Cancer Drugs for Women & Pain Management

1. Cancer Drugs for Women& Pain Management

2. Medicines Used Exemestane is also called Aromasin. It is a type of hormone therapy drug called an aromatase inhibitor and is used to treat breast cancer. It is only suitable for women who have had their menopause. How exemestane works Many breast cancers are stimulated to grow by the female sex hormones oestrogen and progesterone. These breast cancers are called hormone sensitive or hormone receptor positive and can be treated with drugs that block the effects of these hormones.

3. Medicines Used In women who have had their menopause, oestrogen is mainly produced by changing androgens (sex hormones produced by the adrenal glands) into oestrogens. This process is called aromatisation and happens mainly in the fatty tissues, muscle and the skin. It needs a particularenzyme called aromatase. Exemestane blocks the process of aromatisation. So it lowers the amount of oestrogen in the body. In early breast cancer, taking exemestane can help to stop breast cancer coming back. In advanced breast cancer the cancer cells may grow more slowly or stop growing completely.

4. Medicines Used How you take exemestane You take exemestane as a tablet, once a day after a meal. You need to take them at approximately the same time each day. You usually take them for a few years. It is very important that you take tablets according to the instructions your doctor or pharmacist gives you. For example, whether you have a full or empty stomach can affect how much of a drug gets into your bloodstream. You should take the right dose, not more or less. And never stop taking a cancer drug without talking to your specialist first. If you accidentally take more exemestane than you should, let your doctor know straight away. If you forget to take a tablet, take it as soon as you remember. If it is nearly time for the next dose, take that tablet at the usual time. Don't take a double dose to make up for the missed one.

5. Medicines Used Tests during treatment You have blood tests before starting treatment and regularly during your treatment. The tests check your levels of blood cells. They may also check how well your liver and kidneys are working.

6. Medicines Used You may have 1 or 2 or a few side effects. They may be mild or more severe. A side effect may get better or worse through your course of treatment, or more side effects may develop as the course goes on. This depends on How many times you've had the drug before Your general health The amount of the drug you have (the dose) Other drugs you are having Tell your doctor or nurse straight away if any of the side effects get severe.

7. Medicines Used Common side effects More than 10 in every 100 people have one or more of these effects. Hot flushes and sweats – this happens in more than 1 in 5 women (22%) Painful joints or muscles – this happens in just under 1 in 5 women (18%) Tiredness (fatigue) – this happens in about 1 in 6 women (16%) Feeling or being sick – this is usually mild and can be easily controlled by anti sickness tablets. It affects more than 1 in 10 women (12%) Difficulty sleeping (insomnia) – more than 1 in 10 women have this Hair thinning affects more than 1 in 10 women Headaches

8. Medicines Used Occasional side effects Between 1 and 10 in every 100 people have one or more of these. Loss of appetite Lowered interest in sex Stomach ache Indigestion Skin rashes – these are usually mild. Let your doctor or nurse know if you have a rash. This happens in about 1 in 10 women taking exemestane (10%) Feeling dizzy – about 1 in 10 women (10%) have some dizziness. Don't drive or operate machinery if you have this

9. Medicines Used Feeling very sad, including depression Loss of bone strength – this is caused by a lack of oestrogen over a long period of time and bones may break more easily. You should have a DEXA scan to check your bone density before you start treatment Diarrhoea or constipation – if this happens it is usually mild. You should drink plenty of fluids. Vaginal bleeding occurs in less than 1 in 20 women (5%) – this mainly happens during the first few weeks of treatment when women have changed from one type of hormone therapy to another. Tell your doctor or nurse if the bleeding continues Swelling in the hands and feet caused by a build up of fluid Carpal tunnel syndrome – let your doctor or nurse know if you have any pain, tingling or weakness in your hands

10. Medicines Used Rare side effects Fewer than 1 in 100 people have these effects. Drowsiness Muscle weakness Inflammation of the liver – let your doctor know straight away if you feel generally unwell, or have yellowing of the skin and eyes, itching, abdominal pain on the right hand side, and loss of appetite

11. Medicines Used Tamoxifen Tamoxifen is a hormone therapy for breast cancer. It is occasionally used to treat other types of cancer. How tamoxifen works Many breast cancers are stimulated to grow by the female sex hormones oestrogen and progesterone. These breast cancers are called hormone sensitive or hormone receptor positive. Tamoxifen is usually prescribed for women who are ER positive. That means that their breast cancer cells have oestrogen receptors (ER). The oestrogen receptor is the part of the breast cancer cell that oestrogen locks on to, stimulating the cell to divide and grow. Tamoxifen blocks the oestrogen receptor. It lowers the risk of breast cancer coming back (recurring) after surgery or developing in the other breast. 

