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Commentary

Clinical practice guidelines for the care and treatment of breast cancer: the management of chronic pain in patients with breast cancer (summary of the 2001 update)

Chris Emery, Romayne Gallagher, Maria Hugi, Mark Levine and The Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer
CMAJ October 30, 2001 165 (9) 1218-1219;
Chris Emery
Ms. Emery is with the Fraser Valley Cancer Centre, Delta, BC; Dr. Gallagher is with the Division of Palliative Care, University of British Columbia, Vancouver, BC; Dr. Hugi is with Providence Health Care, Vancouver, BC; and Dr. Levine is with the Cancer Care Ontario Hamilton Regional Cancer Centre and the Departments of Medicine and of Clinical Epidemiology and Biostatistics, McMaster University, and is the Buffet Taylor Chair in Breast Cancer Research, McMaster University, Hamilton, Ont. The Steering Committee is part of Health Canada's Canadian Breast Cancer Initiative.
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Romayne Gallagher
Ms. Emery is with the Fraser Valley Cancer Centre, Delta, BC; Dr. Gallagher is with the Division of Palliative Care, University of British Columbia, Vancouver, BC; Dr. Hugi is with Providence Health Care, Vancouver, BC; and Dr. Levine is with the Cancer Care Ontario Hamilton Regional Cancer Centre and the Departments of Medicine and of Clinical Epidemiology and Biostatistics, McMaster University, and is the Buffet Taylor Chair in Breast Cancer Research, McMaster University, Hamilton, Ont. The Steering Committee is part of Health Canada's Canadian Breast Cancer Initiative.
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Maria Hugi
Ms. Emery is with the Fraser Valley Cancer Centre, Delta, BC; Dr. Gallagher is with the Division of Palliative Care, University of British Columbia, Vancouver, BC; Dr. Hugi is with Providence Health Care, Vancouver, BC; and Dr. Levine is with the Cancer Care Ontario Hamilton Regional Cancer Centre and the Departments of Medicine and of Clinical Epidemiology and Biostatistics, McMaster University, and is the Buffet Taylor Chair in Breast Cancer Research, McMaster University, Hamilton, Ont. The Steering Committee is part of Health Canada's Canadian Breast Cancer Initiative.
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Mark Levine
Ms. Emery is with the Fraser Valley Cancer Centre, Delta, BC; Dr. Gallagher is with the Division of Palliative Care, University of British Columbia, Vancouver, BC; Dr. Hugi is with Providence Health Care, Vancouver, BC; and Dr. Levine is with the Cancer Care Ontario Hamilton Regional Cancer Centre and the Departments of Medicine and of Clinical Epidemiology and Biostatistics, McMaster University, and is the Buffet Taylor Chair in Breast Cancer Research, McMaster University, Hamilton, Ont. The Steering Committee is part of Health Canada's Canadian Breast Cancer Initiative.
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Ms. Emery is with the Fraser Valley Cancer Centre, Delta, BC; Dr. Gallagher is with the Division of Palliative Care, University of British Columbia, Vancouver, BC; Dr. Hugi is with Providence Health Care, Vancouver, BC; and Dr. Levine is with the Cancer Care Ontario Hamilton Regional Cancer Centre and the Departments of Medicine and of Clinical Epidemiology and Biostatistics, McMaster University, and is the Buffet Taylor Chair in Breast Cancer Research, McMaster University, Hamilton, Ont. The Steering Committee is part of Health Canada's Canadian Breast Cancer Initiative.
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This article provides a summary of changes made by Health Canada's Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer to the article “Clinical practice guidelines for the care and treatment of breast cancer: 10. The management of chronic pain in patients with breast cancer,” originally published in 19981 (the 2001 update can be found online at www.cma.ca/cmaj/vol-165/issue-9/breastcpg/guideline10rev.htm). Although the updated guideline does not contain many changes, it highlights the importance of optimal pain management in these patients (Table 1).

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Table 1.

