Publications
APS Bulletin • Volume 7, Number 1, January/February 1997
The Pain Facts
Ernest Volinn, PhD, Department Editor
Breast Cancer Facts: Manifestations of the Disease
Charles Chabal, MD
Because cancer of the breast is the most common cancer in women worldwide, pain clinicians are likely to care for patients with this disease. Clinician understanding of the disease course, prognosis, likely metastatic spread, potential complications, and common patient concerns enhances treatment. This article summarizes data from a variety of sources to provide a succinct overview of the clinical manifestations of breast cancer. Most of the pain-related information is specific to breast cancer, but where breast cancer information is not available or is incomplete, I have provided data associated with other types of cancer. These facts may provide an essential understanding of the biological and psychosocial factors associated with breast cancer.
Incidence, staging, and survival
According to American Cancer Society statistics, more than 180,000 women annually are diagnosed with breast cancer in the United States (Boring, Squires, & Tong, 1992). This disease is a leading cause of death among women-almost 50,000 die each year (Harris, Morrow, & Bonadonna, 1992). In the United States, the incidence rate for breast cancer increased 24% between 1973 and 1991 (King & Schottenfeld, 1996). Factors contributing to this rise include higher rates of mammography screening and increased risk factors such as age at first childbirth, age at menarche, estrogen therapy, diet, physical activity, alcohol intake, and exposure to environmental organochlorines (King & Schottenfeld). Table 1 provides comparative statistics for two other common cancers, colon and prostate.
Table 1. Breast, Colon, and Prostate Cancer in the United States: Annual Incidence and Death Rates
| TYPE OF CANCER | NUMBER OF CASES | NUMBER OF DEATHS | ||
|---|---|---|---|---|
| Breast | 180,000 | 50,000 | ||
| Colon (male/female ratio 1:1) | 155,000 | 56,000 | ||
| Prostate | 134,000 | 32,000 | ||
| Source: Harris, Morrow, & Bonadonna (1992); Harrison, Seale-Hawkins, Schum, Dunn, & Scardino (1992). | ||||
The staging and ultimate prognosis of breast cancer depend on the size of the primary tumor, the spread of the tumor to regional lymph nodes, and the presence or absence of distal metastasis, as demonstrated in Table 2. Perhaps because of methods of earlier detection or improvements in treatment, most patients, including those with positive lymph nodes, survive at least 5 years. Breast cancer patients with metastatic bone disease survive for a median of 48 months (Sherry, Greco, Johnson, & Hainsworth, 1986), and patients with metastatic pulmonary disease survive for a median of 33 to 58 months (Staren, Salerno, Rongione, Witt, & Faber, 1992). Table 3 compares survival statistics for three common cancers.
Table 2. Breast Cancer Staging and Survival Statistics
| TUMOR STAGE | APPROXIMATE SURVIVAL RATE (PERCENTAGE) | |||
|---|---|---|---|---|
| Primary Tumor | Regional Lymph Nodes |
Distal Metastatis |
5 year | 10 year |
| Carcinoma in situ | Negative | None | >98 | 90 |
| <2 cm | Negative | None | 95 | 65 |
| <2 cm | Positive | None | 85 | 55 |
| >2 cm but <5 cm | Positive | None | 70 | 70 |
| >5 cm | Positive | None | 52 | 40 |
| Any size | Positive or negative | Present | 17 | 5 |
Source: Haskell, Barsky, Bassett, & Love (1995).
Table 3. Survival Rates, Based on the Spread of Disease at Time of Diagnosis
| TYPE OF CANCER | TUMOR STAGE | ||
|---|---|---|---|
| Nodes Negative |
Nodes Positive |
Distal Metastatis |
|
| Breast (5-year survival) | 95-98% | 52-85% | 17% |
| Colon (5-year survival) | 73-82% | 26-40% | <10% |
| Prostate (10-year survival) | 80% | 40% | 10% |
Source: Beahrs & Myers (1992).
Metastatic spread
The metastatic spread of breast cancer can involve a wide variety of organ systems. Table 4 displays autopsy results from four separate studies.
