7 Approaches to Managing Bone Mets Pain

Patients who have advanced breast, prostate or lung cancer become especially worried that tumor cells will spread to the bone (bone metastasis, or simply bone mets). Pain from bone mets can range from mild to extremely severe. In addition to increased risk for painful fractures, bones are rich in nerves that transmit pain messages to the brain. Growing tumors can stimulate these nerves. Pain diminishes quality of life on several levels: physical, psychological, emotional, and social. Thus, doctors and patients recognize that managing bone mets pain is a top priority bone mets cases.

Depending on the degree of pain, and each individual’s tolerance or pain threshold, treatments for bone mets pain range from over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) to aggressive interventions. The following table summarizes current management strategies in order from mild to severe pain:

NSAIDS	Over-the-counter NSAIDS can alleviate mild-to-moderate pain. Under a doctor’s direction, different products can be tried, and the dose gradually increased until maximum effect is reached. If pain worsens, NSAIDS can safely be mixed with some opioid pain relievers to boost effectiveness. Patients should not exceed a doctor’s recommended dosage since liver or kidney damage can occur.
“Weak” opioids	At initial dosages, prescription drugs such as codeine, dihydrocodeine, hydrocodone, oxycodone, and propoxyphene can provide significant relief either as needed or around the clock. The dose can be increased as needed. Some are available in prescriptions that also contain NSAIDS, but the potential liver/kidney toxicity of the NSAIDs limits the maximum daily dose.
“Pure” opioid drugs	When weaker opioids begin to have less effect even at higher doses, one of the following drugs such as morphine, hydromorphone, oxycodone (high strength), and fentanyl may be introduced. Controlled-release formulations may provide more consistent relief than taking a pill at intervals.
Drugs for nerve pain	Depending on the location and size of the bone tumors, as well as the type of bone damage they create, there may be nerve pain that requires a different class of drugs in addition to NSAIDS or opioids. Certain types of antidepressants, anticonvulsants, and corticosteroids may be prescribed to lessen nerve pain.
Physical interventions	Applications of heat or cold, acupuncture, exercise as tolerated, and physical therapy may be helpful strategies to improve quality of life, improve mobility, and increase strength. There is research evidence that placing demand on the affected bones if the mets are detected early helps to rebuild healthy bone and make it more difficult for tumors to develop.
Systemic therapies	Bisphosphonates and other systemic drugs (some are in clinical trials) interfere with tumor activity in ways that have not been fully explained. By discouraging tumor growth, they indirectly prevent or in some cases lessen pain. Radioisotopes are radioactive molecules that are administered intravenously and are formulated to bond with bone tumors. They affect only the tumors and not surrounding healthy tissue because their radiation travels only a very short distance. Because they travel through the bloodstream, they can treat tumors in multiple locations per a single IV administration. There may be some manageable side effects, and studies show upwards of 60% of patients reporting pain relief for up to 4 months.
Local therapies	There are noninvasive therapies that are intended to destroy the tumor(s), deaden the nerve, or both: Radiation therapy uses radioactivity to interfere with the tumor cells’ ability to reproduce and grow. It does not take immediate effect; 40-80% of patients may begin to experience pain relief within 2-12 weeks of treatment. The duration of relief averages 3 months, and patients may experience side effects which can be treated. There are two types of radiation: one type is aimed at the local tumor(s); the other has a wider body field. A drawback of radiation is that it cannot be repeated. MR-guided Focused Ultrasound (MRgFUS) uses beams of ultrasound focused to intersect at the target, where they generate lethal heat. It can be used for both tumor destruction and nerve deadening. It is usually effective with 1-7 days, with 64-100% of patients reporting durable pain relief upwards of 6 months.

New treatments for bone mets pain are continually in development or in clinical trials. It’s vital that bone mets patients let their care team know of any new pain, or increase in existing pain. The sooner action is taken, the better the chance of matching the right treatment with the type and intensity of pain, and controlling it long term.

The Sperling Medical Group offers MRgFUS for the treatment of bone pain. Contact us for more information.