Dr. MJ Bazos MD,
Q & A
on Chronic 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?
Pain after breast cancer surgery
and treatment may occur for several reasons. In many cases, the pain may be
caused by something that has nothing to do with breast cancer or its treatment.
It may also be a result of the surgery, radiotherapy or chemotherapy you have
experienced. Another possibility is that breast cancer has returned. If you have
persistent pain at any time, you should consult your physician for assessment
and advice. Additional investigations may be required. Regardless of the cause
of pain, effective treatment is
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 have also had lymph nodes removed in the armpit
area. Usually, this type of pain is not severe and will gradually
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 that drain
lymph from the arm. This leads to swelling and can be painful for some
Could my pain be related
to anticancer 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).
pain caused by cancer?
grows in the bones may cause pain. If you have new or increasing pain in the
bones, you should discuss this with your physician. These symptoms could occur
because breast cancer has spread to the
Although the bones are the most
common site in which cancer returns, pain can also occur from cancer spreading
to nerves and other organs.
One type of
nerve 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. Although this
kind of pain may rarely be a side effect of radiotherapy or surgery, this pain
may mean that cancer has come back in the lymph nodes behind the collarbone.
Careful investigation may be necessary to rule out
Should medication get rid of
all my pain?
Regardless of the
cause of pain, anti-pain medication prescribed by your physician can usually
provide good pain control.
If the pain
is caused by cancer, anticancer treatment such as radiotherapy or chemotherapy
may treat the cause of the pain and reduce the need for pain
It is important not to
ignore pain or hope you will get used to it. People do not get used to pain.
Putting up with pain can make it even harder to control later with medication.
The goal of pain medication is to control pain as rapidly and completely as
possible. This may require adjusting the type and amount of your pain
medication. Remember, only you can report on your pain, and you need to let your
doctors know if your pain is not
If the pain is persistent
or chronic, you will need to take pain medication in regular doses around the
clock. Additional doses may be necessary in case of "breakthrough" pain between
regular doses. If you often have breakthrough pain, your regular dosage may need
to be adjusted or another medication
What kind of medication
should I be taking to get rid of the pain?
If your pain is mild to moderate,
painkillers you can buy without a prescription, such as acetylsalicylic acid
(ASA), acetaminophen and ibuprofen (part of the family of drugs called
nonsteroidal anti-inflammatory drugs), may be effective alone. You can choose
the brand you are most familiar with, or ask your doctor or pharmacist to
Ibuprofen and ASA are
effective pain relievers, but they can have side effects. They may aggravate
asthma and cause stomach ulcers or kidney damage. If you have stomach problems,
there are new medications in the nonsteroidal anti-inflammatory group (for
example, Cox 2 inhibitors) that may reduce your chances of having side
If drugs like ASA,
acetaminophen and ibuprofen alone do not control the pain, do not take more than
the recommended dose. Higher doses will not help the pain but will increase your
risk of having side effects. If these medications alone are not effective, your
doctor can prescribe stronger medications. Opiates are a strong pain
Several types are available.
Your physician can work with you to select an opiate that is most effective for
you (for example, codeine or oxycodone). Opiates are often most effective when
they are prescribed with drugs such as ibuprofen, acetaminophen or
Many types of pain may require
strong opiates such as morphine, hydromorphone or fentanyl. Any of these drugs
may be effective depending on the patient and the situation. Usually a
short-acting opiate is prescribed on a regular schedule (for example, every 4
hours). The dose taken will be increased every day or so until pain is
Some patients find that
taking pain medications frequently is difficult. If your pain is well
controlled, then you can consider switching to a long-acting opiate, which some
patients find more convenient. Several long-acting preparations are available.
Long-acting tablets are taken twice a day, and a long-acting patch, which allows
pain medicine to be absorbed through the skin, works for 3 days. You should
discuss with your physician whether one of these approaches is right for
Occasionally, some patients will
need to take opiates by injection under the skin instead of by mouth. As well,
suppositories can be used in some patients. Your physician can advise you which
is the best option depending on your
If I take opioids, what
side effects should I watch out for?
All opioids can cause
constipation. Laxatives should always be prescribed along with them. You will
need to take the prescribed laxatives regularly to prevent
Nausea and vomiting may
occur when you start taking an opioid, but these symptoms often disappear
completely after a short time. In the meantime, there are many drugs that can
control these side effects, such as dimenhydrinate (Gravol). You can buy these
drugs without a prescription under several brand names. Additional options to
prevent or treat nausea are available by
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.
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
an unpleasant reaction to morphine, your doctor can try other opioids such as
hydromorphone, oxycodone or
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
It is important to report
side effects to your doctor. You should not stop taking opiates because of side
effects without first discussing it with your
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 requires higher doses or switching to a
Rarely, you may
develop "tolerance" to the pain medication. With tolerance, your body gradually
becomes resistant to the medication and needs increasing amounts to get the same
relief. Fear of developing tolerance is never a good reason to avoid taking
enough pain medication to be pain free. Remember, there is no maximum dose for
opioids, and the right amount to take is the amount that relieves your pain. If
tolerance occurs, switching to another type of pain medication will relieve the
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. When the cause of the pain improves and an opioid drug is no
longer needed for pain, it should be reduced gradually over a couple of
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, some local anesthetics and bone-strengthening drugs called
In prescribing any of
these drugs, your doctor should explain the possible side
Are there other ways to
help me deal with pain?
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 such as diathermy and
ultrasound should be used with caution, since they may help cancer cells to
grow. Compression therapy may help control the swelling and discomfort caused by
There are also many
alternative therapies such as meditation, biofeedback, prayer, visualization,
yoga, Qi Gong, Tai Chi, therapeutic touch, Reiki, healing touch, homeopathy and
herbal medicines. Although you should be aware that there is a lack of
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 are depressed, tired or anxious. For this reason, you may find real
benefit in joining a support group or trying psychological techniques such as
What if I have tried
everything, including medication, without satisfactory pain relief?
This kind of stubborn pain happens
very rarely. If possible, you should see a pain specialist who can use a variety
of surgical measures to block the nerves involved.