who has been taking opioids for a long time can expect to develop "tolerance" to the drug and physical dependence. With tolerance, your body gradually gets resistant to the medication and needs increasing amounts to get the same relief. This is a normal process. Fear of developing tolerance is never a good reason for keeping medication from someone in pain.
Anyone who takes an opioid for longer than a few weeks may become "physically dependent." This means that your body gets used to the drug, and withdrawal symptoms will appear if it is suddenly stopped. If ever a drug is no longer needed for pain, it should be reduced gradually over a couple of weeks.
Are there other drugs that can be used?
Some drugs that are primarily used for other conditions have also proved useful in the relief of pain caused by cancer. These drugs are taken together with the pain medications already mentioned. Among these are corticosteroids, tricyclic antidepressants, anticonvulsants and some local anesthetics.
In prescribing any of these drugs, your doctor should explain the possible side effects.
Are there other ways to help me deal with pain?
There are various methods that may help, including exercise, electrical stimulation of nerves, acupuncture, massage, vibration and the application of heat or cold to the overlying skin. However, deep-heating methods like diathermy and ultrasound should be used with caution, since it is possible that they may help cancer cells to grow. Compression and massage therapy may help control the swelling and discomfort caused by lymphedema.
There are also many alternative therapies such as meditation, biofeedback, yoga, prayer, visualization, Tai Chi, therapeutic touch and herbal medicines. Although you should be aware that there is still no scientific evidence supporting these methods, there is also no proof that they do not work. In fact, many patients report significant benefit from their use. Remember, too, that pain always has a psychological element, and pain can be worse if you're depressed, tired or anxious. For this reason, you may find real benefit in joining a support group or trying psychological techniques such as hypnosis.
What if someone has tried everything, including medication, without satisfactory relief?
This happens very rarely. If possible, people with this kind of stubborn pain should see a pain specialist who can employ a variety of surgical measures to block the nerves involved.