Pain is a common problem in women with metastatic breast cancer. The principles of pain management, such as thorough assessment, judicious investigation, comprehensive management and frequent reassessment, remain the same. There is an emphasis on determining the type of pain — somatic, visceral or neuropathic — as a means of determining the best treatment. The principle of the patient as the primary source of information about her pain, its severity and response to medication is emphasized.

Once again, a stepwise approach to the use of analgesics is recommended. Mild to moderate pain can be managed with the use of acetaminophen or an NSAID. Since the publication of the 1998 guideline, selective cyclo-oxygenase-2 (COX-2) inhibitor NSAIDs have become available. They have been evaluated in patients with osteoarthritis and rheumatoid arthritis.2,3 Compared with older NSAIDs, COX-2 inhibitors reduced the risk of gastrointestinal bleeding; however, no difference was detected in efficacy against arthritis. Currently, there are no data from randomized controlled trials of the use of selective COX-2 inhibitors in cancer patients. Based on available data from the arthritis trials, the guideline recommends that these medications be considered if dyspepsia develops. When pain is not adequately controlled with acetaminophen or an NSAID, a weak opioid such as codeine or oxycodone should be added. When pain is severe or unresponsive to the previous approach, one should immediately switch to potent opioids with or without NSAIDs. The 1998 guideline recommended that, when switching from long-term oral use of an opioid to parenteral use, a ratio of 3:1 should be used. The determination of equivalent analgesic doses of oral versus subcutaneous administration of the same narcotic or of 2 different agents is derived from single-dose studies, which may not be generalizable to long-term use.4 The updated recommendation for switching doses using a ratio of 2:1 instead of 3:1 is based on consensus and clinical experience. Finally, there are additional data supporting the use of bisphosphonates in patients with metastatic cancer to bone.5

Footnotes

  • The patient version of these guidelines has also been updated and can be found online at www.cma.ca/cmaj/vol-165/issue-9/breastcpg/guideline10revpt.htm.

    Competing interests: None declared for Drs. Hugi and Levine. Ms. Emery has received a speaker fee from Janssen-Ortho, and Dr. Gallagher has received speaker fees from Purdue Pharma and Janssen-Ortho.

References

  1. 1.↵
    Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. Clinical practice guidelines for the care and treatment of breast cancer. CMAJ 1998;158(Suppl 3):S71-81.
  2. 2.↵
    Bombardier C, Laine L, Reicin A, Shapiro D, Burgos-Vargas R, Davis B, et al. Comparison of upper gastrointestinal toxicity of rofecoxib and naproxen in patients with rheumatoid arthritis. N Engl J Med 2000;343:1520-8.
  3. 3.↵
    Fitzgerald GA, Patrono C. The coxibs, selective inhibitors of cyclooxygenase-2. N Engl J Med 2001;345:433-42.
    OpenUrlCrossRefPubMed
  4. 4.↵
    Anderson R, Saiers JH, Abram S, Schlicht C. Accuracy in equianalgesic dosing: conversion dilemmas. J Pain Symptom Manage 2001;21:397-406.
    OpenUrlCrossRefPubMed
  5. 5.↵
    Hortobagyi GN, Theriault RL, Lipton A, Porter L, Blayney D, Sinoff C, et al. Long-term prevention of skeletal complications of metastatic breast cancer with pamidronate. J Clin Oncol 1998;16:2038-44.
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Clinical practice guidelines for the care and treatment of breast cancer: the management of chronic pain in patients with breast cancer (summary of the 2001 update)
Chris Emery, Romayne Gallagher, Maria Hugi, Mark Levine, The Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer
CMAJ Oct 2001, 165 (9) 1218-1219;

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Clinical practice guidelines for the care and treatment of breast cancer: the management of chronic pain in patients with breast cancer (summary of the 2001 update)
Chris Emery, Romayne Gallagher, Maria Hugi, Mark Levine, The Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer
CMAJ Oct 2001, 165 (9) 1218-1219;
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