Navigating Treatment Options for Bone Metastasis in Breast Cancer

Treatment issues for bone metastases in breast cancer?

Hello Doctor,
In mid-March of this year, I was diagnosed with bone metastasis from breast cancer (the metastatic areas range from the skull to the left foot, with larger metastases in the left hip and left pelvis).
Currently, I am only receiving pain management, but the control is not effective.
I have researched related treatments online and discussed them with my attending physician at a regional hospital in Yunlin.
He believes that the options are not feasible.
During my recent follow-up in early May, he honestly told me that it is too late for treatment now and asked where I would like to be referred (there is a hospice hospital in Chiayi).
Therefore, I would like to ask how to make the correct choice.
Online doctors have suggested oral targeted therapy and monthly Zometa injections.
For pain control, they recommended using APO + Voltaren SR 75 mg/tablet, a non-steroidal anti-inflammatory drug.
If the dosage is heavy, it could be changed to Voltaren SR 75 mg/tablet combined with a pain reliever containing acetaminophen.
It is best to take these medications with a proton pump inhibitor like Pantoloc or Takepron.
After discussing with my attending physician, he replied that the oral targeted therapy requires prior approval and that, given my condition, it is already too late.
Regarding pain medication, the health insurance regulations only allow for one type of pain medication, so he could only prescribe Voltaren SR 75 mg/tablet, one in the morning and one in the evening.
For the stomach medication, he asked me to purchase Amed tablets out of pocket, but this medication does not alleviate the abdominal and gastric bloating and burning sensation.
Therefore, during my mid-May follow-up, I told him that I no longer needed the out-of-pocket prescription.
The abdominal and gastric bloating and burning sensation have persisted, and he indicated that cancer cells have spread to the abdomen (but he did not order any tests related to this).
During this period, a morphine patch was prescribed, but after applying it for four hours, I started feeling dizzy and continued to vomit.
When I saw the doctor the next day, he said it was due to my constitution and that I should just remove it.

May I ask if the health insurance only allows for one type of pain medication? Is it true that for significant abdominal and gastric discomfort, health insurance cannot cover gastric medications? Is it too late for chemotherapy or radiation therapy now? I hope to achieve better pain control at the very least.
Thank you!

kim, 40~49 year old female. Ask Date: 2014/06/03

Dr. Chen Sirong reply Oncology

1.
So how should one choose correctly? Some breast cancer patients with bone metastasis have survived for 5 years.
I don't understand if it's due to: A) You have already used many types of medications, leaving no options available now; B) Your physical condition cannot withstand further chemotherapy; C) The extent of bone metastasis is too widespread, leading the physician to believe that only oral targeted therapy is possible, and receiving ZOMETA monthly for pain control.
How to choose? It still requires: A) Reviewing all previously used medications and dosages to understand what options are still available; B) A personal consultation to assess your physical condition; C) Reviewing the bone scan images; D) Discussing your personal treatment preferences to make a decision.
2.
Online physician recommendations: oral targeted therapy, receiving ZOMETA monthly, and pain control.
A) In principle, I agree; B) However, the attending physician has seen you in person, while the online physician, like me, has not seen you, so I cannot determine if (oral targeted therapy requires prior approval and, given my condition, it may be too late).
3.
Is it true that the insurance can only prescribe one type of pain medication? (Insurance regulations only allow one type of pain medication) This may be a misunderstanding, as your attending physician has already prescribed two types.
However, it is sufficient to prescribe only one type from the same category of pain medications; different categories can be used in combination.
A) VOLTAREN SR 75MG/TAB, one tablet in the morning and one in the evening.
B) Morphine patch.
4.
May I ask, if there is significant gastric discomfort, can insurance not cover gastric medication? A) For this part, I use Targamet and cimetidine, which only cost 2 NT dollars, twice a day for a total of 4 NT dollars, so the out-of-pocket burden is not heavy.
B) Expensive gastric medications must be confirmed with an endoscopy to have a gastric ulcer before they can be used for 2 weeks to 1 month.
5.
I hope to have better pain control, thank you! It may still be necessary to use the morphine patch.
I have had patients who experienced dizziness and vomiting the first time they used it, but it was fine after removing it.
However, after a week, using it again did not cause these side effects.
You might adapt to it now, or take oral morphine before bed, and after a few days, you might be able to tolerate it during the day.
6.
Is it too late to undergo chemotherapy or radiotherapy now? I suggest you prepare your previous treatment records and personally consult with a chemotherapy or radiotherapy physician to receive clear advice.
Dr.
Chen Si-Rong, Taoyuan Hospital.

