Pain is one of the most common but misunderstood and feared symptoms of cancer. According to published data, as many as two-thirds of people with cancer-related pain also experience episodes of breakthrough cancer pain (BCP). BCP is varied; the most common type is a flare of the background pain, which may occur without warning and typically has a fast onset with a duration of less than 30 minutes. BCP is often triggered by a specific activity or movement. It may result from walking, dressing, changing positions, or even simpler events, such as coughing or sneezing. Most patients with BCP have several episodes each day. Compared with patients who do not have BCP, those that do have more severe pain overall, more pain-related distress, and poorer functioning. “BCP leaves many cancer patients fearful of the next episode,” says Russell K. Portenoy, MD. “It unduly burdens patients and their families.”

New Survey Data

A recent survey commissioned by the American Pain Foundation (APF) and conducted online by Harris Interactive explored the impact BCP has on patient quality of life, medical treatment, and finances among adults diagnosed with cancer, living with cancer-related pain, taking medication to manage their pain, and experiencing sudden, temporary pain flares (Table 1). “Although the APF survey was internet-based and not epidemiological, it serves a good purpose in that it provides a snapshot of the problem in an affected subgroup,” explains Dr. Portenoy. “A key finding was that BCP can be highly significant and is associated with many adverse effects on quality of life. As cancer is becoming more treatable, clinicians must recognize the importance of improving quality of life to ensure that the whole patient is treated, not just the cancer.”

According to the APF survey, BCP can disrupt sleep in the majority of cancer patients and survivors, which in turn negatively affects relationships with family members, limits their ability to perform household chores, and reduces their desire to participate in activities they would normally enjoy. “BCP can also interfere with patients’ ability to cope with other aspects of cancer treatment,” Dr. Portenoy adds. In addition, BCP affects medical treatment and causes financial hardships. Two of every three respondents reported taking more medications as a result of their pain. Nearly three of four respondents reported that BCP increased their daily medical expenses, and two-thirds said they have experienced medical-related financial issues resulting from this pain.

More Dialogue Needed

The APF survey also demonstrated that a little more than half of patients reported that their healthcare provider had described BCP as a normal side effect of cancer or its treatment (Table 2). Dr. Portenoy says “the APF survey should be interpreted as a call to reinvigorate a discussion within the oncology community about cancer pain in general, and also about the importance of these common episodes of acute pain. BCP is challenging for patients and their providers because it occurs even when patients are taking the right dose of medication regularly. Providers and patients should not accept BCP as a normal side effect of cancer. Physicians must realize that BCP reflects an unmet need for patients and recognize the importance of assessing and treating it in tandem with background pain.”

To optimize outcomes, Dr. Portenoy recommends that clinicians apply the best practices of cancer pain management to this specific problem. “Effective pain management is critical to restoring quality of life in these individuals. This means assessing pain and determining causes of both background pain and BCP attacks. The identified causes or precipitants of BCP should be treated while around-the-clock medications are adjusted to optimize the balance between analgesia and side effects. For the BCP itself, short-acting analgesics should be used. The pharmaceutical industry has developed rapid-onset formulations—some are already on the market and others coming along. These therapies may be very useful for some patients.”

Raising Awareness

To increase awareness of BCP among patients and caregivers, APF’s website (http://www.painfoundation.org) offers clinicians several resources, including an online toolkit about the basics of breakthrough pain, tips for ensuring that pain management is an integral part of cancer care, and treatment options. The site also provides online chats and interactive webinars which offer more insight on the condition. “Physicians should also participate in CME activities that discuss BCP in greater detail,” says Dr. Portenoy. “Providers need to become more aware of this pain and recognize that medications are being developed to treat it and reduce its burden.”

References

American Pain Foundation. Breakthrough Cancer Pain Survey Fact Sheet. Available at: http://www.painfoundation.org/learn/programs/breakthrough-cancer-pain/btcp-fact-sheet.pdf. Accessed March 5, 2010.

Portenoy RK, Hagen NA. Breakthrough pain: definition, prevalence and characteristics. Pain. 1990;41: 273-281.

Fine PG, Busch MA. Characterization of breakthrough pain by hospice patients and their caregivers. Pain Symp Manage. 1998;16:179-183.

Portenoy RK, Payne D, Jacobsen P. Breakthrough pain: characteristics and impact in patients with cancer pain. Pain. 1999;81:129-134.

Mercadante S, Costanzo BV, Fusco F, Buttà V, Vitrano V, Casuccio A. Breakthrough pain in advanced cancer patients followed at home: a longitudinal study. J Pain Symptom Manage. 2009;38:554-560.

Zeppetella G. Impact and management of breakthrough pain in cancer. Curr Opin Support Palliat Care. 2009;3:1-6.