Skip to main content

Breakthrough Cancer Pain

  • Chapter

Abstract

Breakthrough pain is a relatively new concept, first coined by Portenoy and Hagen in 1990 [1], and anecdotal observation suggests that awareness of breakthrough pain as a distinct clinical entity remains relatively low [2]. Cancer pain is often variable, with a waxing and waning course throughout a day. For example, variations in activity level may be associated with exacerbations of pain that are somewhat predictable. On the other hand, sudden and significant changes in pain intensity may also occur spontaneously. While these are both examples of breakthrough pain, the strategy for addressing each scenario may be quite different. Breakthrough pain may also have variable pathophysiologic underpinnings, sometimes from a neuropathic process, while at other times from more nociceptive or mixed etiologies. Given the complexity and heterogeneity of breakthrough cancer pain (BtCP) as a distinct clinical entity, a separate chapter dedicated to its assessment and management is appropriate. BtCP can have a dramatic impact on the quality of a patient’s life, as well as key pain-related outcomes, and therefore warrants focused attention and expert management.

Keywords

  • Breakthrough Pain
  • Opioid Dose
  • Nociceptive Pain
  • Distinct Clinical Entity
  • Malignant Bowel Obstruction

These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

This is a preview of subscription content, access via your institution.

Buying options

Chapter
USD   29.95
Price excludes VAT (USA)
  • DOI: 10.1007/978-3-319-24814-1_8
  • Chapter length: 11 pages
  • Instant PDF download
  • Readable on all devices
  • Own it forever
  • Exclusive offer for individuals only
  • Tax calculation will be finalised during checkout
eBook
USD   89.00
Price excludes VAT (USA)
  • ISBN: 978-3-319-24814-1
  • Instant PDF download
  • Readable on all devices
  • Own it forever
  • Exclusive offer for individuals only
  • Tax calculation will be finalised during checkout
Softcover Book
USD   119.99
Price excludes VAT (USA)

References

  1. Portenoy RK, Hagen NA. Breakthrough pain: definition and management. Oncology (Williston Park). 1989;3(8 Suppl):25–9.

    CAS  Google Scholar 

  2. Lossignol DA, Dumitrescu C. Breakthrough pain: progress in management. Curr Opin Oncol. 2010;22(4):302–6.

    CrossRef  PubMed  Google Scholar 

  3. Payne R. Recognition and diagnosis of breakthrough pain. Pain Med. 2007;8 Suppl 1:S3–7.

    CrossRef  PubMed  Google Scholar 

  4. Swarm RA, Abernethy AP, Anghelescu DL, Benedetti C, Buga S, Cleeland C, et al. Adult cancer pain. J Natl Compr Canc Netw. 2013;11(8):992–1022.

    PubMed  Google Scholar 

  5. Zeppetella G. Breakthrough Pain. In: Hanks G, editor. Oxford textbook of palliative medicine. 4th ed. London: Oxford University Press; 2011. p. 654–61.

    Google Scholar 

  6. Caraceni A, Davies A, Poulain P, Cortes-Funes H, Panchal SJ, Fanelli G. Guidelines for the management of breakthrough pain in patients with cancer. J Natl Compr Canc Netw. 2013;11 Suppl 1:S29–36.

    PubMed  Google Scholar 

  7. Davies A, Buchanan A, Zeppetella G, Porta-Sales J, Likar R, Weismayr W, et al. Breakthrough cancer pain: an observational study of 1000 European oncology patients. J Pain Symptom Manage. 2013;46(5):619–28.

    CrossRef  PubMed  Google Scholar 

  8. Caraceni A, Bertetto O, Labianca R, Maltoni M, Mercadante S, Varrassi G, et al. Episodic (breakthrough) pain prevalence in a population of cancer pain patients. Comparison of clinical diagnoses with the QUDEI – Italian questionnaire for intense episodic pain. J Pain Symptom Manage. 2012;43(5):833–41.

    CrossRef  PubMed  Google Scholar 

  9. Caraceni A, Martini C, Zecca E, Portenoy RK, Ashby MA, Hawson G, et al. Breakthrough pain characteristics and syndromes in patients with cancer pain. An international survey. Palliat Med. 2004;18(3):177–83.

    CrossRef  PubMed  Google Scholar 

  10. Deandrea S, Corli O, Consonni D, Villani W, Greco MT, Apolone G. Prevalence of breakthrough cancer pain: a systematic review and a pooled analysis of published literature. J Pain Symptom Manage. 2014;47(1):57–76.

    CrossRef  PubMed  Google Scholar 

  11. Greco MT, Corli O, Montanari M, Deandrea S, Zagonel V, Apolone G. Epidemiology and pattern of care of breakthrough cancer pain in a longitudinal sample of cancer patients: results from the cancer pain outcome research study group. Clin J Pain. 2011;27(1):9–18.