Table 4. Metastatic Spread of Breast Cancer (Data from Autopsies After Breast Cancer Deaths)
| SITE OF METASTASIS | PERCENTAGE OF AUTOPSIES (N = 403) | |
|---|---|---|
| Lymph nodes | 72-76 | |
| Local reoccurrence | 61-76 | |
| Lung | 59-69 | |
| Liver | 58-65 | |
| Bone | 44-71 | |
| Pleura | 37-51 | |
| Adrenal system | 31-49 | |
| Brain | 24 | |
| Intestine | 18 | |
| Spleen | 17-23 | |
| Kidneys | 14-17 | |
| Pericardium | 5-21 | |
| Sources: Holland, Veling, Mravunac, & Hendricks (1985), Warren & Witman (1937), Saphillo & Parker (1941), Carty, Foggitt, Hamilton, Royle, & Tylor (1995). | ||
Tumor involvement of local structures and bone may cause somatic pain, metastasis to internal organs may cause visceral pain, and extension to the nervous system may elicit neuropathic pain. Table 5 lists the types of pain syndrome seen in 2,118 patients with a variety of cancers (Zech, Grond, Lynch, Hertel, & Lechmann, 1995). These data support the notion that most patients with metastatic disease, including breast cancer patients, suffer from multiple types of pain and from multiple pain locations (Twycross & Fairfield, 1982).
Table 5. Specific Types of Pain Syndrome Experienced by Cancer Patients Treated by the World Health Care Guidelines (N = 2,118)
| PAIN SYNDROME | PERCENTAGE OF PATIENTS | |
|---|---|---|
| Somatic only | 35 | |
| Neuropathic and somatic or visceral | 25 | |
| Visceral only | 17 | |
| Somatic and visceral | 13 | |
| Neuropathic only | 9 | |
| Source: Zech et al. (1995). | ||
Pain, symptoms, and impact on quality of life
Cancer, as well as cancer treatments, can cause an array of disturbing symptoms The spectrum of problems caused by cancer varies with the type of cancer, the stage of disease, the type of treatment, and the general health of the patient. While staging and survival statistics for breast cancer are abundant, little information exists on the time course of cancer pain syndromes and the side effects associated with disease progression. Data compiled from a variety of cancer studies provide some insight into pain-related symptoms associated with breast cancer. Table 6 lists some common symptoms collected prospectively for 2,118 patients with a variety of cancers. The effect of pain on the quality of life of 80 women with breast cancer is summarized in Table 7. Pain significantly affected both physiological and psychological aspects of these patients' lives.
Table 6. Symptoms Experienced by Late-Stage Cancer Patients Treated by the World Health Care Guidelines (N = 2,118)
| SYMPTOM | PERCENTAGE OF PATIENTS | |
|---|---|---|
| Insomnia | 52 | |
| Anorexia | 44 | |
| Constipation | 31 | |
| Nausea | 27 | |
| Sweating | 27 | |
| Dysphagia | 22 | |
| Neuropsychiatric symptoms | 20 | |
| Vomiting | 19 | |
| Source: Zech et al. (1995). | ||
Table 7. Effects of Pain on Quality of Life in 80 Women with Breast Cancer
| EFFECT OF PAIN | PERCENTAGE OF PATIENTS | |
|---|---|---|
| Interfered with work | 77.5 | |
| Caused fatigue | 73.5 | |
| Interfered with daily activities | 65 | |
| Affected body functions | 64 | |
| Interfered with sleep | 56> | |
| Caused helplessness | 54 | |
| Caused concern that cancer is worse | 40 | |
| Caused irritability | 39 | |
| Disturbed concentration | 35 | |
| Affected eating | 34 | |
| Source: Arathuzik (1991). | ||
There are several pain syndromes specific to breast cancer. Postmastectomy pain (Stevens, Dibble, & Miaskowski, 1995), chest wall pain, and brachial plexus neuropathies each have a 20% prevalence rate. About 50% of patients develop a chronic pain problem such as parathesias or local hypersensitivity after surgical breast resection. Interestingly, in Tasmuth, von Smitten, Hietanen, & Kalso (1995), chronic pain was more common after breast-conserving surgery (limited breast resection) than after more extensive modified radical mastectomy.
The most common causes of death from breast cancer are direct tumor involvement (50%), overwhelming infection (25%), hemorrhage (10%), or miscellaneous cardiopulmonary complications (15%) (Haskell, Barsky, Bassett, & Love, 1995).
