Pain

It’s very common to worry about whether breast cancer and its treatment will cause pain. People diagnosed with any stage of breast cancer may experience pain caused by the cancer or its treatment. Still, not everyone experiences pain.

If pain does happen, the level, type, and nature of pain can vary. The pain you feel may be very different from what someone else feels, even when it comes from the same source.

Being in pain can make it harder to eat and sleep, take care of yourself, do daily activities, or be with others. Pain can affect your overall health and quality of life, so it’s important to let your care team know if you're having pain. There are many things you can do to prevent pain, or to manage pain if it develops. Getting relief is an important part of your breast cancer treatment and care.

What does pain related to breast cancer and treatment feel like?

Pain caused by breast cancer or breast cancer treatment may feel:

• Aching
• Sharp or stabbing
• Burning
• Itching
• Dull
• Pinching
• Throbbing
• Pressured
• Shooting

Describing pain with a pain scale

Because your experience of pain is unique to you, it can be hard to describe or measure it. Your doctors will use a pain scale, or range, to help you explain how much pain you feel. Using the pain scale helps your care team observe how pain changes or stays the same as you try different management strategies.

The pain scale may look like this:

• 0-1: no pain
• 2-3: mild pain
• 4-5: moderate pain/discomforting pain
• 6-7: severe pain/distressing pain
• 8-9: very severe pain/intense pain
• 10+: unbearable pain

There are also visual versions of the pain scale that include facial expressions (smiling, neutral, frowning, upset) that you can circle to describe how severe the pain is.

In addition to letting your care team know how severe pain is, it also helps to let them know how long pain lasts. This can be described as:

• Acute: Acute pain is happening right now.
• Intermittent: Intermittent pain comes on, goes away completely, and then comes back. This cycle can repeat.
• Chronic: Chronic pain is always there, though it may get worse or better at times.

What causes treatment-related pain?

Different breast cancer treatments can cause different types of pain.

Surgery can cause pain for several reasons:

• Surgery to remove breast cancer (mastectomy and lumpectomy) can damage tissues and nerves.
• Sometimes the scars from surgery may hurt.
• If you have breast reconstruction surgery, pain can be related to the type of reconstruction you have:
  • Implant reconstruction may involve stretching the skin over tissue expanders to make room for an implant, which can cause temporary pain. For some people, scar tissue may harden around an implant (capsular contracture), which can be painful.
  • Tissue reconstruction procedures, also called flap reconstructions, remove donor tissue from other areas of your body to create a new breast shape, which can temporarily cause pain. In rare cases, chronic pain can develop.
• Lymph node removal can lead to pain in the armpit, arm, or chest. Removing nodes or cutting lymphatic vessels increases the risk of lymphedema, which can cause pain and swelling.
• Some people feel phantom pain after a breast is removed. Phantom pain is pain that seems as though it's coming from the breast that is no longer there. This pain is real, and it comes from signals in the spinal cord and brain.

Pain can also be caused by other breast cancer treatments:

• Chemotherapy and some targeted therapies may cause pain due to mouth sores, hand-foot syndrome, or neuropathy.
• Radiation therapy can cause painful skin irritation, blistering, and scarring.
• Hormonal therapy, especially aromatase inhibitors, may cause bone, joint, and muscle pain. Tamoxifen also may cause these types of pain.
• Olaparib (Lynparza), a PARP inhibitor given to people with BRCA gene mutations, can cause joint, muscle, and back pain.
• Chemotherapy, CDK 4/6 inhibitors, tyrosine kinase inhibitors (TKIs), PARP inhibitors, and some hormonal therapies may cause headaches.
• Pembrolizumab, an immunotherapy, can cause back pain, muscle pain, mouth sores, ulcers in the nose or genitals, and abdominal pain.

How long will pain last?

Some pain begins soon after a treatment starts. Other pain develops much later. It may take only a few hours for pain to end, or it can take days. Other pain may come and go. Chronic pain continues steadily for several months or longer.

It's important to know that you do not have to suffer through any pain that you may be feeling. If you have pain, let your care team know. They can help identify the source of the pain and recommend ways to control and treat it.

How can I manage pain?

Good pain treatments exist. You may need to try several ways, or a combination of methods, to find what is best for you.

It’s a good idea to keep a pain journal where you can write down details about your pain to share with your care team. Whenever you have pain, write down:

• When you have pain
• Where you have pain, such as the back, the knees, or the fingers
• What the pain feels like
• How intense the pain is
• What makes the pain worse
• If the pain comes and then goes away completely, or if it’s always there
• How you would rate your pain on a scale of 0–10

Be as specific as possible, and let your team know how much the pain impacts your life.

