Controlling the symptoms of secondary breast cancer

Secondary breast cancer may cause unpleasant symptoms. Sometimes, the symptoms can be relieved by treating the cancer itself. Sometimes treatments can work very quickly and you may notice an improvement within a few days. At other times treatments may take longer to work and it can be a couple of weeks before you begin to feel their full benefits.

Apart from treating the actual cancer there are many other ways to help relieve symptoms. This page gives ideas on what may be helpful.

Pain

There are many different types of painkillers which vary both in their strength and in the way they work. Some painkillers are better for certain types of pain and some suit certain women better than others. If you are taking painkillers, it is better to take them regularly, even if you are not in pain when the next dose is due. This is because painkillers not only relieve pain at the time, but work to prevent the pain coming back. Painkillers can be taken as tablets, liquids or as suppositories (by insertion into the back passage). Some are also given as injections under the skin.

It is important to tell your doctor if the painkillers you are taking aren’t easing your pain. Your doctor can either change the dose or change the painkillers to one that will be more effective for you.

Pain caused by secondary breast cancer cells in a bone can be severe. Radiotherapy is very good at easing this type of pain, but can take 2–3 weeks to work. Often, drugs containing morphine are needed while the treatment is being planned or while you are waiting for the radiotherapy to work.

Some women find that morphine makes them feel drowsy when they first start taking it, but this usually only lasts for a day or so. Taking morphine may also make some women feel sick at first, and they may need an anti-sickness tablet (anti-emetic) prescribed by the doctor for the first few doses. It may cause constipation (see below for information about how to deal with this).

Besides painkillers, a number of other drugs can be very helpful in relieving pain. If the pain is due to secondary breast cancer cells in a bone, drugs known as non-steroidal anti-inflammatory drugs (NSAIDs) can be very helpful. These drugs are often referred to as anti-inflammatories and have few side effects other than sometimes irritating the lining of the stomach.

Drugs known as bisphosphonates can also help to relieve bone pain. They may be given into a vein (intravenously) in the outpatient department every 3–4 weeks. Some bisphosphonates can be taken as tablets, but some of these must be taken on an empty stomach an hour before food and may cause stomach upsets.

Bisphosphonates can help to strengthen bones and lower the risk of fractures. They can also reduce high levels of calcium in the blood (hypercalcaemia) as well as reducing pain.

Your doctor can also prescribe sleeping tablets, or a mild relaxant, which may be particularly helpful if you are having trouble sleeping because of the pain. Anxiety and lack of sleep can make pain worse. For this reason some women also find that practising relaxation techniques helps them feel more comfortable.

Heat and gentle massage can also help ease aches and pains. A good long soak in a warm bath, a well protected hot-water bottle, and some baby oil or lotion massaged into the skin can often make a difference.

Being in pain can make you feel very low and it is important to let your doctor know if the drugs prescribed aren’t working. It is also important to keep in mind that there are many different ways in which pain can be controlled. There are also special NHS pain clinics run by doctors and nurses expert in treating pain. You can ask your doctor to refer you to a pain clinic if your pain is not controlled by any of the above methods.

Breathing problems

Breathing problems may happen; either if the secondary breast cancer spreads to the lining on the outside of the lungs (the pleura) or if the cancer has spread to the lungs themselves.

Cancer cells irritate the sensitive pleura and cause a pocket of fluid to build up (known as a pleural effusion). This fluid can press on the lung, making it harder to expand the lungs fully, and may cause breathlessness.

Pleural effusions can be treated by passing a narrow tube into the chest, between the ribs, to drain off the fluid. This is done by first numbing the area with a local anaesthetic, then passing the tube through the skin and between the ribs to reach the outside of the lungs. The tube is stitched securely to the skin on the chest and the other end is connected to a drainage bottle. The tube may be left in overnight, or longer, to drain off as much fluid as possible. This may mean you need to spend a few days in hospital.

Once the pleural effusion has been drained, the breathlessness will ease. The effusions can be drained as often as necessary and sometimes a procedure called pleurodesis can be done, which sticks the two linings of the lung together so that fluid cannot collect there.

If the cancer cells have spread to the tissue of the lungs, morphine can be used to relieve the breathlessness. It can be very frightening to feel breathless, and anxiety and fear can make breathlessness worse. Morphine makes people feel relaxed, which also helps to control the breathing rate.

It is less effort for your lungs to expand if you are upright rather than lying completely flat. Using extra pillows in bed or getting a large triangular support pillow (which can be bought from most department stores) can help you stay more upright when you are in bed or resting on a sofa. If treatment reduces the number of cancer cells, this will relieve breathlessness.

Feelings of sickness (nausea)

The most common cause of nausea for women with secondary breast cancer is the treatment – radiotherapy, chemotherapy and painkillers may all make you feel sick at some time. However, sickness caused by treatment is usually only a temporary problem and eases off completely once the treatment is over. Occasionally, nausea may be caused by the secondary breast cancer cells themselves, especially if they affect the liver or cause high levels of calcium in the blood (hypercalcaemia).

There are many anti-sickness drugs (anti-emetics) available. They work in different ways, so let your doctor know if the anti-emetic you are taking is not working completely, as another type can be tried.

Most anti-sickness medicines take about 20–30 minutes to start to work properly. Many are now available as suppositories (tablets inserted into the back passage) and this can be a good way of taking the drug if you feel too sick to swallow a tablet.

Some women find that relaxation exercises help to ease their nausea. Doing something you enjoy, such as finding time to relax with a magazine, book, favourite CD or TV programme, can help take your mind off the sick feeling.

