Effective Management of Breast Cancer-Related Pain Calls for a Multimodal Approach

Jacob Hutchins, MD

Pain in patients with breast cancer who have had surgery or who have late-stage disease is common, and managing it effectively can be difficult. Fortunately, there are new approaches that can help, explained Jacob Hutchins, MD, Director of Pain Management for the Department of Anesthesiology at the University of Minnesota. He provided insight into these new ways of thinking about breast cancer pain management in a recent interview with Oncology Nursing News.

Please explain how state-of-the-art pain control can improve the patient experience?

The old way of taking care of a patient’s pain control has been with opioids. So patients would have surgery, and after surgery you’d treat them with opioids. If they had more pain, you’d add more opioids, and if they continued to have pain you’d either add even more opioids or maybe you’d switch to a different opioid.

That isn’t the best way to treat patients’ pain. It used to be systemic opioids until patients experienced a lot of the side effects associated with opioids, such as constipation, drowsiness, and even side effects as serious as respiratory depression. We found that a multimodal approach to patients’ pain control leads to better outcomes, both in the acute phase and in the long term. It also improves patient satisfaction.

A multimodal approach starts before surgery and continues through to postsurgery. It will consist of different medications—not just opioids—and usually some local anesthetics either at the site or regional anesthesia to provide pain control to all areas of the body and then some surgical site-specific pain. This approach reduces the systemic effects of opioids because pain is not just mediated by opioid; it is also mediated by other pain receptors in the body.

What does a multimodal approach consist of?

The multimodal approach isn’t new; it’s been around for a while but it just hasn’t been well adopted by the entire surgical field. It consists of NSAIDs, acetaminophen, intermittent opioids if needed, antiepileptics and local anesthetic.

Even before surgery, patients get pain medication that’s continued in the acute postsurgical phase. Prior to surgery, patients should be taking acetaminophen and some sort of antiepileptic. During surgery patients receive more acetaminophen, some short-acting opioids and regional anesthesia before surgery, which I prefer because the patients are able to get the local anesthetic directed to the site of surgery prior to any incisions. This also allows the doctors to use fewer anesthetics and opioids during surgery.

The multimodal approach continues after surgery by minimizing opioids as much as possible and moving patients to oral opioids. Patients should also start taking NSAIDs as soon as the surgeon allows and continue acetaminophen postoperatively for up to 7 days after surgery.

Then, patients should have minimal need for opioids, and the pain should be relatively well controlled. Again, these patients should be encouraged to get back to normal activities as soon as possible. The longer they stay in bed, the worse things will get.

All of these therapies are necessary for postoperative pain control. This will lead to better pain control, better patient satisfaction, and maybe even decreased recurrence of cancer.

Why do doctors not like prescribing opioids? Are patients afraid of taking them?

The pendulum has kind of swung, and pain control is now a focus. So the doctors were really advised to be pro-opioids. Many patients were prescribed large amounts of opioids after surgery. We found that this approach wasn’t beneficial for the patients. Most patients don’t like taking opioids. It makes them feel drowsy, they feel nauseous, and they get constipated. They don’t like the way they feel when they’re on opioids. So if we can give them other options, the majority of patients are happy with that approach.

The other aspect that we’ve seen, and there’s a lot of data in the literature lately, is that prescribing large doses of opioids for patients when they go home has contributed to other problems. Patients who take these opioids home tend to not be on them for very long, so they’ll have a bottle of 30 or so opioids around, and one of the highest drugs of abuse is opioids. Overprescribing can lead to people stealing pills and abusing them.

There has also been some research on opioid-related deaths from overdose in elderly patients. We really need to be careful about how much opioid medication we are giving patients to minimize the risk to them and society as a whole.

Is there something specific about breast cancer patients that make managing pain a challenge?

It has been shown that if a breast cancer patient has poor acute pain control that may lead to increased risk for chronic pain. Breast cancer patients have a high risk of chronic pain at the site of surgery, and somewhere between 30% and 60% of patients who have had breast cancer surgery develop chronic pain. The surgery takes place close to nerves, and if those nerves are cut or injured, they can develop chronic pain.

What would you recommend to nurses and oncologists to better manage these patients’ pain?

After that acute phase with all the different approaches that we use, at some point patients have to get back to their normal activities. Part of the multimodal approach is getting patients back to activity as soon as possible. The longer they are not at their normal activity, the higher risk they have of developing chronic pain. If patients are seen by their surgeon or oncologist after surgery and are still having issues with pain, some aggressive regimens can be used to make sure their pain is controlled by looking at their medications and adjusting them as needed.

But there are also some nonpharmacologic approaches that can be utilized after surgery. Different patients respond to different approaches, for example, you can look at acupuncture, massage, or healing touch. You can look into those areas and see if patients respond, because some nonpharmacologic approaches may be just as beneficial as adding more medications, and 3-4 weeks out of surgery patients shouldn’t need opioids for pain control. If they’re still having pain, there may be something else that’s going on.

Also, when physicians or nurses are following up with patients after surgery to see how well their pain is being controlled, they should ask “how have you been doing with your regimen?” Very commonly, patients who are discharged don’t follow the doctor’s instructions. Following up with patients after surgery to make sure they’re following the treatment regimen can help the physician or nurse determine if more medication is needed or if the patient just has to do a better job of taking the medication.

How does the approach change when managing patients with late-stage breast cancer?

This is a much different approach because this is a person with late-stage breast cancer who most likely has chronic pain from the actual cancer, previous surgery, cancer treatment, or metastases.

These patients come in with chronic pain, and they’re difficult to manage. They’re either being managed by their oncologist or primary care physician, but it’s really important that these patients be referred to a palliative care specialist very early on.

Palliative care is usually negatively associated with end-of-life care, but palliative care specialists are really good at helping with pain control and the psychological effects that can occur with late-stage breast cancer. It’s a very good area of care for patients to be connected with.

If they do have chronic pain, patients should work with a palliative care specialist and a chronic pain physician to help manage it, because there are a lot of different ways to manage the pain; it’s difficult for one physician to provide all of that care.

How would you recommend treating these patients?

It’s a three-tiered approach of nonpharmacologics, pharmacologics, and interventional approaches.

The nonpharmacologic tier is getting the patient connected with palliative care and working with the psychological effects. Other nonpharmacologic approaches, including acupuncture, massage, and aromatherapy, can be beneficial for these patients. Unlike the acute postsurgical pain where you’re expecting the pain to go away, this is pain that is not going to go away. A lot of it is getting patients to manage their pain so that they can live their life.

Pharmacologic approaches include low-dose opioids, acetaminophen, and NSAIDs as well as some SNRIs [serotonin and norepinephrine reuptake inhibitors], which help with neuropathy. For bone metastasis pain, that’s where bisphosphonates come into play.

Interventional approaches depend on what’s happening with the patient. Surgery may be an option to remove metastases of the spine or relieve spinal cord compression. Sometimes nerves are compressed, so an injection would be used to help relieve pain.