A review of basic cancer pain and neuropathy management in metastatic breast cancer.

1. Treating Pain and Neuropathy
in Metastatic Breast Cancer
September 24, 2016
Lida Nabati, MD
CLINICAL MANAGEMENT OF BREAST AND
GYNECOLOGIC CANCERS IN SPECIAL POPULATIONS

2. Goals
• To review basic cancer pain and
neuropathy management

3. Pain
• The body’s way of telling us about damage
or perceived damage to tissue.
• Don’t ignore! Report it.
• Treating pain is part of treating your cancer.
• Subjective, personal
– only you can “measure” your pain

4. Cancer Pain
Tumor
Surgery
Radiation
Chemotherapy

5. Treat Cancer
• Radiation Therapy
• Surgery
• Chemotherapy

6. PAINED
• Place
• Amount
• Intensifiers
• Nullifiers
• Effects
• Description

7. Keep Pain Diary
• Record:
– Pain score
– Trigger
– Medication use
– Medication effect (pain score 1 hour after)
– Other comments

8. WHO Step Ladder

9. Approach To Pain Control
1.Thorough assessment by skilled and
knowledgeable clinician.
2.What are the goals of care?
3.Investigations: Radiology studies – how
burdensome, will they affect care?
4.Treatments: pharmacological and non-
pharmacological, interventional analgesia.
5.Ongoing reassessment and review of
options, goals, expectations.

10. Opioids
• Short-Acting
• Oxycodone
• Morphine
•Long-acting
•Oxycontin
•Mscontin
•Fentanyl Patch
•Methadone

11. Opioid Side Effects
• Nausea
• Sleepiness
• Constipation

12. Opioid Rotation
• If one opioid is not well toelrated, may try
another
• Conversion tables do not account for
incomplete cross tolerance
• Recommend reduction by 25-50% of
calculated equianalgesic dose when rotating
opioids.

13. How Often can one Escalate?
 Short acting oral__________Each dose interval
 Opioid continuous infusion_____Every 8 hours
 Long acting oral______________Every 2 days
 Methadone_________________Every 3-7 days
 TD Fentanyl_________________Every 3 days

14. Will I become addicted?
• Tolerance and physiologic dependence are
expected with chronic opioids, this is not
addiction.
• Addiction is misuse of medications with
harm resulting. It is not common but can
happen – increased risk if personal or
family history of addiction

15. Common reasons for the use
of alternate routes
• Severe nausea and/or vomiting
• Difficulty swallowing
• Complications of the gut
• Diminished consciousness

16. Peripheral Neuropathy
• Results from lesion or disease of nervous
system
• Shooting, burning, tingling
• Can be associated with numbness,
weakness
• Can result form tumor, surgery
• Many chemotherapies can cause this:
– Taxanes, Platinum based drugs, Eribulin

17. Neuropathy Treatments
• Gabapentin
• Tricyclic antidepressants
• Capsaicin
• Opioids
• Cannabinoids

18. Pain Treatment
• Genetic, hormonal, and other factors
influence one’s perception, experience, of
pain.
• There are established genetic variabilities in
metabolism of pain medications.

19. Pain Interventions
• Interventional Radiology
– Bone interventions
– Cryoablation
• Anesthesia
– Nerve blocks
– Epidurals

20. © Pain and Palliative Care Program
Dana-Farber Cancer Institute 2002
Total Pain

21. Causes of Suffering in Serious Illness
PHYSICAL
 Pain
 Dyspnea
 Delirium
 Nausea/ vomiting
PSYCHOLOGICAL
 Anxiety
 Depression
 Loss of Meaning
 Loss of Control
 Loss of Dignity
SPIRITUAL
 Uncertainty
 Fear of disability
 Fear of death
 Hopelessness
 Remorse
SOCIAL
 Loneliness
 Functional decline
 Loss of roles

22. A Team Approach
“ Caring for the whole person and family
requires a caregiver who is whole….
Until one comes along,
use a team.”
Balfour Mount

23. Other Modalities
• Acupuncture
• Physical Therapy
• Reiki
• Massage
• Meditation
• Heat/ice

24. Summary
• Pain management is an important par t of
cancer treatement
• There are many ways your pain can be
effectively managed