Cancer-induced bone pain

Refer to the pain assessment guideline for an overview of assessment of pain.

 

Clinical features of CIBP

• Often localised to a site of known bone metastases.
• Can be referred or present as radicular pain.
• Common sites include the lower back, pelvis, long bones and ribs.
• Often described as gnawing, aching, nagging, constant or dull.
• Can consist of all or some of the following:
  • background pain
  • breakthrough pain, and
  • incident pain: rapid onset pain associated with movement.

 

Skeletal-related events

Assess for skeletal-related events associated with CIBP.

Hypercalcaemia

Carry out blood tests including full blood count (FBC), urea and electrolytes (U&E), liver function test (LFT), calcium, magnesium and phosphate levels.

Be aware that hypercalcaemia itself can cause increased pain, including bone pain, because the mu opioid receptor is calcium gated.

If hypercalcaemia is identified, refer to the hypercalcaemia guideline.

Malignant spinal cord compression (MSCC)

Refer to the malignant spinal cord compression guideline for key signs and symptoms suggestive of MSCC, and for the approach to investigation and management. Early recognition is critical to prevent irreversible neurological damage.

Pathological fracture

Pathological fractures occur in approximately 10% of patients with bone metastases and are associated with increased pain, reduced quality of life and higher mortality.

Seek urgent orthopaedic advice if a current or impending pathological fracture is suspected. This will guide imaging and potential surgical management.

Mirels’ scoring system may be used to predict the risk of pathological fracture and guide decisions about fixation based on pain, anatomical site, lesion size and radiographic appearance.

Multidisciplinary approach

Consider discussion and collaboration with other specialties including oncology, orthopaedics and interventional cancer pain services, as well as psychological support, allied health professional input and complementary therapies.

Oncology

• External beam radiotherapy and radioisotope treatment have a role in CIBP management.
• Discuss the use of osteoclast inhibitors.

Orthopaedic surgical intervention may be considered for:

• actual or impending pathological fractures
• compromised stability of weight-bearing joints, or
• persistent pain unresponsive to other management.

Surgical options include fixation, reconstruction, arthroplasty, cementoplasty and resection, aiming to relieve pain and restore function.

Allied health professional (AHP) input

• Physiotherapy: maintain mobility, risk management, energy conservation and the use of mobility aids.
• Occupational therapy: home adaptations and aids to reduce pain and maximise function.
• Orthotics: consider if referral for assessment/reassessment of orthotics, where appropriate.

Emotional and spiritual assessment

• Identify and address total pain, encompassing physical, psychological, social and spiritual struggles.
• Consider a trauma-informed care approach depending on how CIBP and the patient’s experience of cancer interacts with previous trauma.
• Refer to the care for spiritual distress guideline for further information.

 

Non-pharmacological measures

In addition to AHP input, other non-pharmacological measures can be trialled.

The application of hot or cold packs to the site of pain can be beneficial.

Consider using a transcutaneous electrical nerve stimulation (TENS) machine, where available.

 

Pharmacological measures

A stepwise approach to analgesia should be used. Refer to the pain management guidelines.

Opioids are the mainstay of pharmacological management for CIBP.

Adjuvant analgesics, such as non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, osteoclast inhibitors and neuropathic agents, can be considered when pain does not respond adequately to opioids or to reduce side effects by reducing the total dose of opioid required.

Opioids

CIBP is likely to be at least partially opioid sensitive.

• Patients usually require modified-release (MR) background opioid, and immediate-release (IR) as required or pro re nata (PRN) opioid to manage breakthrough and incident pain, which is a rapid onset pain associated with movement.
• It can be helpful to administer IR opioid in anticipation of painful events such as 15 minutes before care or before mobilising.
• When IR opioid is used for incident pain it should not routinely be included in calculations to titrate the MR background opioid, as this is likely to result in toxicity at rest.
• In consultation with specialist palliative care only. The use of rapid-onset opioids, including short-acting fentanyl products, for management of incident pain may be considered when patients are already established on a minimum of 60 mg oral morphine or equivalent pain relief per 24 hours. Patients should take their prescribed dose 10–30 minutes prior to anticipated movement. Use for a maximum of four episodes in 24 hours.

