Team Tough Titties Knockin Out Cancer's blog: "Breast Cancer"

For women affected by breast cancer, overcoming pain can be a major part of dealing with the disease and its treatment. Pain is a common side effect of treatment and also a side effect of cancer.

But you don't have to suffer. With proper treatment, most people can get relief from most, if not all, of their pain.

Pain medications have become increasingly sophisticated and effective. There are more ways for you to take them, new knowledge of how to use them, and fewer side effects. Today, we also understand more about how complementary therapies, which don't use medication, may help reduce or end pain.

Try not to be discouraged. It's normal for anyone plagued by pain to feel frustrated, exhausted, and depressed. This section of breastcancer.org helps you combat those feelings with suggestions for identifying and treating your pain and strategies for building a pain-free recovery.

Pain from surgery may not be as scary as other kinds of pain. But it hurts, and it can make you worry.

After having mastectomy, lumpectomy, or lymph node surgery, you might feel breast pain or armpit discomfort because:

The skin gets numb and sometimes extra-sensitive when nerves are cut.
There's pain and tenderness under the surface because your surgeon had to do a lot of pulling, pushing, and cutting there.
Fullness and swelling are part of your body's reaction to the trauma of surgery.
Pain from specific surgical procedures
Lumpectomy: Once the area of the lumpectomy "wakes up" after the shock of surgery and radiation, it can recover some of its senses, which can cause mild discomfort in the breast. The pain improves slowly and can linger for a long time.
Lymph node removal: Many women report discomfort and fullness in their armpit after axillary dissection (underarm lymph node removal). This pain may be made worse by radiation. Lymph nodes and ducts help drain fluid from tissues in the body. So if your lymph nodes were removed, fluid may back up in your arm and cause swelling. The extra fluid buildup puts extra pressure on the normal tissues, which can be uncomfortable. This swelling is called lymphedema and may not completely go away for months. In some cases it can even be permanent. Special physical therapy and light massage plus compression stockings can help reduce the swelling.
In addition, nerves in the armpit can become painful after they have been moved out of the way to remove your lymph nodes. This nerve damage pain can be shooting, cold, hot, tingly, pins and needles, or feel like a sunburn in your armpit going into your chest and shoulder and down the inner part of your arm. This pain can last from weeks to months and even years. But you can reduce it by taking special nerve pain medicines such as antiseizure medicines and antidepressant medicines.
Mastectomy: Right after mastectomy, some women have numbness, pain, and weakness in the affected hand, arm, and shoulder.
Most of these symptoms are related to the stretching or cutting of sensory nerves (the nerves responsible for feeling things). When these nerves are damaged because of surgery, you may feel several kinds of discomforts: itching, burning, a "crawling" feeling, aches, and shooting sharp pains.

Also, any time you have discomfort in an area, you tend to not use it because it hurts. That lack of use can make the problem worse. Your arm and shoulder area may also try to protect the painful area from any bumps or further upset. Over time, the arm and shoulder can get tired, stiff, and sore from all that "guarding." This can lead to different conditions, including frozen shoulder, tendinitis, or arthritis.

Physical therapy can help get your muscles working again. This should be followed by regular exercise. You may need medicine to control the pain in muscles, tendons, and nerves so you can do all the exercises you need to get movement back and eventually reduce the pain.

Radiation pain
Radiation causes different degrees of pain for different people. Some may feel just an occasional twinge. Others might have significant pain. Most people have mild to moderate discomfort that builds up slowly over the course of radiation.

Radiation treatment produces pain due to:

nerve irritation
swelling around scar tissue and treated areas
skin soreness
rubbing of one part of your body against another (such as the arm against the outside of the breast)
infection (sometimes)
Pain from radiation treatment usually goes away with time. It often improves a lot in the first year after treatment, and then continues to improve more slowly for another year or two.
Knowing the difference between cancer and non-cancer pain helps you understand what to do about the pain and how to cope with it.

If you've just started treatment, you may have trouble distinguishing between pain arising from the cancer itself and pain from other causes. You and your doctor may be better able to figure out the source of your pain as you have more treatment.

Once you've had cancer, any pain may alarm you. Be reassured that new aches and pains are usually not from cancer. Still, if your pain changes or worsens, you should be evaluated.

Here are important points that can help you tell the difference between cancer and non-cancer pain.

