Advanced Breast Cancer

Managing side effects

Treatment for your advanced breast cancer targets cancer cells. However, sometimes it also affects healthy cells, which can cause side effects. There are many ways to manage these side effects.

Hormone therapy

Hormone therapy may cause fatigue, muscle and joint pains, vaginal dryness or discharge, hot flashes and mood swings. Your doctor will work with you to manage these effects. Blood clots are a less common but more serious side effect of tamoxifen. If a blood clot develops, it is usually in a leg, but sometimes a clot breaks off and travels to the lungs. A clot in the lungs is called a pulmonary embolism and can be life-threatening. If pain, redness or swelling develops in your calf or you have shortness of breath or chest pain, call your doctor right away. These could be symptoms of a clot.

Steroid therapy

The initial treatment for brain metastasis is usually a corticosteroid, which helps decrease swelling around the brain. Treatment with a corticosteroid may continue for several weeks. Some common side effects of corticosteroid use include weight gain, acid indigestion, muscle weakness, difficulty sleeping, mood swings, elevated blood sugar, acne and swelling of the face.

Chemotherapy

Chemotherapy targets cells that divide quickly because cancer cells divide quickly. Unfortunately, chemotherapy also affects normal cells that divide quickly, such as hair and nail cells. Because of this, side effects of chemotherapy can include hair loss, nail changes, mouth sores, low blood cell counts and risk of infection. Chemotherapy may also cause nausea, vomiting and changes in appetite. Your doctor may prescribe anti-nausea drugs to help you navigate chemotherapy. Cooling caps may reduce hair loss due to chemotherapy. A cooling cap is a computer-controlled system that circulates cooled liquid to a cap worn on the head during chemotherapy. The cooling cap is covered by a second cap made of neoprene, which holds the cooling cap in place and provides insulation.

Targeted therapy

This class of drugs has its own unique side effects depending on the therapy (see Table 1). Most side effects of HER2-targeted therapy such as pertuzumab (Perjeta) and trastuzumab (Herceptin) are mild, such as diarrhea. However, some drugs carry a risk of congestive heart failure, which usually goes away after the drug is no longer taken. Palbociclib (Ibrance) can cause low white counts and fatigue, while everolimus (Afinitor) can cause mouth sores, fatigue and lung inflammation. Talk with your doctor before making any treatment decisions.

Table 1. Targeted therapy drugs

Drug name How administered Common side effects
everolimus (Afinitor) Oral Mouth sores, fatigue, lung inflammation
palbociclib (Ibrance) Oral Low white count, fatigue
pertuzumab (Perjeta) IV Diarrhea, hair loss, low white count
trastuzumab (Herceptin) IV Diarrhea, nausea, fever

Radiation therapy

Radiation therapy can help relieve pain from metastasis to the bone. With radiation therapy, high-energy rays or particles are targeted to the area of the metastasis. Pain relief is usually immediate but may not be complete. Side effects that may occur with radiation therapy include fatigue, loss of appetite, skin changes and low blood cell counts. In cases of increased fracture risk, surgery may be required, and radiation is typically done after surgery.

Whole-brain radiation therapy can improve or stabilize symptoms of brain metastasis, such as headaches, pain and seizures. It is most often used when there are several sites of metastasis in the brain. Among the potential side effects are memory loss, extreme fatigue, temporary baldness, skin rash and hearing loss. For smaller brain metastases, stereotactic (also known as gamma knife) radiation can be done to one or more focused areas and has fewer side effects than whole-brain radiation.

Surgery

Surgery for bone metastasis can help relieve pain and prevent fractures. Placing screws, rods, pins, plates or other devices can help stabilize the bone, making fractures less likely. For a bone that is already broken, surgery may relieve pain. Side effects include soreness at the incision site and pain.

 

Questions to ask your medical team

Don't be embarrassed to ask your medical team about any side effects you have. They've heard it before and need to know about your side effects in order to help you.

  • How can I treat hot flashes and vaginal dryness?
  • Do I have any risk factors for a blood clot?
  • Am I a candidate for a cooling cap?

Medical supportive therapies

Your doctor will likely recommend daily calcium and vitamin D supplements. In addition, your doctor may prescribe a bone-modifying drug (see Table 2) to help prevent bone problems. These drugs may damage the jawbone, so people taking bone-modifying drugs should take care of their mouth, gums and teeth. They should also avoid invasive dental work.

Be sure to tell your medical team when symptoms persist despite treatment or if you experience any new symptoms. They will work with you to manage your symptoms, provide you with greater control over your daily activities and improve your quality of life.