If you're having difficulty with pain, your care team might refer you to a cancer pain specialist or palliative care specialist. These specialists work to prevent and manage pain and discomfort. Palliative care team members can be nurses, social workers, spiritual care professionals, pharmacists, or other medical providers. If you do not have access to palliative care specialists where you get care, your regular care team can help you.

There are medical and nonmedical ways to get relief from pain. If your doctor or nurse prescribes medicine to keep pain from starting or getting worse, do not wait to use it until your pain is intense. It’s easier to prevent pain than it is to manage it once it starts.

Medical methods to manage pain include:

• Over-the-counter medicines for mild-to-moderate pain, such as aspirin, ibuprofen (Advil, Motrin), and acetaminophen (Tylenol)
• Antidepressants and anticonvulsants for nerve pain
• Corticosteroids for inflammatory pain
• Medical marijuana for chronic pain
• Physical therapy for pain caused by damage to muscle or tissues

Complementary, or nonmedical, methods can also help relieve pain and may be used in addition to pain medicines. Cancer centers often offer complementary medicine programs, which can include:

• Acupuncture
• Yoga
• Gentle massage
• Mindfulness-Based Stress Reduction
• Hypnotherapy
• Guided imagery
• Relaxation exercises
• Tai Chi

Pain, especially chronic pain, can be frustrating. It can affect your mood, your outlook, and your relationships. For some people, it can help to seek emotional support along with other methods. Counselors, support groups, religious or spiritual communities, and trusted people can help.

Pain and metastatic breast cancer

If you have metastatic breast cancer (MBC), pain can be caused by treatments you receive or by metastases themselves.

Metastatic tumors may cause pain in bones, tissue, and elsewhere by pressing on nerves and organs, or constricting other areas. There are several types of treatments that can shrink tumors to reduce pain.

Treatment for MBC is ongoing, and managing pain caused by treatments is important. If a treatment causes significant pain that doesn’t ease with pain management methods, your doctor may recommend switching to a different treatment or changing the timing or dose of your current treatment. Studies show that changing the dose or timing of treatments does not interfere with how well it works against the cancer. Keep your care team informed of how much pain you feel and how often.

Treating pain specific to MBC

Since metastatic tumors can be found anywhere in the body, they can cause pain in more areas of the body than early-stage tumors, which are contained mostly in the breast and chest area.

Treatments that can ease pain caused by metastatic breast cancer include:

• Bisphosphonates and other medicines that treat pain and protect bones from complications of bone metastases
• Radiation therapy for bone metastases
• Interventional radiotherapy techniques, such as radio frequency ablation for bone metastases
• Surgery to treat metastasis-related fractures or spinal cord compression
• Anesthetic procedures, such as nerve blocks, to ease pain by removing or reducing feeling

MBC treatments that may cause pain

Some MBC treatments can cause different kinds of pain. These include:

• Chemotherapy, which can cause painful mouth sores
• Fulvestrant (Faslodex), a hormonal therapy injection, which can cause muscle and joint pain, as well as pain at the site of injection
• Elacestrant (Orserdu), a hormonal therapy pill, can cause muscle pain, joint pain, and stomach pain
• Targeted therapies:
  • mTOR and CDK 4/6 inhibitors, given for hormone receptor-positive disease, which may cause abdominal and back pain
  • TKIs and monoclonal antibodies, given for HER2-positive disease, which may cause stomach pain or bone and joint pain
  • Margetuximab (Margenza), given for HER2-positive disease, which can cause neuropathy, a side effect that can include pain in the hands or feet
  • Olaparib (Lynparza), a PARP inhibitor given to people with BRCA gene mutations, which can cause joint, muscle, and back pain
  • Sacituzumab govitecan (Trodelvy), an antibody-drug conjugate given for triple-negative MBC, which can cause stomach pain

If treatment-related pain is difficult to manage even after following your care team's pain management recommendations, talk with your doctor about options, such as adjusting the dose or trying a new treatment.

It’s also possible to take opioid or narcotic medicines for ongoing and breakthrough pain. These include medicines such as the fentanyl patch, morphine (MS Contin), and oxycodone. Taken as prescribed for cancer pain, you are unlikely to become addicted to these medicines.

And no matter what might be causing pain — whether it's a treatment, the cancer, or you're just not sure — always let your doctor know. The goal of MBC treatment is to keep the cancer under control for as long as possible while supporting your quality of life, and that includes relief from pain if you're experiencing it.