Important: Dose interval and maximum total dose vary according to which rapid-onset, short-acting fentanyl product is used. Refer to the British National Formulary (BNF) for full information.

 

Adjuvants

Corticosteroids

There is evidence that corticosteroids are effective in the management of CIBP. Dexamethasone doses range from 2–8 mg per day given either once daily in the morning or divided between a morning and lunchtime dose.

• The side effects of steroid use, including avascular necrosis, should be considered.
• Avoid coprescription of corticosteroids and NSAIDs.
• Gastroprotection and blood glucose monitoring are recommended.
• Ensure a clear plan for review and reducing doses to avoid unnecessary, prolonged use.
• If ongoing use is required for symptom control, aim to continue at the lowest effective dose.
• A short course of corticosteroids can be helpful in managing pain flares after radiotherapy. For example, 8 mg dexamethasone daily for 5 days.

NSAIDs

NSAIDs can be a helpful adjuvant analgesic when patients are not on corticosteroids. They are usually administered via the oral route. If patient is unable to take oral NSAIDs, please consult medicine information leaflets (MILs) for guidance on subcutaneous administration.

Gastroprotection should be coprescribed with NSAIDs to reduce the risk of gastrointestinal bleeding. Increased cardiac risk should be considered on an individual basis.

Consider monitoring renal function in view of increased risk of acute kidney injury.

NSAID use after orthopaedic surgery should be at the lowest effective dose for the shortest period necessary. NSAID use can confer a higher risk of delayed fracture healing, but not at low doses or for short durations. Seek local orthopaedic advice.

Neuropathic agents

There is mixed evidence for the role of neuropathic agents such as gabapentin and pregabalin in the management of CIBP. See advice on general neuropathic pain.

 

Considerations under specialist advice

Osteoclast inhibitors, such as bisphosphonates or denosumab

These drugs work by reducing excessive bone resorption, which occurs in the context of bony metastases. There is weak evidence to support an analgesic role for bisphosphonates and denosumab in CIBP. Bisphosphonates and denosumab may prevent pain by delaying the onset of bone pain rather than by producing an analgesic effect.

• Consider osteoclast inhibitors when analgesics or radiotherapy have been ineffective and where prognosis is more than two weeks.
• Zoledronic acid and pamidronate are commonly used, and denosumab is an alternative.
• Onset of benefit is about two weeks.

Some people may be prescribed bisphosphonates prophylactically to reduce the risk of developing painful skeletal-related events (SREs) related to metastatic hormone-relapsed prostate cancer, breast cancer or myeloma.

Practice points if using bisphosphonates or denosumab for pain

• Bisphosphonates and denosumab have a well-recognised role in primary prevention of SREs, therefore preventing bone pain.
• The role of bisphosphonates and denosumab in the treatment of pain remains to be established.
• Bisphosphonates or denosumab should only be initiated for established bone pain on specialist palliative care advice when first- and second-line analgesics have been ineffective.
• Consider prescription of calcium supplement with Vitamin D (choice as per local formulary guidance) if the patient is calcium low or within normal range.
• Do not supplement vitamin D if calcium is high prior to administration, as this will drive recurrent hypercalcaemia.

• Blood monitoring seven days after bisphosphonate administration is necessary to exclude hypocalcaemia, hypomagnesaemia, acute kidney injury or other electrolyte disturbances, particularly in patients with normal or low calcium prior to administration.
• If there are any concerns around osteonecrosis of the jaw in the first instance see dental clinical guidance from the Scottish Dental Clinical Effectiveness Programme

Complex pain

In complex situations with refractory bone pain, seek specialist palliative care advice. Specialist initiation only drugs such as calcitonin, methadone and ketamine may be considered by specialist palliative care teams in these situations.

Interventional cancer pain service

Consider referral to interventional cancer pain services if there is uncontrolled pain or intolerable side effects. Cordotomy may be helpful for unilateral bone pain. In Scotland this can be discussed with the West of Scotland Interventional Cancer Pain Service based at the Beatson and is available nationwide. Delivery of intrathecal analgesia, where available, may also be considered.

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