Treating Pain and Neuropathyin Metastatic Breast Cancer

September 24, 2016 Lida Nabati, MD

CLINICAL MANAGEMENT OF BREAST AND GYNECOLOGIC CANCERS IN SPECIAL POPULATIONS

Goals

• To review basic cancer pain and neuropathy management

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

Cancer Pain

Tumor

Surgery

Radiation

Chemotherapy

Treat Cancer

• Radiation Therapy• Surgery• Chemotherapy

PAINED

• Place• Amount • Intensifiers• Nullifiers• Effects • Description

Keep Pain Diary

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

WHO Step Ladder

Approach To Pain Control1. 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.

Opioids

• Short-Acting • Oxycodone• Morphine

•Long-acting •Oxycontin •Mscontin •Fentanyl Patch •Methadone

Opioid Side Effects

• Nausea• Sleepiness• Constipation

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.

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

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

Common reasons for the use of alternate routes

• Severe nausea and/or vomiting• Difficulty swallowing • Complications of the gut• Diminished consciousness

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

Neuropathy Treatments

• Gabapentin • Tricyclic antidepressants • Capsaicin • Opioids • Cannabinoids

Pain Treatment

• Genetic, hormonal, and other factors influence one’s perception, experience, of pain.

• There are established genetic variabilities in metabolism of pain medications.

Pain Interventions

• Interventional Radiology – Bone interventions – Cryoablation

• Anesthesia – Nerve blocks– Epidurals

© Pain and Palliative Care ProgramDana-Farber Cancer Institute 2002

Total Pain

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

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

Other Modalities

• Acupuncture• Physical Therapy • Reiki• Massage • Meditation • Heat/ice

Summary

• Pain management is an important par t of cancer treatement

• There are many ways your pain can be effectively managed