As part of our MBCC coverage, we discuss how physicians can improve the patient experience through pain control both during and after breast cancer treatment.
Jacobs Hutchins, MD
As part of Cancer Network’s coverage of the 32nd Annual Miami Breast Cancer Conference, we spoke with Jacob Hutchins, MD, interim director of pain management and director of perioperative and interventional pain at the University of Minnesota. At this year’s meeting, Dr. Hutchins will be presenting information on how to improve the patient experience through state of the art pain control.
-Interviewed by Leah Lawrence
Cancer Network: Dr. Hutchins, thanks so much for speaking with us today.
Dr. Hutchins: Thank you so much for having me.
Cancer Network: First, provide us with a little background, how might patients with breast cancer experience pain? Is it related to the disease itself or more often to the treatments?
Dr. Hutchins: It is actually related to both, depending on the stage of breast cancer. If it is end-stage breast cancer, they may experience some pain related to the cancer itself. It may be localized at the breast tissue or related to the metastases, a good portion of the metastases are bone metastases in these patients. The treatments also can also cause pain, such as radiation, which can cause scarring to the localized tissue. Chemotherapy is also associated with a neuropathy type of pain in these patients. You may be treating those types of pain in patients as well. In postoperative patients, those patients’ pain is mainly related to the surgery itself.
Cancer Network: How common is pain among women with breast cancer?
Dr. Hutchins: It is actually quite common. Chronic pain post-surgery is very common in these patients. You will see somewhere between 43% to 65% of patients that have a mastectomy have some sort of chronic pain after surgery and that continues on throughout the next 3 months or the rest of their life. In patients with end-stage breast cancer, it is almost definite that they are going to have some sort of pain dealing with that cancer, whether it is the cancer itself, having localized pain, or metastases to bone, which is quite painful. Even in lower-stage patients, just having surgery puts them at risk for chronic pain and development of pain throughout the rest of their life.
Cancer Network: How then should clinicians be assessing pain in their patients with breast cancer?
Dr. Hutchins: I think it is something that needs to be discussed when patients come in for treatment or are coming in to see their providers: asking how their pain is and making sure that that is one of the focal points of the conversation, because it could be something that is definitely limiting their life. How is it affecting their relationships with other family members, or their friends, or their work, or just how it is affecting their day to day? It is something that needs to be talked about and, especially in patients that have end-stage breast cancer, whether it’s stage III or stage IV, making sure that they get connected with a palliative care physician who has good specialty advise in these situations. Making sure they are connected with them so they can assist with their pain, but also a lot of the other psychosocial aspects that pain brings to patients.
Cancer Network: Finally then, what are some of the most state-of-the-art methods that are being used for pain control in women with breast cancer?
Dr. Hutchins: For the acute surgical patients I think there are some newer techniques that we are seeing. The old way of treating patients after surgery was to give them opioids. If they had more pain you would just increase the amount of opioids you gave them, and if they had more pain after that you could maybe switch to a different opioid. We are finding that a multimodal approach, which is using medications of different families that attack pain in different areas, because opioids only affect one type of pain and they are systemic. For the acute postoperative patient a multimodal approach involves patients getting acetaminophen, that involves patients getting non-steroidal anti-inflammatories, that involves patients getting some sort of anti-epileptic such as gabapentin or pregabalin, as well getting some sort of local anesthetic, whether it be infiltration or regional anesthesia to assist the postoperative pain. We have found that there is increasing data that show that if pain is well controlled in the acute phase that they may improve not only acute outcomes but also long-term outcomes. You may see that these patients are having less risk of chronic pain because their acute pain was well controlled after surgery. This involves a multimodal approach from before surgery, during surgery, as well as in the acute post-operative period. All are important to treating pain for these patients.
With the newer aspects of pain control, one of the newest things, especially for breast cancer surgery, is the use of liposomal bupivacaine. We have found that using that in an infiltration technique, with a surgeon infiltrating the surgical sites with this medication, or whether we, as anesthesiologists use this in a regional anesthesia effect-and currently its use in regional anesthesia is off label-but we found that with either way these patients are having better control of their pain. The nice thing about liposomal bupivacaine is that it lasts up to 72 hours. We see somewhere between 40 and 72 hours of pain relief where this is injected and that was much longer than the previous medication, which lasted 12 to 16 hours. We are better able to control their acute pain, and it is site specific so they act only on the surgical site, as opposed to opioids or other medications, which are systemic and may lead to other complications or other side effects.
Cancer Network: That was an excellent overview of the topic. Thank you again for taking a little bit of time today to talk to us about pain control in breast cancer patients.
Dr. Hutchins: You’re welcome. I really appreciate the time spent with you.