Clinical practice guidelines: breast cancer pain
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* Marcel Dvorak
* Charles G. Fisher

It is disturbing to read the 2001 update of the clinical practice guideline on the management of chronic pain in patients with breast cancer as summarized in *CMAJ* by Chris Emery and colleagues.1 In the full text of these guidelines the authors state that bone pain from vertebral metastases is very common; however, there is absolutely no mention of surgical stabilization techniques despite the fact that they are an effective evidence-based option for treating mechanical axial skeletal pain due to bone metastases.

Among their descriptions of treatment options the authors are careful to include descriptions of complementary techniques with little or no evidence for their effectiveness, including neurosurgical ablative procedures such as rhizotomy and cordotomy, and psychotherapy. They fail to mention the excellent outcomes seen with surgical stabilization of pathological vertebral fractures and impending fractures. They even state that “except for spinal cord compression, neurosurgical interventions are rarely required in the management of cancer pain.” There is now a large body of literature that supports the surgical decompression and stabilization of spinal metastases as effective palliation of mechanical pain (not only for metastatic epidural spinal cord compression) with acceptable levels of morbidity.2,3,4,5 In fact, surgery followed by radiation appears to be more effective than radiation alone in improving local pain control and survival and reducing postoperative morbidity.2,3,4,5,6

No longer is it acceptable practice to deny surgical stabilization to appropriate patients with vertebral metastases. At the Combined Neurosurgical and Orthopaedic Spine Program at Vancouver General Hospital we have reported favourable outcomes in these surgically treated patients; we continue to follow their outcomes prospectively and are perfoming an economic evaluation of surgical treatment in these patients. It is a pity that the guidelines published by Emery and colleagues continue to perpetuate the lack of appropriate referral and access to effective spinal surgical care for this often inadequately palliated patient population.

**Marcel Dvorak** **Charles G. Fisher** Combined Neurosurgical and Orthopaedic Spine Program Vancouver General Hospital Vancouver, BC

## References

1.  1. Emery C, Gallagher R, Hugi M, Levine M, for the 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: the management of chronic pain in patients with breast cancer (summary of the 2001 update) [editorial]. CMAJ 2001; 165 (9): 1218-9.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMDoiMTY1LzkvMTIxOCI7czo0OiJhdG9tIjtzOjIxOiIvY21hai8xNjcvMS8xNC4yLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

2.  2. Galasko CSB, Norris HE, Crank S. Current concepts review. Spinal instability secondary to metastatic cancer.J Bone Joint Surg Am 2000; 82: 570.
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=10761947&link_type=MED&atom=%2Fcmaj%2F167%2F1%2F14.2.atom) 

3.  3. Jonsson B, Sjostrom L, Olerud C, Andreasson I, Bring J, Rauschning W. Outcome after limited posterior surgery for thoracic and lumbar spine metastases.Eur Spine J 1996;5:36-44.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1007/BF00307825&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=8689415&link_type=MED&atom=%2Fcmaj%2F167%2F1%2F14.2.atom) 

4.  4. Weigel B, Maghsudi M, Neumann C, et al. Surgical management of symptomatic spinal metastases. Postoperative outcome and quality of life. Spine 1999;24(21):2240-6.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1097/00007632-199911010-00012&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=10562991&link_type=MED&atom=%2Fcmaj%2F167%2F1%2F14.2.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000083457600012&link_type=ISI) 

5.  5. Wise JJ, Fischgrund JS, Herkowitz HJ, Montgomery D, Kurz LT. Complications and survival rates, and risk factors of surgery of metastatic disease of the spine. Spine 1999;24:1943-51.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1097/00007632-199909150-00014&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=10515021&link_type=MED&atom=%2Fcmaj%2F167%2F1%2F14.2.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000082691800016&link_type=ISI) 

6.  6. Ghogawala A, Mansfield FL, Borges LF. Spinal radiation before surgical decompression adversely affects outcomes of surgery for symptomatic metastasis spinal cord compression. Spine 2001; 26(7):818-24.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1097/00007632-200104010-00025&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=11295906&link_type=MED&atom=%2Fcmaj%2F167%2F1%2F14.2.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000167809300020&link_type=ISI)