What is Breakthrough Cancer Pain?

By Dr. Amod Manocha in Pain Management

Feb 16 , 2022 | 3 min read


Cancer pain remains a major problem despite all the medical advancements, affecting 30–40% of patients at the time of diagnosis, and 75% of those with advanced cancer. Effective pain control has been shown to improve the quality of life in all stages of the disease and fortunately, with appropriate therapy, cancer pain can be effectively managed in most individuals even though eliminating it completely may not always be possible.

Breakthrough pain is one pain that troubles even those cancer patients whose pain is otherwise well controlled. It can be seen in association with any cancer although is seen more commonly in association with cancers such as head and neck cancer, gastrointestinal, lung, and breast cancer.

What is breakthrough pain?

Breakthrough cancer pain (BTP) refers to the sudden, relatively short lasting severe pain episodes one experiences from time to time, often catching one unprepared, despite having controlled background pain. This pain is

  • Moderate to severe in intensity
  • Has a rapid or gradual onset reaching peak intensity within a few minutes.
  • Average duration of each episode is 30 min although it may vary from 1 min to 4 hours and there may be multiple episodes in a day
  • Pain episodes may be predictable or unpredictable

How common is breakthrough pain and what causes this pain?

BTP is a common problem with an incidence of 50% to 75%. Patients with severe persisting pain, advanced cancer and aggressive anticancer treatments are more likely to experience this. Common examples of BTP include mouth pain on swallowing due to inflammation of mouth lining (mucositis) or bone pain due to movements like posture change. The underlying cause for BTP may not be the same as that of the constant background pain and requires a careful assessment with attention to detail.

Why do we need to treat breakthrough pain and what are the treatment options?

Breakthrough cancer pain often robs the sufferers of their independence and their ability to perform routine tasks, adversely affecting the quality of life. Besides causing suffering, the severity and unpredictability of breakthrough pain can adversely impact one’s confidence level, emotional health and social interactions

All cancer pain patients should be assessed for the presence of BTP. Effective cancer pain management requires assessment of responsible factors and having a management plan in place for dealing with this pain rather than reaching out for emergency services during unsocial hours in a panic mode. A standard practice is to prescribe medications for the constant background pain and a separate on-demand dose of pain relieving measures for breakthrough pain. In BTP there is no one treatment which works universally and the treatment needs to be individualised.

Selecting the right option requires a fair amount of expertise and familiarity with all the available options. There are a number of factors which need to be taken in to account when deciding on the treatment and these include

  • Underlying cause of pain
  • Type of pain
  • Pain characteristics (onset, duration, severity)
  • Predictable or unpredictable pain
  • Previous response to pain relieving medications
  • Background painkillers and drug interactions
  • Patient-related factors including age, other organ function, cancer stage and individual preferences
  • Cost, availability and safety aspects

Opioids (morphine like drugs) are considered as the preferred medications for treating BTP. The profile of the drug selected to treat the BTP needs to mirror the pain profile one is experiencing. For example, in cases of sudden onset short-lasting pain episodes, drugs like oral morphine may not be as effective as they take time to work and rapidly acting drugs are more likely to be useful. A mismatch between pain profile and drug selected is likely to produce poor relief and/or side effects. A predictable episode of BTP triggered by known factors for example, eating can be managed by a planned administration of medicine prior to the activity taking into account the time taken for the medication to work. The route of drug administration is important as it controls how quickly the pain relieving effects are apparent.

The dose of ‘rescue medication’ is determined by individual titration to ensure maximum relief with minimal side effects and may be subject to change over time. Once the trial medication has been started, dose titration and regular reassessments are essential. All patients with new BTP medications should be re-evaluated within 48–72 h. Patient education regarding the correct and appropriate use of medications is essential as research evidence demonstrates incorrect usage, misuse / abuse and underuse in a significant proportion.

Other non-opioid drugs are also useful in the management of BTP. Examples include anti-inflammatories, benzodiazepines, paracetamol etc. Preventing and treating BTP is not just about medications as interventional techniques and non-pharmacological methods are other options which can be helpful.