Cancer Pain

What cancer pain feels like

Cancer pain varies with its cause. It may be:

• Dull, aching, constant and well localized, typical of bone pain
• Burning, shooting, electric or tingling, typical of nerve pain
• Deep, squeezing, cramping or hard to pin down, typical of organ pain
• Breakthrough pain: sudden flares on top of a background pain, triggered by movement, coughing or occurring at the end of a dose

Many people have more than one type at the same time. Describing your pain in these terms helps your team choose the right treatment.

Causes of cancer pain

Pain from the cancer itself

• Bone involvement: cancer that spreads to bone (bone metastases) from breast, prostate, lung, kidney and thyroid cancers, and myeloma, is the commonest cause of cancer pain. It is often worse at night and with weight-bearing.
• Nerve compression or invasion: a tumor pressing on a nerve, the spinal cord or a nerve plexus causes neuropathic pain.
• Organ stretching or blockage: liver capsule stretching, bowel blockage, or a blocked ureter.
• Soft tissue invasion and skin ulceration.
• Raised pressure in the skull from brain tumors, causing headache.

Pain from cancer treatment

• Surgery: wound pain, and sometimes long-term pain such as post-mastectomy or phantom limb pain.
• Chemotherapy: chemotherapy-induced neuropathy (burning and numbness in hands and feet), mouth sores and muscle and joint aches.
• Radiation: skin soreness, mouth and throat pain, and later scarring.
• Hormone treatments: aromatase inhibitors cause joint pain in many women.
• Procedures: biopsies, bone marrow tests and line insertions.

Pain unrelated to cancer

People with cancer also get arthritis, back pain and headaches. These still need treatment and should not be ignored.

Types of cancer pain compared

When cancer pain is an emergency

Metastatic spinal cord compression is the most important emergency. Warning signs are new back or neck pain, especially pain that feels like a band around the chest or belly, is worse lying down or coughing, and comes with weakness, numbness, tingling in the legs or bladder or bowel problems. Same-day MRI and steroids, then radiotherapy or surgery, can prevent permanent paralysis.

How cancer pain is assessed

Your team will ask you to:

• rate your pain from 0 (no pain) to 10 (worst imaginable)
• describe where it is, what it feels like and what makes it better or worse
• say how it affects sleep, mood, eating and activity
• list everything you take, including over-the-counter medicines and supplements

They will examine you and may order X-rays, bone scans, CT or MRI to find the cause. Keeping a pain diary helps track patterns and the effect of changes.

How cancer pain is treated

Medicines

Pain medicines are usually given on a regular schedule, not only when pain appears, with extra doses for breakthrough pain. The World Health Organization approach matches the strength of medicine to the severity of pain:

• Mild pain: acetaminophen (paracetamol) and NSAIDs such as ibuprofen, which are especially useful for bone pain. NSAIDs need caution with kidney problems, stomach ulcers, low platelets and some chemotherapy.
• Moderate to severe pain: opioids such as morphine, oxycodone, hydromorphone or fentanyl patches. Doses are adjusted until pain is controlled.
• Adjuvant medicines added to either: nerve pain medicines (such as gabapentin, pregabalin, duloxetine or amitriptyline), steroids for swelling around tumors and nerves, and bone-strengthening drugs (bisphosphonates or denosumab) for bone metastases.

Doses are individualized by your care team. Take them exactly as prescribed.

Managing opioid side effects

• Constipation is almost universal, so a laxative is started at the same time
• Nausea usually settles within a few days
• Drowsiness often improves after a few days at a stable dose
• Store opioids securely, away from children

Fear of addiction is common, but when opioids are used as prescribed for cancer pain, addiction is uncommon. Tolerance and physical dependence are expected effects and are managed by your team.

Non-drug and procedural treatments

• Radiotherapy: often a single dose relieves painful bone metastases within 2 to 4 weeks
• Nerve blocks: for example a celiac plexus block for pancreatic cancer pain
• Intrathecal pumps that deliver medicine directly around the spinal cord, for pain not controlled otherwise
• Surgery to stabilize weakened bones or relieve blockages
• Physical therapy, heat, cold, massage, gentle exercise and relaxation techniques
• Psychological support: anxiety, depression and poor sleep make pain worse, and treating them helps

Palliative care

Palliative care teams specialize in pain and symptom control and can be involved at any stage of cancer, alongside treatment aimed at cure. Asking for a palliative care referral does not mean giving up on treatment.

Frequently asked questions

What does cancer pain feel like?

It depends on the cause. Bone pain is deep and aching, often worse at night. Nerve pain burns, tingles or shoots. Organ pain is vague, deep and cramping. Many people also have breakthrough pain, which flares suddenly on top of background pain.

Can cancer pain be controlled?

In most people, yes. A combination of regular medicines, extra doses for breakthrough pain, radiotherapy, nerve treatments and supportive care controls pain for the large majority. Tell your team if your pain is not controlled, because there are always more options to try.

Will I become addicted to opioids for cancer pain?

Addiction is uncommon when opioids are taken as prescribed for cancer pain. Your body will get used to the medicine, which is expected and not addiction. Your team will monitor doses, side effects and safety, and adjust treatment if your pain changes.

Is bone pain a sign that cancer has spread?

It can be, especially new, persistent pain that is worse at night, in someone with breast, prostate, lung, kidney or thyroid cancer or myeloma. Many other things cause bone and joint pain too. Report any new persistent pain to your cancer team so it can be checked.

Why should I report new pain to my cancer team?

New pain may signal cancer growth, a fracture, an infection or spinal cord pressure, all of which are better treated early. It also helps your team adjust your pain plan before pain becomes severe.