Managing bone pain associated with cancer in palliative care

Bone pain is the most common complication of metastatic bone disease; other complications include pathological fractures, spinal cord compression and bone marrow suppression.

The pathophysiology of bone pain appears to be a combination of inflammatory and neuropathic features. Clinical experience and limited data indicate that a trial of multimodal analgesia including a nonsteroidal anti-inflammatory drug, an adjuvant analgesic and an opioid may be helpful; see Pharmacological management of pain in palliative care.

Incident bone pain can be difficult to treat and may limit activity. A rapid-onset opioid (eg transmucosal fentanyl) in anticipation of movement may be beneficial.

Bisphosphonates and denosumab do not have a role in treating acute bone pain. These drugs appear to reduce bone pain by preventing bone-related adverse events (eg fractures) in patients with multiple myeloma or bone metastases from a solid tumour (particularly breast or castrate-resistant prostate cancer), rather than by a specific analgesic effectFallon, 2018O'Carrigan, 2017Porta-Sales, 2017.

A pathological fracture may be a relatively late complication or the first sign of metastatic bone disease. Management is multidisciplinary, requiring input from a variety of healthcare teams (eg surgical, orthopaedics, medical and radiation oncology, palliative care, allied health). Chemotherapy, radiotherapy, analgesia, a bisphosphonate or denosumab, and surgical fixation may have a place in management. Surgical fixation can allow more effective nursing care and improve pain control, even in the last days of life.