Table 2. Bone-modifying drugs

Drug name How administered Common side effects
denosumab (Xgeva) Injection Fatigue, nausea, low phosphate levels
pamidronate (Aredia) Injection Fever, fatigue, nausea, anemia
zoledronic acid (Zometa) Injection Nausea, fatigue, anemia

 

Defining cancer-related pain

Cancer-related pain is caused by several different factors. In most cases, it is directly related to the cancer itself and the location of the tumor(s). As a tumor grows, it can press on internal organs, tissues and joints, creating pressure that ultimately leads to pain in that specific area. Pain can also be caused by cancer that has spread to bone. This pain is typically felt in the back, pelvis and hips, as these bones are the most common sites of cancer spread (metastasis). Cancer-related pain may be felt in parts of the body other than where the primary tumor is located, especially in advanced disease.

In addition to cancer-specific pain, diagnostic procedures and treatments, including surgery, chemotherapy and radiation therapy, may cause different types of pain. After surgery, pain is usually felt in the area of the surgery. This pain will gradually lessen as the body heals and recovers. The pain or discomfort caused by chemotherapy and radiation therapy can be mild to severe, but often (although not always) ends when treatment does. Sometimes, a hormone imbalance or treatment-related nerve damage may contribute to chronic pain.

 Types of pain

Doctors refer to pain in three categories: nociceptive somatic, nociceptive visceral and neuropathic. These terms seem complicated, but their meaning can be simplified. Nociceptive pain arises when nerve cells (called nociceptors) are stimulated to send pain signals by some kind of ongoing injury, such as pressure by a tumor or the cut of a surgical scalpel. Pain caused by stimulation of nerve cells in soft tissues or muscles is defined as nociceptive somatic; pain caused by stimulation of nerve cells in body organs is defined as nociceptive visceral. Neuropathic pain is caused by damage to nerves, causing these nerves to send pain signals even though there isn’t ongoing injury. Each of these categories of pain has distinct causes. Pain is also defined by its timing:

  • Acute pain is pain that occurs suddenly; it is sometimes related to a diagnostic procedure or treatment. This type of pain is time-limited; in other words, the pain usually resolves once the body recovers and heals.
  • Chronic pain, also called persistent pain, lasts for at least one month — usually longer — after treatment. This type of pain is usually related to the direct effects of a tumor or cancer treatment but, in a small number of people, pain may be unrelated to either the cancer or the treatment.
  • Breakthrough pain includes severe flares of pain that “break through” during treatment with pain medication. Breakthrough pain can range from mild to severe and can last minutes to hours.

 Descriptions of pain

Your doctor will ask you to describe your pain. Think about your pain and describe it carefully, as your doctor will be better able to determine the cause of your pain. For example, if pain feels like burning or “shock-like,” it is most likely related to damaged nerves. Your doctor will also ask about the severity of your pain. A scale of 0 to 10 (with 10 being the worst) is the most common way to rate how bad pain is.

Also give your doctor details about your pain: What makes it worse? Does anything make it better? How does it affect your daily life?

 Causes of cancer-related pain

Some of the more common side effects of cancer and cancer treatments that can cause pain include the following:

  • Loss of motion may occur after surgery. For example, many people have pain related to loss of motion in the arm after a mastectomy.
  • Lymphedema occurs when excess fluid builds up and causes abnormal swelling, typically in an arm or a leg. Swelling ranges from mild to extreme and is most likely to occur after surgery involving removal of lymph nodes from the underarm, groin, pelvis or neck. Typically, the more lymph nodes removed, the greater the risk for lymphedema.
  • Peripheral neuropathy is a condition caused by damage to the peripheral nerves, the nerves outside the brain and spinal cord. Some chemotherapy drugs cause peripheral neuropathy, which is experienced as numbness and tingling in the hands and feet, a decreased sensation of hot and cold, muscle weakness, cramping and balance problems.
  • Osteoporosis occurs when healthy bone isn’t rebuilt at the same rate as it is being destroyed by cancer cells or certain treatments. As a result, bone becomes weak, brittle and painful. This condition can happen naturally with age but is intensified by cancer.
  • Bone metastasis is the spread of cancer into bones. Pain is caused by damage to bone cells as cancer cells invade.

 Talking about pain

Regardless of the cause or type of cancer-related pain, there are options for managing it so that you can have less pain and a better quality of life. Be sure to talk to your doctor or other member of your cancer treatment team about your pain so that they can discuss options with you.

Additional Resources

 

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