Tiredness

You may find that you easily become very tired and that your body is no longer as strong and reliable as it once was, either because of the cancer, or because of the side effects of treatment. It may feel as though you have no strength and everything is more of an effort.

It can be difficult to adjust if tiredness makes it difficult for you to drive or take part in sports, or if you have to walk more slowly than before. It will take time for you to get used to these changes and to accept having to rest, or not being able to do activities that you once took for granted.

‘When I ask my daughters to have a meal, I’m not really up to cooking it. They don’t seem to mind – I buy the food and they cook it – but I feel I’m letting them down as I’ve always done the cooking.’

If you have little energy, save it for the things you really want to do. Very often, re-organising your daily activities can be helpful – for example, by setting aside a time to rest every day. Practical aids such as wheelchairs can also be useful. You may feel that by using a walking stick, frame or wheelchair you are ‘giving in’ to your illness, but they can greatly improve your life, allowing you to move around more easily than you could on your own.

Sometimes the cancer or the treatment can cause anaemia, which can lead to tiredness. If this happens you can be given a blood transfusion which can quickly give you more energy and reduce the tiredness.

Constipation

Constipation can be caused by strong painkillers, or if there is too much calcium in your blood (caused by secondary breast cancer cells affecting a bone). Constipation can also occur if treatment has made you lose your appetite and you are not eating as much as before.

Having fibre in your diet, drinking plenty of fluids and walking will help, but you may also need to take a medicine to stimulate the bowel (a laxative). Your doctor will be able to prescribe a suitable one for you. Your nurses can also advise you on ways to prevent or relieve constipation.

Difficulty sleeping

Even though you may feel tired it is not uncommon for women with secondary breast cancer to have difficulty in sleeping. There can be many reasons for this, not least that you probably have a lot on your mind.

Sleeping tablets are now less likely to make you feel drowsy the following day. You can also try some natural remedies for sleeplessness — malted milk drinks before bed, a glass of brandy or whisky in the evening, warm baths with soothing bath oils, or a relaxing body massage to relieve muscle tension.

Swelling of the arm (lymphoedema)

The best treatment for swelling of the arm (lymphoedema) is a programme of exercise, massage, skin care and a properly fitted support sleeve or bandage. The aim of treatment is to control the swelling and prevent it from getting worse. It is only occasionally possible to reverse swelling caused by damage to the lymph nodes. You can be referred to a lymphoedema clinic for specialist treatment from a breast care nurse or physiotherapist.

Good care of the skin on the arm is vitally important if you have lymphoedema. Even small cracks or cuts can allow germs to get in, which may lead to infection in the whole arm. Repeated infections can further weaken the lymphatic system in the arm and this leads to more swelling.

You can reduce the risk of infection by:

• Wearing gloves for gardening and washing up
• Avoiding playing with animals that may scratch
• Treating small grazes and cuts with antiseptic and keeping them clean until they heal
• Protecting the arm from sunburn
• Using an electric razor if you shave your underarm hair, or using hair removing cream
• Moisturising the skin every day to keep it supple.

You may need to wear a support (or compression) sleeve or bandage to prevent fluid building up in the arm and support the muscles. The support sleeves are worn all day and taken off just before going to bed. Most women who have lymphoedema need to wear a support sleeve every day to keep the swelling down.

High levels of calcium in the blood – hypercalcaemia

Secondary breast cancer cells affecting a bone may make extra calcium pass out of the damaged bone and into the blood. High levels of calcium in the blood can make you feel extremely tired and thirsty, and pass lots of urine. Hypercalcaemia can also make you feel sick and some people become irritable and confused. You may need to spend a few days in hospital for treatment.

Your doctor may ask you to start drinking plenty of water and will put up a ‘drip’ to give you extra fluids into a vein in your arm (an intravenous infusion). This will increase the fluid content of your blood, encouraging the kidneys to take out the extra calcium from the blood and flush it from the body in the urine. Your doctor will give you drugs known as bisphosphonates to speed up the process. These drugs are given as a drip over 15 minutes to an hour, and can be repeated every few weeks. They are usually effective at getting the calcium levels back to normal. You should feel much better within a couple of days.

As well as controlling calcium levels, bisphosphonates can help to reduce bone pain from cancer secondaries, and may also reduce the risk of a weakened bone breaking.

Strengthening a weakened bone

If a secondary breast cancer has weakened a bone so much that there is a risk of it breaking, you may need an operation to strengthen the bone. This is done under a general anaesthetic: the surgeon will put a metal pin into the centre of the bone and may also fix a metal plate to the bone. This holds the bone firm so that it will not break. The pin and plate can stay in permanently to protect the bone. This is mainly used for the long bones in the legs but is sometimes used for secondaries in other bones, such as the spine. If the hip is affected, the hip joint may be replaced.

You will need to stay in hospital for a week, or longer, after the operation so that you can recover fully. However, most women are able to get up and start walking a couple of days after the surgery.

Sometimes an operation like this is done before radiotherapy is given to the secondary cancer cells in the bone, if there is a chance the bone may break before the radiotherapy has treated the cancer cells.

When a bone is weakened but doctors feel it is not likely to fracture, bisphosphonates may be used to help strengthen the bone and prevent it breaking.

Headaches and feeling sick

Secondary breast cancer cells in the brain may cause headaches and sickness, as the cancer cells can cause pressure to build up within the skull. Steroids, such as dexamethasone, can be used to reduce the inflammation and so relieve symptoms. Steroids are usually given in short courses and have few side effects, but if taken for long periods they can cause weight gain, a puffy face, muscle weakness and thinning of the skin. A short course of radiotherapy treatment may also be used to treat secondary cancer in the brain.