Cancer pain
Breast cancer pain may come from these sources:

Breast tumor: Sometimes the mass in your breast may hurt. You may feel moderate to severe pain in your breast if you have inflammatory breast cancer, because there will be cancer in the skin above the breast tumor. Or you may feel pain if the tumor has made an ulcer (sore) through the skin over your breast.
Metastases: The spread of cancer into other parts of the body—called metastatic disease—may produce pain in the affected areas. For example, if the cancer spreads to the bone, it can cause pain in the back, hips, or other bones. Cancer that has spread to the brain may cause headaches. Severe back pain with leg weakness may be from cancer that has metastasized to your spinal cord. If the cancer spreads to the adrenal glands, you may feel a dull back pain. If it spreads to the liver, you could have pain in the upper right part of the abdomen.
Treatment: Sometimes the treatment you get makes the cancer hurt more. For example, the start of hormone therapy or radiation for bone metastases may cause a flare of bone pain. This happens because the cancer swells in response to treatment and puts more pressure on the bone's nerve supply.
Breast pain: Although breast pain is usually non-cancerous, new and persistent discomfort in only one breast may be of concern. This is especially true if the pain is getting worse without any clear explanation. See your doctor and ask for a referral to a breast cancer surgeon. A breast exam, radiology studies, and possibly a biopsy may be recommended.
Non-cancer pain
Pain can also come from these non-cancer sources:

Surgery
Radiation
Chemotherapy
Recovery phase
Non-cancerous breast changes


Bring your pain diary or report to your doctor. Depending upon what stage of treatment you're in, this might be your surgeon or oncologist.

If that person does not listen, or you are unsatisfied with the response, then look further. Your primary care doctor may be able to help.

If you feel your doctor is not taking your pain seriously enough or simply can't find a solution, find a doctor who will. You may also want to ask your doctor to refer you to a pain management center at a hospital near you.

Talk about your pain with adult family members and others who care about you. Don't stay silent because you want to protect them. They'll be more concerned if you don't tell them what you're feeling.


Doctor-patient communication
Reporting or describing pain is not complaining! Don't hesitate to talk about your pain because you're afraid of bothering the doctor or seeming like a whiner.

Sometimes you might forget to discuss your pain with the doctor because you're more focused on talking about treatment or recovery. That's especially true if you're not hurting while in the doctor's office. Come to your medical appointments with a list of topics to discuss, and include pain on that list.

You and your doctor must fully understand each other. Be clear about what you say and what you hear. Sometimes, you both may use words that mean different things to the other person.

Indicate which side effects you are willing to tolerate and which ones you find unacceptable. For instance, all morphine and codeine-like products (narcotics, or opioids—pronounced OH-pee-oydz) cause lethargy (sleepiness and low energy). One patient may say, "I'll accept a little sleepiness if I can get complete pain relief." Someone else may insist on a clear mind above all, with pain relief being less important. In the first few days of taking a new opioid or increasing the dose of an opioid, you may feel sleepy. Most people adjust to this feeling and feel fine in two or three days.

Continuous communication is essential to sustained pain relief. It will take some trial and error to find the right pain medications and get them working well for you. The nature of your pain might change, and this may require a change in your treatment. Tell your doctor and nurse if:

the pain medication isn't working
you have side effects such as nausea, constipation, or excessive sweating
you develop trouble breathing, a rash, or itching. These may be signs that you are allergic to a medication, and you may need to stop taking it immediately
Remember:
Nearly all pain is treatable.
It's not heroic to suffer. If you hurt, speak up!
Keep a pain diary.
Communicate with your doctor AND nurse.
If your pain is not being treated successfully, ask for a referral to a pain management specialist.
If you're on around-the-clock opioids you'll probably need to take regular doses of laxative to prevent constipation.
If you take your medications as directed, your pain can be controlled with opioids without any significant risk of addiction or tolerance. You will not become immune to the benefit of opioids. If you have more pain, your dose can be increased without any preset upper limits.
The team approach
Many hospitals now have special pain management centers. Here, teams of doctors and other specialists identify and assess pain, and then design individualized treatment plans. Most centers help the patient gain an improved sense of control over pain.

Pain management centers generally bring together a group of experts from different fields to provide a comprehensive pain relief plan. The specialists include pain specialists, internal and physical medicine specialists, physical therapists, psychiatrists, chiropractors, and acupuncturists.

Hospital-based pain centers often also have access to advanced diagnostic equipment, new techniques, and information gained from on-site research studies.

A hospital near your home may have recently begun such a program. If your pain continues to be unrelieved, ask your doctor for a referral to a pain management center.


A wide range of medications may be prescribed for your pain. These include:

aspirin
acetaminophen (brand name: Tylenol)
NSAIDs (pronounced EN-seds) or nonsteroidal anti-inflammatory drugs, such as ibuprofen (brand names: Advil, Motrin)
opioids (pronounced OH-pee-oydz), such as hydrocodone, oxycodone, morphine, hydromorphone, and fentanyl
coanalgesics (pronounced koh-an-ul-JEE-ziks), drugs that may make NSAIDs and opioids work more effectively
Pain medications work only if you take them, if you take the right ones, and if you take enough of them.

