Management of Breakthrough Pain in Cancer Patients
Jeffrey A. Gudin, MD
Director, Pain Management Center
Englewood Hospital and Medical Center
Charles E. Argoff, MD
Albany Medical College Director of the Comprehensive Pain Management Center
Albany Medical Center Albany, NY
Jeri Ashley, RN
Director, Life Planning
Palliative Medicine Services
Vitaly Gordin, MD
Professor, Anesthesiology Associate
Vice Chair of Chronic Pain Division
Director, Pain Medicine Division
Penn State Hershey Pain Management
Milton S. Hershey Medical Center Hershey, PA
Marc Rappaport, DO
Western Connecticut Medical Group
Breakthrough pain is a common and disabling reality for patients with advanced cancer. Its root causes vary, and experts agree that this type of pain is often inadequately managed. Treatments are available, yet greater awareness and understanding of these formulations are needed in the oncology setting. An expert group of pain specialists, together with an oncology nurse and a medical oncologist, assembled recently as part of the OncLive
Peer Exchange® series to share insights on therapies to manage breakthrough pain
, offering perspectives on diagnosis, assessment, individualized treatment approaches, and patient monitoring.
What Is Breakthrough Pain?
Approximately 70% of patients with advanced cancer will indicate pain as their primary complaint, noted Vitaly Gordin, MD. Patients with cancer may experience several types of pain, including suddenonset pain, chronic pain, and breakthrough pain. In many situations, these patients may experience persistent pain that lasts more than 12 hours per day, which can be controlled with various medications.
However, breakthrough pain, defined by the National Cancer Institute as “intense increases in pain that occur with rapid onset even when pain-control medication is being used,” can result in severe, transient pain flares. “Breakthrough cancer pain comes in very short spurts, and normally doesn’t have a good target to hit,” explained Marc Rappaport, DO.
Vitaly Gordin, MD
“It varies from patient to patient,” added Jeri Ashley, RN. “Sometimes it begins and then it progressively gets worse until it’s managed. Other times it spikes and goes back down before the patient even reaches for the medicine bottle.”
Breakthrough pain occurs in patients not only with active disease, but also those in remission—for example, patients experiencing postchemotherapeutic effects such as neuropathy, or postsurgical pain, which are the most common pain-related issues in patients receiving curative therapy, according to Rappaport. “There still are breakthrough cancer pain issues that they have to deal with long term.” As an example, he cited a 40-year-old patient with chronic postmastectomy pain, although her therapy was curative.
Tools to Assess Patients Available
Because pain is so heterogeneous, noted Jeffrey A. Gudin, MD, “The best management of an individual’s pain—including breakthrough pain in cancer— requires a thorough assessment to individualize treatment strategies.”
Among the diagnostic tools available are the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology—Adult Cancer Pain, the Brief Pain Inventory (BPI) developed by Charles Cleeland, MD, for rapid assessment of the severity and impact of pain in patients with cancer, and the MD Anderson Symptom Inventory (MDASI).
Numeric rating scales can be employed to assess the severity of breakthrough pain for patients with cancer, noted Gudin. However, in addition to numerical tools, daily activities and medical history should also be considered, such as whether the patient is at the end of the dose or has undertaken new activities, explained Charles E. Argoff, MD.
Including these questions in the assessment will provide an accurate measure of the events leading to the breakthrough pain. For example, “Is this breakthrough pain occurring at the end of a person’s dose, when they’re about to take their next drug?” Argoff continued. “Is the pain spiking idiosyncratically, idiopathically for no apparent reason, which is, of course, less predictable, or is the pain spiking because they’re now more active than ever before, being positive, and they’re gardening?”