    CrossRef  PubMed  Google Scholar 

  12. Mercadante S, Villari P, Ferrera P, Arcuri E, David F. Breakthrough pain in advanced cancer patients followed at home: a longitudinal study. J Pain Symptom Manage. 2009;38(4):554–60.

    CrossRef  PubMed  Google Scholar 

  13. Fine PG, Busch MA. Characterization of breakthrough pain by hospice patients and their caregivers. J Pain Symptom Manage. 1998;16(3):179–83.

    CAS  CrossRef  PubMed  Google Scholar 

  14. Green CR, Montague L, Hart-Johnson TA. Consistent and breakthrough pain in diverse advanced cancer patients: a longitudinal examination. J Pain Symptom Manage. 2009;37(5):831–47.

    CrossRef  PubMed  Google Scholar 

  15. Portenoy RK, Bruns D, Shoemaker B, Shoemaker SA. Breakthrough pain in community-dwelling patients with cancer pain and noncancer pain, part 2: impact on function, mood, and quality of life. J Opioid Manag. 2010;6(2):109–16.

    CrossRef  PubMed  Google Scholar 

  16. Mercadante S, Zagonel V, Breda E, Arcara C, Gebbia V, Porzio G, et al. Breakthrough pain in oncology: a longitudinal study. J Pain Symptom Manage. 2010;40(2):183–90.

    CrossRef  PubMed  Google Scholar 

  17. Bhatnagar S, Upadhyay S, Mishra S. Prevalence and characteristics of breakthrough pain in patients with head and neck cancer: a cross-sectional study. J Palliat Med. 2010;13(3):291–5.

    CrossRef  PubMed  Google Scholar 

  18. Haugen DF, Hjermstad MJ, Hagen N, Caraceni A, Kaasa S. Assessment and classification of cancer breakthrough pain: a systematic literature review. Pain. 2010;149(3):476–82.

    CrossRef  PubMed  Google Scholar 

  19. Webber K, Davies AN, Zeppetella G, Cowie MR. Development and validation of the Breakthrough Pain Assessment Tool (BAT) in cancer patients. J Pain Symptom Manage. 2014;48(4):619–32. pii: S0885-3924(14)00071-2. Epub ahead of print. April 22, 2014.

    CrossRef  PubMed  Google Scholar 

  20. Caraceni A, Cherny N, Fainsinger R, Kaasa S, Poulain P, Radbruch L, et al. Pain measurement tools and methods in clinical research in palliative care: recommendations of an expert working group of the european association of palliative care. J Pain Symptom Manage. 2002;23(3):239–55.

    CrossRef  PubMed  Google Scholar 

  21. Basch E, Autio K, Ryan CJ, Mulders P, Shore N, Kheoh T, et al. Abiraterone acetate plus prednisone versus prednisone alone in chemotherapy-naive men with metastatic castration-resistant prostate cancer: patient-reported outcome results of a randomised phase 3 trial. Lancet Oncol. 2013;14(12):1193–9.

    CAS  CrossRef  PubMed  Google Scholar 

  22. Lutz ST, Jones J, Chow E. Role of radiation therapy in palliative care of the patient with cancer. J Clin Oncol. 2014;32(26):2913–9. pii: JCO.2014.55.1143. [Epub ahead of print].

    Google Scholar 

  23. McCahill LE, Krouse R, Chu D, Juarez G, Uman GC, Ferrell B, et al. Indications and use of palliative surgery-results of society of surgical oncology survey. Ann Surg Oncol. 2002;9(1):104–12.

    CrossRef  PubMed  Google Scholar 

  24. Podnos YD, Juarez G, Pameijer C, Uman G, Ferrell BR, Wagman LD. Surgical palliation of advanced gastrointestinal tumors. J Palliat Med. 2007;10(4):871–6.

    CrossRef  PubMed  Google Scholar 

  25. Stinnett S, Williams L, Johnson DH. Role of chemotherapy for palliation in the lung cancer patient. J Support Oncol. 2007;5(1):19–24.

    CAS  PubMed  Google Scholar 

  26. Clemons MJ, Dranitsaris G, Ooi WS, Yogendran G, Sukovic T, Wong BY, et al. Phase II trial evaluating the palliative benefit of second-line zoledronic acid in breast cancer patients with either a skeletal-related event or progressive bone metastases despite first-line bisphosphonate therapy. J Clin Oncol. 2006;24(30):4895–900.

    CAS  CrossRef  PubMed  Google Scholar 

  27. Cleeland CS, Body JJ, Stopeck A, von Moos R, Fallowfield L, Mathias SD, et al. Pain outcomes in patients with advanced breast cancer and bone metastases: results from a randomized, double-blind study of denosumab and zoledronic acid. Cancer. 2013;119(4):832–8.

    CAS  CrossRef  PubMed  Google Scholar 

  28. Paley CA, Johnson MI, Bennett MI. Acupuncture: a treatment for breakthrough pain in cancer? BMJ Support Palliat Care. 2011;1(3):335–8.