Conclusion
Breast cancer is a common disease among women in the United States and worldwide. With early detection and treatment, 95% of affected women survive 5 years, and 65% survive at least 10 years (see Table 2). Causes of pain from breast cancer include patterns of metastasis, local tumor invasion, and treatments such as surgery, radiation, or chemotherapy. A substantial number of patients will develop chronic pain from surgery of the breast or axcilla. It is likely that an individual patient may suffer simultaneously from several different sites of pain, as well as from several different types of pain. These pain types include visceral, somatic, and neuropathic pain. Quality pain management depends on an understanding of the disease process, proper diagnosis, knowledge of possible physiological and psychological effects of the disease, and selection of appropriate therapies.
References
Arathuzik, D. (1991). Pain experience for metastatic breast cancer patients. Cancer Nursing, 14(l), 41-48.
Beahrs, O.H., & Myers, M., (Eds). (1992). American Joint Committee on Cancer manual for staging of cancer (4th ed). Philadelphia: Lippincott.
Boring, C.C., Squires, T.S., & Tong, T. (1992). Cancer statistics. CA: A Cancer Journal for Clinicians, 42, 19-38.
Carty, N.J., Foggitt, A., Hamilton, C.R., Royle, G.T., & Tylor, I. (1995). Pattern of clinical metastasis in breast cancer: An analysis of 100 patients. European Journal of Surgery and Oncology, 21(6), 607-608.
Harris, J.R., Morrow, M.,& Bonadonna, G. (1992). Cancer of the Breast. In V.T. DeVita, S. Hellman, S.A. Rosenberg, (Eds.), Cancer principles and practice of oncology (pp. 1264-1332). Philadelphia: Lippincott.
Harrison, S.H., Seale-Hawkins, C., Schum, C.W., Dunn, J.K., & Scardino, P.T. (1992). Correlation between size of palpable tumor and size of pelvic lymph node metastasis in clinically localized prostate cancer. Cancer, 69, 750-754.
Haskell, C.M., Barsky, S.H., Bassett, L.U., & Love, S.M. (1995). Natural history and pre-treatment assessment of breast cancer. In C.M. Haskell & J.S. Berek (Eds.), Cancer treatment (4th ed., pp. 323-337). Philadelphia: W.B. Saunders.
Holland, R., Veling, S., Mravunac, M., & Hendricks, J. (1985). Histologic multifocality of Tis, T1-2 breast carcinomas: Implications for clinical trials of breast conserving surgery. Cancer, 56, 979-990.
King, S.E., & Schottenfeld, D. (1996). The "epidemic" of breast cancer in the U.S: Determining the factors. Oncology, 10(4), 453-462.
Saphillo, O., & Parker, M. (1941). Metastases from primary carcinoma of the breast with special reference to spleen, adrenal glands, and ovaries. Archives of Surgery, 42, 1003-1010.
Sherry, M.M., Greco, F.A, Johnson, D.H., & Hainsworth, J.D. (1986). Metastatic breast cancer confined to the skeletal system: An indolent disease. American Journal of Medicine, 81(3), 381-386.
Staren, E.D., Salerno, C., Rongione, A., Witt, M., & Faber, L.P. (1992). Pulmonary resection for metastatic breast cancer. Archives of Surgery, 127(11), 1282-1284.
Stevens, P.E., Dibble, S.L., & Miaskowski, C. (1995). Prevalance, characteristics, and impact of postmastectomy pain syndrome: An investigation of women's experiences. Pain, 61(l), 61-68.
Tasmuth, T., von Smitten, K., Hietanen, P., & Kalso, E. (1995). Pain and other symptoms after different treatment modalities of breast cancer. Annals of Oncology, 6(5), 453-459.
Twycross, R.G., & Fairfield, S. (1982). Pain in far-advanced cancer. Pain, 14, 303-310.
Warren, S., & Witman, E. (1937). Studies on tumor metastases: The distribution of metastases in cancer of the breast. Surgery & Gynecology, 57, 1018-1023.
Zech, D.F.J., Grond, S., Lynch, J., Hertel, D., & Lechmann, K.A. (1995). Validation of World Health Organization guidelines for cancer pain relief: A 10-year prospective study. Pain, 63, 65-76.
ACKNOWLEDGMENT:
This article was supported by National Cancer Institute grant #CA68854-0lAl.