The Special Pains Breast Cancer Can Cause

March is International Women’s Month. So, I am using this month’s newsletter to focus on a few of the tough-to-manage pain syndromes and concerns of women with breast cancer.

As an oncology clinician, you are well-versed in the use of nonopioid and opioid agents and adjuvants to treat pain syndromes that occur in these patients. In what follows, therefore, I’ll review mostly non-pharmacologic strategies for pain syndromes that are common in patients with breast cancer: aromatase inhibitor (AI)-induced arthralgia; post-mastectomy/post chemotherapy port-insertion pain; prevention of chemotherapy-induced peripheral neuropathy (CIPN); exercise, and post-treatment anxiety.

Aromatase inhibitor-induced arthralgias
Acupuncture
AI-induced arthralgias can cause patients to discontinue this very effective class of therapy. Some women gain no benefit from or cannot tolerate the nonsteroidal anti-inflammatory drugs that are often recommended. Acupuncture may be the answer. In a 2022 study, patients receiving acupuncture had a statistically significant decrease in their AI-associated joint pain. That relief continued when patients were assessed as long as 40 weeks after they completed the acupuncture.

Post-mastectomy or post-port insertion pain
Lidocaine patches
The skin around a mastectomy or lumpectomy scar, or around a chemotherapy port insertion can be so hypersensitive from associated nerve injuries that even the touch of clothing is uncomfortable. Lidocaine patches (i.e., lidocaine-impregnated dressings that stick to the skin) eliminate this hypersensitivity by producing skin anesthesia under the patch. They can stay on for up to 12 consecutive hours a day and can be cut to size or to surround an infusion port. As many as four patches can be used at the same time. Systemic concentrations of lidocaine do not reach a level at which they would affect cardiac function. Of course, the patches should not be used where the skin is broken or over skin directly in the radiation port when the patient is receiving radiation therapy.

Strategies to prevent CIPN
CIPN is, unfortunately, very common. Thirty to 40 percent of people who are given drugs that injure peripheral nerves, as do the taxanes that are usually a part of adjuvant chemotherapy for breast cancer, develop CIPN. Sensory loss can make using a cellphone or even a computer keyboard difficult. In some women, CIPN is so severe that the deficits caused in proprioception lead to ataxia and problems walking.

Symptoms do lessen with time, but maximal recovery may not occur for 6 months to a year. Unfortunately, the symptoms and their associated functional impairments rarely resolve completely. Six years after treatment, 47 percent of patients with CIPN from treatment were still reporting significant symptoms, including increased risk of falls.

Predisposing factors
Prevention may be possible. The first step is to avoid using agents that can induce peripheral neuropathy in patients who have increased risk factors for CIPN. Breast cancer patients who were overweight or obese or had a low “moderate to vigorous physical activity” (MVPA) score had a greater incidence of CIPN from taxanes. In patients over 65, diabetes increased the risk twofold.

Prevention with cooling gloves and socks
Limb hypothermia was effective in pilot trials in breast cancer patients on paclitaxel. In each of two trials, one of the patient’s hands and feet were cooled, and the other hand and foot were not. The “control” extremities demonstrated significantly more CIPN. In a third trial, women given prophylactic cryotherapy were more likely to complete the planned dose of adjuvant paclitaxel. In this randomized trial, in which patients received no cooling, or intermittent -20-or-30-degree C hand and foot cooling, cooling was effective for improving symptoms and ability to perform day-to-day activities. All temperatures tested were well-tolerated and safe.

Exercise to reduce breast cancer associated symptoms
Therapeutic exercise is effective for post-treatment shoulder pain, arthralgias from aromatase inhibitors, and pain during chemotherapy. The exercise can be done with or without assistance from a physical therapist, aide, or trained family member. Range-of-motion exercises can be done for the patient by one of these caregivers. In cancer survivors, exercise can improve not only physical function and body composition, but also psychological well-being and quality of life.

Exercise during chemotherapy reduced CIPN for patients who had received platinum, vinca alkaloids, or taxanes, and was particularly effective in older patients.

Exercise also plays a favorable role in alleviating fatigue. Yoga and aerobic exercise (at least three times per week with 30 to 60 min per session) were recommended in one systematic review. The ACSM Guidelines for Cancer Survivors recommend that cancer patients and survivors slowly progress up to participating in 150 minutes of moderate intensity or 75 minutes of vigorous intensity aerobic exercise weekly plus strength training across all the major muscle groups 2 to 3 times weekly and regular stretching.

Anxiety after adjuvant treatment ends
I’m sure you would not be surprised to learn that anxiety peaks in breast cancer survivors after the end of adjuvant chemotherapy. In some studies, the post-treatment anxiety exceeded the anxiety before the patient started therapy. It would be helpful, therefore, to prepare your patients by anticipating that; let them know that it’s very normal to begin to feel more anxious as the adjuvant treatment is ending. Specifically, reassure them you’ll be monitoring them carefully, and are happy to discuss their concerns, prescribe anxiolytics, or refer them to mental health supports. Let them know that the anxiety is likely to decrease the longer they are past the treatment.

As an oncology clinician, while you may not feel qualified to help your patients with their spiritual, social, psychological, existential, and financial sources of distress during or following adjuvant therapy, you are likely to be able to identify the contributing strands from conversations you or your infusion nurses or front office staff have with patients and their families. Patients are much more likely to seek that specialized help if you validate the concerns and urge them to get the expert help they need.

If you don’t have access to social workers in your practice or psychologists, spiritual counselors, or practitioners of integrative services such as yoga and acupuncture in the community you serve, your patients can access the American Cancer Society website to get details about the location and cost of these services. We have made great strides made in extending the lives of women with breast cancer. By becoming familiar with the strategies I discussed above, you are likely to improve not just the quantity but also the quality of life of your breast cancer survivors.

Please visit Resources here on the website to see the many other topics we address for palliative and supportive care for patients with cancer including Pain & Symptom Management, Communication Techniques, Special Topics, and End of Life & Bereavement.

Additional Listening
For anyone interested in more thoughts I shared recently on how palliative care can play an important role in navigating breast cancer, including breast cancer pain, please listen to my conversation with host Laura Carding on the podcast, Breast Cancer Conversations.