Breast Cancer Palliative Care

Symptom Management

The most important component of palliative management is symptom management.

• Pain

  • Nonpharmacologic

    • The idea of mind and body healing has been around for decades. How these enter symptom management varies, typically by patient.

    • Rehabilitative physical modalities include ultrasound, therapeutic exercise, occupational therapy, hydrotherapy, therapy for specific disorders such as lymphedema, and heat and cold therapies.

    • Psychological therapies include psychoeducation interventions, cognitive behavioral therapy, relaxation therapy, guided imagery, other types of stress management, hypnotherapy, and other forms of psychotherapy.

    • Neurostimulation includes implanted neurostimulators, both transcutaneous and transcranial.

    • Additional complementary therapies include acupuncture, massage, physical/movement (e.g., yoga), music therapy, art therapy, and other ideas such as mind occupational therapy (cognitive exercises such as coloring books or games such as sudoku).

• Pharmacologic

  • Nonopioid

    • Treatment of cancer-related pain typically incorporates a pyramid strategy. Pain control with nonopioid measures is encouraged prior to consideration of opioids.

    • Nonopioid medications include acetaminophen, nonsteroidal anti-inflammatory drugs, topical agents, antidepressants, anticonvulsants, oral local anesthetics, steroids, cannabinoids, alpha-2 agonists, and ketamine.

    • Interventional therapies include nerve blocks, spinal analgesics, and surgical neuroablation.

    • Opioid

    • Opioids remain an integral part of the management of pain in terminally ill cancer patients. The difficulties with opioids are the serious nature of the addiction issues surrounding these medications, and as a result, these medications are heavily regulated.

    • We continue to encourage the use of opioids in situations where nonopioid measures fail to gain adequate pain control.

• Nausea/vomiting

  • Although nausea and vomiting continue to be important to control clinically, many patients receive adequate coverage with standard premedication for their chemotherapy.

  • Antiemetic medications are classified based on drug type ( Table 14.6 ).

    Table 14.6

    Classification of Antiemetic Medications

    Prokinetic agents	Metoclopramide
    Antihistamines	Diphenhydramine
    	Hydroxyzine
    	Promethazine
    Dopamine agonists	Haloperidol
    	Chlorpromazine
    	Prochlorperazine
    	Olanzapine
    Serotonin 5HT3 receptor antagonists	Ondansetron
    	Granisetron
    Neurokinin receptor antagonists	Aprepitant
    Benzodiazepine	Diazepam
    	Lorazepam
    Corticosteroids	Dexamethasone
    	Prednisone
    Cannabinoids	Dronabinol
    Other anticholinergics	Scopolamine
    	Hydrobromide

  • Each class of drug type functions better depending on the nausea that is induced. Prokinetic agents are primarily used for gastric stasis and gastrointestinal dysmotility from various causes. Antihistamines are useful for vestibular and gut receptor nausea and vomiting. They are relatively contraindicated for constipation because they may further slow the bowel. Dopaminergic agents are best used for medication- and metabolic-related nausea. Serotonin 5-HTZ receptor antagonists are used for postoperative and radiation- and chemotherapy-induced nausea. Neurokinin receptor antagonists are particularly helpful for delayed chemotherapy-induced nausea and vomiting. Benzodiazepines are useful for anticipatory or anxiety-provoked nausea. Corticosteroids are useful for hepatic capsular distension, anorexia, and increased intracranial pressure. Cannabinoids help with chemotherapy-induced nausea and vomiting. Other anticholinergics are used for motion- or movement-related nausea and vomiting.

  • Gabapentinoids (gabapentin and pregabalin) have been used successfully for neuropathic pain. A summary of the benefits of gabapentinoids was published in 2015. It showed improvement (50% reduction in pain intensity) for gabapentin when treating postherpetic neuralgia. The number needed to treat to harm a single patient was 25.6, demonstrating a wide therapeutic index, and gabapentin has been successfully used for cancer-related pain. It does appear that if pain does not respond to one gabapentinoid, it can respond to the alternative gabapentinoid.

  • Analgesic antidepressants have also been widely studied for varied types of chronic pain. Duloxetine is often used in conjunction with gabapentinoids and appears to be a more powerful pain medication as an alternative to opioids in cancer-related pain. It is common for duloxetine or a similar antidepressant to be used in combination with gabapentinoids for adequate cancer-related pain control.

• Opioids

  • The use of opioid analgesics is important to sustain control of cancer-related pain. The goal of therapy is to improve quality of life while limiting opioid-related side effects. Guidelines exist to provide a rationale for drug selection, route of administration, dosing, and side effect management.

  • A position paper from the EFIC (European Pain Federation) Task Force illustrated opioid use for the management of pain ( Table 14.7 )

    Table 14.7

    Different Opioids for Effective Pain Management

    Opioids for moderate intensity pain	Codeine
    	Dihydrocodeine
    	Tramadol
    Opioids for moderate-to-severe intensity pain
    Immediate release opioids as oral or injectable	Morphine
    	Oxycodone
    	Hydromorphone
    Sustained release opioids as oral	Morphine
    	Oxycodone
    	Hydromorphone
    	Tapnetadol
    Transdermal formulations	Fentanyl
    	Buprenorphine
    Opioids for specialist use only	Rapid onset transmucosal fentanyl-based formulations
    	Methadone

  • The World Health Organization (WHO) has published a Cancer Pain Ladder, with its steps summarized here:

    • Step I: When pain is mild, it may be sufficient to start with acetaminophen, a nonsteroidal anti-inflammatory drug, or an adjuvant analgesic targeting a specific type of pain (e.g., neuropathic).

    • Step 2: When pain persists, increases, or presents as a mild-to-moderate pain, an opioid regimen should be considered. The choice of opioid pain medications is based on the severity of pain, as illustrated earlier by the EFIC Task Force.

    • Step 3: When pain persists, increases, or initially presents as moderate to severe, single-entity, pure mu-agonist opioids are administered (e.g., morphine, oxycodone, oxymorphone, hydromorphone, methadone, or fentanyl). Adjuvant analgesics may be considered as well.

    • Step 4: For chronic and unrelieved severe pain or intolerable opioid-related side effects, consider treatment with interventional techniques.

The WHO analgesic ladder approach selects different opioids based on moderate (e.g., codeine) or severe (e.g., morphine) pain intensity. Any of the single-entity, pure mu-agonist drugs can be prescribed at doses low enough to manage safely moderate pain, which eliminates the second step of the ladder.

Additionally, in some circumstances, switching opioids or opioid route of administration or opioid formulation to a different opioid regimen becomes necessary. There are any of several reasons to switch regimens, including poorly controlled pain, the development of an adverse effect, change in patient condition, formulary issues, drug shortages, or patient health beliefs. It is recommended that the drugs be switched using an opioid conversion calculator.

• Fatigue

  • Many cancer patients report a decline in energy levels. Although it remains important to maximize a patient’s energy, there are many variables. The most important things to patients are adequate sleep, dietary intake, and exercise.

  • The management of fatigue is often cause specific when conditions known to cause fatigue can be managed. Nonpharmacologic measures include cognitive behavioral therapy, exercise therapy, nutrition, sleep therapy, and other psychosocial interventions. Pharmacologic therapy can include psychostimulants (e.g., Ritalin), antidepressants (e.g., duloxetine), steroids, and hematopoietic stimulants. Erythrocyte-stimulating agents are indicated only in the palliative care setting when dealing with a malignancy.

• Depression and anxiety

  • Up to 70% of oncology patients report depression symptoms. These symptoms are complicated in the setting of psychosocial issues often related to a patient’s malignancy.