Treating Pain and Neuropathy 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

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