Schneider Guido, Voltz Raymond, Gaertner Jan
Department of Palliative Care, University Hospital Cologne, BMBF 01KN1106, Germany.
Breast Care (Basel). 2012 Apr;7(2):113-120. doi: 10.1159/000338579. Epub 2012 Apr 27.
Breast cancer patients with bone metastases often suffer from cancer pain. In general, cancer pain treatment is far from being optimal for many patients. To date, morphine remains the gold standard as first-line therapy, but other pure μ agonists such as hydromorphone, fentanyl, or oxycodone can be considered. Transdermal opioids are an important option if the oral route is impossible. Due to its complex pharmacology, methadone should be restricted to patients with difficult pain syndromes. The availability of a fixed combination of oxycodone and naloxone is a promising development for the reduction of opioid induced constipation. Especially bone metastases often result in breakthrough pain episodes. Thus, the provision of an on-demand opioid (e.g., immediate-release morphine or rapid-onset fentanyl) in addition to the baseline (regular) opioid therapy (e.g., sustained-release morphine tablets) is mandatory. Recently, rapid onset fentanyls (buccal or nasal) have been strongly recommended for breakthrough cancer pain due to their fast onset and their shorter duration of action. If available, metamizole is an alternative non-steroid-anti-inflammatory-drug. The indication for bisphosphonates should always be checked early in the disease. In advanced cancer stages, glucocorticoids are an important treatment option. If bone metastases lead to neuropathic pain, coanalgetics (e.g., pregabalin) should be initiated. In localized bone pain, radiotherapy is the gold standard for pain reduction in addition to pharmacologic pain management. In diffuse bone pain radionuclids (such as samarium) can be beneficial. Invasive measures (e.g., neuroaxial blockage) are rarely necessary but are an important option if patients with cancer pain syndromes are refractory to pharmacologic management and radiotherapy as described above. Clinical guidelines agree that cancer pain management in incurable cancer is best provided as part of a multiprofessional palliative care approach and all other domains of suffering (psychosocial, spiritual, and existential) need to be carefully addressed («total pain»).
患有骨转移的乳腺癌患者常遭受癌痛。总体而言，对许多患者来说，癌痛治疗远未达到最佳状态。迄今为止，吗啡仍是一线治疗的金标准，但也可考虑使用其他纯μ激动剂，如水杨酸吗啡、芬太尼或羟考酮。如果无法采用口服途径，透皮阿片类药物是一个重要选择。由于美沙酮药理学复杂，应仅限于疼痛综合征复杂的患者使用。羟考酮和纳洛酮的固定复方制剂的出现，对于减少阿片类药物引起的便秘而言是一个有前景的进展。尤其是骨转移常导致爆发性疼痛发作。因此，除了基线（常规）阿片类药物治疗（如缓释吗啡片）外，还必须提供按需使用的阿片类药物（如即释吗啡或起效迅速的芬太尼）。近来，由于起效迅速且作用持续时间较短，起效迅速的芬太尼（颊用或鼻用）被强烈推荐用于治疗爆发性癌痛。如果有美洛昔康，它是一种替代性非甾体抗炎药。双膦酸盐的适应证应在疾病早期就始终进行检查。在癌症晚期，糖皮质激素是重要的治疗选择。如果骨转移导致神经性疼痛，应开始使用辅助镇痛药（如普瑞巴林）。在局限性骨痛中，除药物性疼痛管理外，放射治疗是减轻疼痛的金标准。在弥漫性骨痛中，放射性核素（如钐）可能有益。侵入性措施（如神经轴阻滞）很少必要，但对于上述癌痛综合征患者，如果对药物治疗和放射治疗无效，却是一个重要选择。临床指南一致认为，不可治愈癌症的癌痛管理最好作为多专业姑息治疗方法的一部分来提供，并且所有其他痛苦领域（心理社会、精神和生存方面）都需要得到认真对待（“全面疼痛”）。