    CrossRef  PubMed  Google Scholar 

  29. Hardy J, Quinn S, Fazekas B, Plummer J, Eckermann S, Agar M, et al. Randomized, double-blind, placebo-controlled study to assess the efficacy and toxicity of subcutaneous ketamine in the management of cancer pain. J Clin Oncol. 2012;30(29):3611–7.

    CAS  CrossRef  PubMed  Google Scholar 

  30. Farrar JT, Cleary J, Rauck R, Busch M, Nordbrock E. Oral transmucosal fentanyl citrate: randomized, double-blinded, placebo-controlled trial for treatment of breakthrough pain in cancer patients. J Natl Cancer Inst. 1998;90(8):611–6.

    CAS  CrossRef  PubMed  Google Scholar 

  31. Coluzzi PH, Schwartzberg L, Conroy JD, Charapata S, Gay M, Busch MA, et al. Breakthrough cancer pain: a randomized trial comparing oral transmucosal fentanyl citrate (OTFC) and morphine sulfate immediate release (MSIR). Pain. 2001;91(1–2):123–30.

    CAS  CrossRef  PubMed  Google Scholar 

  32. Portenoy RK, Taylor D, Messina J, Tremmel L. A randomized, placebo-controlled study of fentanyl buccal tablet for breakthrough pain in opioid-treated patients with cancer. Clin J Pain. 2006;22(9):805–11.

    CrossRef  PubMed  Google Scholar 

  33. Kosugi T, Hamada S, Takigawa C, Shinozaki K, Kunikane H, Goto F, et al. A randomized, double-blind, placebo-controlled study of fentanyl buccal tablets for breakthrough pain: efficacy and safety in Japanese cancer patients. J Pain Symptom Manage. 2014;47(6):990–1000.

    CrossRef  PubMed  Google Scholar 

  34. Kress HG, Oronska A, Kaczmarek Z, Kaasa S, Colberg T, Nolte T. Efficacy and tolerability of intranasal fentanyl spray 50 to 200 microg for breakthrough pain in patients with cancer: a phase III, multinational, randomized, double-blind, placebo-controlled, crossover trial with a 10-month, open-label extension treatment period. Clin Ther. 2009;31(6):1177–91. doi:10.1016/j.clinthera.2009.05.022.

    CAS  CrossRef  PubMed  Google Scholar 

  35. Kongsgaard UE, Eeg M, Greisen H. The use of Instanyl(R) in the treatment of breakthrough pain in cancer patients: a 3-month observational, prospective, cohort study. Support Care Cancer. 2014;22(6):1655–62.

    CrossRef  PubMed  PubMed Central  Google Scholar 

  36. Guitart J, Vargas I, De Sanctis V, Ferreras J, Fuentes J, Salazar R, et al. Efficacy and safety of sublingual fentanyl orally disintegrating tablets in patients with breakthrough pain: multicentre prospective study. Clin Drug Investig. 2013;33(9):675–83.

    CAS  CrossRef  PubMed  Google Scholar 

  37. Parikh N, Goskonda V, Chavan A, Dillaha L. Single-dose pharmacokinetics of fentanyl sublingual spray and oral transmucosal fentanyl citrate in healthy volunteers: a randomized crossover study. Clin Ther. 2013;35(3):236–43.

    CAS  CrossRef  PubMed  Google Scholar 

  38. Rauck R, Reynolds L, Geach J, Bull J, Stearns L, Scherlis M, et al. Efficacy and safety of fentanyl sublingual spray for the treatment of breakthrough cancer pain: a randomized, double-blind, placebo-controlled study. Curr Med Res Opin. 2012;28(5):859–70.

    CAS  CrossRef  PubMed  Google Scholar 

  39. Hagen NA, Fisher K, Stiles C. Sublingual methadone for the management of cancer-related breakthrough pain: a pilot study. J Palliat Med. 2007;10(2):331–7.

    CrossRef  PubMed  Google Scholar 

  40. Zeppetella G, Davies A, Eijgelshoven I, Jansen JP. A network meta-analysis of the efficacy of opioid analgesics for the management of breakthrough cancer pain episodes. J Pain Symptom Manage. 2014;47(4):772–85.

    CrossRef  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Thomas W. LeBlanc MD, MA .

Editor information

Editors and Affiliations

Rights and permissions

Reprints and Permissions

Copyright information

© 2016 Springer International Publishing Switzerland

About this chapter

Cite this chapter

LeBlanc, T.W., Howie, L.J., Abernethy, A.P. (2016). Breakthrough Cancer Pain. In: Alberts, D., Lluria-Prevatt, M., Kha, S., Weihs, K. (eds) Supportive Cancer Care. Springer, Cham. https://doi.org/10.1007/978-3-319-24814-1_8

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-24814-1_8

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-24812-7

  • Online ISBN: 978-3-319-24814-1

  • eBook Packages: MedicineMedicine (R0)