Palliative Care Case Study: Pain in Metastatic Breast Cancer

Palliative Care is a medical subspecialty that emphasizes comprehensive and holistic care (physical, emotional, spiritual) of patients with life-limiting illness. By practicing expert symptom assessment and management, palliative medicine strives to optimize quality of life for seriously ill patients across the trajectory of illness. INCTR’s interdisciplinary Palliative Care Team is collaborating with Nepali physicians, nurses and others to establish palliative care programs at a number of local hospitals and cancer centers in the Kathmandu Valley area. The case study presented below illustrates the vital role of the palliative care team in the management of cancer- related pain.

Symptom assessment

Sita* is a 57-year-old Nepali woman with metastatic breast cancer to the liver and bones, referred to the palliative care team for increasing pain not responding to her current pain medication regimen. She complains of chronic, achy pain in her thoracic and lumbar spine, consistent with the location of confirmed multiple bony metastatic lesions. This pain has been present for approximately three months, but has worsened over the past few weeks and is not relieved by her prescribed doses of opioid therapy. The pain often wakes her at night, is aggravated by activity, and has prevented her from being able to participate in her day-to-day activities. She feels the pain is particularly bad upon awakening. She does not report any signs or symptoms of spinal cord compression and denies weakness in her legs, numbness/tingling, or any urinary or bowel incontinence. She says her pain is severe, or very severe, nearly all the time. She currently rates her pain as 8/10 on a scale of 1 to 10.

Medication review

Her current pain medication regimen is morphine sulfate elixir 15 mg PO (by mouth) every 4-6 hours prn (as needed). She reports moderate relief after taking the morphine, but then waits until the pain “becomes unbearable” before taking her next dose. Her typical daily usage of morphine elixir is 15 mg at 6 am, 4 pm and 11 pm. Sita says she is frightened of becoming addicted to the morphine and is reluctant to take the morphine more frequently.

Assessment

Sita’s description of pain is consistent with the deep and aching pain that characterizes bony metastatic lesions. Since the half-life of morphine is approximately 3-4 hours Sita’s use of morphine on an ‘as needed’ basis allows for only brief periods of time when her pain is adequately controlled. It is not surprising that her pain is much worse in the early morning, since she has an extended period of time (from 11 pm - 6 am) when she is not taking any morphine. Also, she reports only moderate relief after taking 15 mg of morphine, suggesting that this dose is not high enough to achieve optimal analgesic effect.

This figure illustrates that “prn” (as needed) dosing of morphine can result in intervals of significant pain. Dosing morphine sulfate around-the-clock as described in the case study above can decrease, or eliminate, these intervals of pain. Diagram provided by M. Downing, Victoria Hospice Society.

Plan

• In order to maximize a ‘steady-state’ level of opioid in the body, Sita is advised to take her morphine on a regular, every four hour schedule around-the-clock.


• To avoid sleep interruption, she can try taking a double dose at bedtime and omit the dose in the middle of the night. This works for many people, but some individuals will have to resume around-the-clock every four hour dosing, even throughout the night to maintain good pain control.


• The dose of morphine elixir will be increased from 15 mg to 20 mg PO in order to achieve greater analgesic effect.


• To prevent opioid-induced constipation Sita is also given a prescription for a daily laxative.


• Sita’s concerns regarding morphine addiction are addressed and she is reassured that her risk for addiction is extremely low.


• She is encouraged to report any adverse side effects, such as nausea, confusion or excessive sleepiness - these are often temporary side effects experienced when starting opioids and resolve over a matter of days and do not normally necessitate discontinuing the opioid.


• The use of other or ‘adjuvant’ medications (such as non-steroidal anti-inflammatory medications or a short course of steroids) or palliative radiation should also be considered to help with her bone pain.


• Sita should be monitored for any neurological changes, as she is at risk for spinal cord compression.


• It will be important to continue close follow-up with Sita as her opioid will likely need further titration to achieve the best pain control (eg., she may in fact require 30 mg PO every four hours). Her requirements may also increase as her illness progresses, necessitating further titration.