Most medications are available in several forms. Depending upon your medical condition and needs, your dose may come in a pill, liquid, suppository, injection, skin patch, or lozenge.

Before your doctor prescribes or changes your pain medication, be sure to mention any allergies you have. Also be sure to discuss any problems you've had with any drug—not just the ones you've taken for pain.

Here are important facts about getting the right amount of relief for your pain:

Medications need to be individually titrated (adjusted) to every person to make sure they're helping as much as possible.
Follow the dosing regimen carefully. It helps to write down each dose and the time you take it, especially if you're taking several medications.
Never change the amount of medication you take or how often you take it without first checking with your doctor.
Never stop taking opioid medications abruptly.
You may have to change your dosing in consultation with your doctor, depending upon your symptoms, the medication, and how much you're taking.
Be sure you have a doctor's prescription before trying any of the medications discussed in this section.

Certain treatments, often called complementary therapies, don't use medications. Yet they have been shown to be powerful aids in reducing pain, curbing drug side effects, boosting energy level and mood, and promoting an overall improvement in quality of life.

Such treatments are being incorporated more and more into mainstream medical care. You can learn to use some of these methods yourself (for example, visualization or yoga). For others, like acupuncture or hypnosis, you need a therapist skilled in the technique.

Don't be embarrassed to mention your interest in these therapies to your doctor. She or he may even be able to refer you to a practitioner.

Integrated care
In integrated care, complementary and conventional therapists work together. This provides the best of both worlds for many people.

At a pain clinic affiliated with the U.S. National Institutes of Health, between 50% and 80% of pain treatment methods do not use medication. The facility offers acupuncture, music therapy, massage, relaxation, hypnosis, and Reiki therapy (a form of natural healing), as well as programs using pet therapy and art therapy. Professionals in these methods work with nurses, doctors, and medical therapists.

Be sure to tell your doctor if you are interested in, or are using, any complementary treatments.

If you're taking herbal supplements and are on chemotherapy, bring a list of those supplements to the chemotherapy doctor to make sure that what you are taking is helpful and not harmful.

Here are some of the complementary healing techniques you may want to try:

Acupuncture
Acupressure (includes shiatsu and reflexology—foot acupressure)
Visualization
Meditation
Music
Hypnosis
Biofeedback
Massage
Yoga
Exercise
Spiritual healing (includes Reiki—spiritual healing by applying "life energy")
Homeopathy
Naturopathy
Applied kinesiology—muscle testing and balancing
Ayurveda—a system developed in India that uses pulse diagnosis and dietary approaches

Pain is emotional as well as physical. Even with medication, pain can wear you down and make you feel emotionally exhausted. You may feel anxious, depressed, and overwhelmed.

You may be afraid to tell anyone about your pain. You may worry that you'll be labeled a complainer or that treating your pain will interfere with your chemotherapy or radiation schedule. You may believe that treatment has to hurt to be effective (not true).

Whenever something new hurts, you may think the cancer has come back. Knowing that most pain has nothing to do with cancer may not reassure you. That fear is understandable, but don't let it control you. Take charge by talking with your doctor about any worrisome pain.

Besides relieving your pain through treatment, you can ease your depression by staying in charge of the manageable responsibilities and activities in your life that you care about. Other ways to cope when you're feeling down include:

finding comfort in family and friends
calling support lines sponsored by breast cancer organizations or joining the online discussion boards and chat rooms like the ones at Breastcancer.org
participating in a support group
seeking individual counseling
staying connected with your place of worship
Talk with your doctor about a full range of effective antidepressant medications. These may help your mood and are also good for improving sleep and relieving some types of pain.

One of the great frustrations about pain is that it's subjective. One person feels it differently than another does. Sometimes, you may feel that your healthcare providers aren't taking your pain seriously. You need to help them understand what you're experiencing, to encourage more supportive care and ease the emotional burden of your pain.


The medical experts for Pain are:

Jeffrey Gudin, M.D., pain medicine specialist, anesthesiologist, and Director of Pain Management, Englewood Hospital and Medical Center, Englewood, NJ
Michael H. Levy, M.D., Ph.D., Vice Chair, Department of Medical Oncology, Director, Pain Management Center, Fox Chase Cancer Center, Philadelphia, PA
Marisa C. Weiss, M.D., breast radiation oncologist, Lankenau Hospital, Thomas Jefferson University Health System, Philadelphia, PA