Reply Date: 2014/06/03

More Info

Navigating treatment options for bone metastasis in breast cancer can be particularly challenging, especially when dealing with pain management and the effectiveness of various therapies. Your situation, as described, indicates that you are facing significant challenges with bone metastasis and pain control, and it is understandable to seek clarity on the best path forward.

Understanding Bone Metastasis in Breast Cancer
Bone metastasis occurs when cancer cells spread from the original tumor in the breast to the bones. This can lead to various complications, including pain, fractures, and decreased mobility. The management of bone metastasis typically involves a multidisciplinary approach, including pain management, systemic therapies, and supportive care.

Pain Management Strategies
1. Medications: Pain control is crucial for improving quality of life. It seems that you have been prescribed non-steroidal anti-inflammatory drugs (NSAIDs) like Voltaren (diclofenac) and have also tried opioids like morphine. It's important to note that while opioids can be effective for severe pain, they can also cause side effects such as dizziness and nausea, as you've experienced. If one opioid does not work well for you, there are other options available, and it may be worth discussing these alternatives with your healthcare provider.

2. Bone-targeting Agents: Medications such as bisphosphonates (e.g., Zometa, or zoledronic acid) or denosumab are often used to help strengthen bones and reduce the risk of fractures in patients with bone metastases. These agents can also help alleviate pain associated with bone metastasis. If your doctor has indicated that it may be too late for these treatments, it might be beneficial to seek a second opinion from a specialist in palliative care or oncology who can provide a fresh perspective on your treatment options.

3. Combination Therapy: Combining different types of pain medications can sometimes provide better relief than using a single medication. For instance, using an NSAID in conjunction with an opioid may help manage pain more effectively. However, it is essential to do this under the guidance of your healthcare provider to avoid potential drug interactions and side effects.

Addressing Gastrointestinal Symptoms
You mentioned experiencing abdominal and gastric discomfort. This is a common issue in cancer patients, and it can be exacerbated by certain pain medications. While some medications may not be covered by insurance, there are often alternatives that can be effective and more affordable. Discussing your symptoms with your healthcare provider is crucial, as they may recommend medications that can help alleviate these gastrointestinal issues.

Timing for Chemotherapy and Radiation
Regarding your question about whether it is too late for chemotherapy or radiation, this largely depends on the extent of the disease and your overall health. While your current physician may feel that aggressive treatment is no longer an option, it is essential to have a thorough discussion about your goals of care. If your primary concern is pain management and quality of life, palliative care specialists can provide valuable support and may offer additional treatment options that focus on symptom relief rather than curative intent.

Seeking a Second Opinion
Given the complexity of your situation, it may be beneficial to seek a second opinion from a cancer center that specializes in metastatic breast cancer. They can provide a comprehensive evaluation of your condition and discuss all available treatment options, including clinical trials that may be appropriate for you.

Conclusion
Navigating treatment options for bone metastasis in breast cancer requires a careful balance between managing pain, addressing the disease, and maintaining quality of life. Open communication with your healthcare team is vital, and do not hesitate to advocate for your needs and seek additional opinions if necessary. Remember, you are not alone in this journey, and there are resources and support systems available to help you through this challenging time.

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