12. Medicines Used Breast cancer is rare in men but tamoxifen can be a helpful treatment if the cancer is ER positive. We have information about breast cancer in men, which includes information about the possible side effects of tamoxifen treatment. To find out if your cancer has hormone receptors, your specialist will arrange tests on your breast cancer cells. Your specialist may also prescribe tamoxifen if your cancer cells are ER negative, but have progesterone receptors (are PR positive).

13. Medicines Used How you take tamoxifen Tamoxifen comes as a tablet that you swallow. It is also available as a sugar free liquid called Saltamox. You take it daily at the same time every day. It is important to keep the tablets or liquid out of the reach of children. It is very important that you take tablets according to the instructions your doctor or pharmacist gave you. Whether you have a full or empty stomach, for example, can affect how much of a drug gets into your bloodstream. You should take the right dose, not more or less. And never stop taking a cancer drug without talking to your specialist first. Most women take tamoxifen for 5 years. 

14. Medicines Used Common side effects More than 10 in every 100 people have one or more of these. Hot flushes and sweats – around 45% of women have moderate to severe hot flushes and sweats while taking tamoxifen Changes to your periods – if you haven’t had your menopause your periods may become irregular. Some women find that their periods stop. They usually start again within 6 to12 months of treatment finishing. However, for some women who are close to the time of their natural menopause they don’t start again Fatigue (tiredness) affects about 1 out of 4 women (25%)

15. Medicines Used Discharge from the vagina, dryness and itching affect about 1 in 10 women – tell your doctor or nurse if you have any of these side effects Feeling light headed – do not drive or operate machinery if you have this Eye problems can very occasionally occur, such as eyesight changes, cataracts or changes in the back of the eye (retina) – it is important to have regular eye check ups while having tamoxifen. If you notice any changes in your eyesight tell your doctor

16. Medicines Used Occasional side effects Between 1 and 10 in every 100 people have one or more of these. Fluid build up may cause ankle and or finger swelling (or weight gain) in about 1 in 10 people (10%) Weight gain – some people put on weight while they are taking tamoxifen Headaches Feeling or being sickusually happens at the start of treatment and goes after a few days or weeks – it tends to be mild and easily controlled by anti sickness tablets

17. Medicines Used Sadness or depression – about 1 in 10 people (10%) have some change in their mood. Let your doctor or nurse know if you feel sad or depressed Hair thinning is usually only slight and not noticeable Bone pain and pain in the area of the tumour – tell your doctor or nurse as painkillers can help Leg cramps – walking may help to stretch the muscle and ease this

18. Medicines Used What anastrozoleis? Anastrozole is also called Arimidex. It is a type of hormone therapy called an aromatase inhibitor. Anastrozole treats breast cancer in women who have had their menopause. How anastrozole works Many breast cancers are stimulated to grow by the female sex hormones oestrogen and progesterone. These breast cancers can be treated with drugs that block the effects of these hormones.

19. Medicines Used How you take anastrozole You take anastrozole as a tablet, once a day. Try to take it at the same time each day. Swallow the tablet whole with a drink of water. You can take it before, with, or after food. Common side effects More than 10 in every 100 people have one or more of these. Headaches Hot flushes and sweats

20. Medicines Used Feeling sick is usually mild and can usually be controlled by anti sickness medicines Skin rashes– these are usually mild but let your doctor or nurse know if you have a rash Painful or stiff joints happen in more than 3 out of 10 women (30%) Swollen joints (arthritis)

21. Medicines Used Feeling weak Loss of bone density caused by a lack of oestrogen over a long period of time – the bones are weaker and more likely to break. You will have a DEXA scan to check your bone density before you start treatment Mood changes happen in up to 2 in 10 women (20%) Tiredness or fatigue happens in up to 2 out of 10 women (20%)  Reduced libido occurs in more than 1 out of 10 women (10%)

22. Medicines Used Occasional side effects Between 1 and 10 in every 100 people have one or more of these. Bone pain Painful hands with a weakened grip and numbness and tingling – carpal tunnel syndrome Hair thinning may happen, but is usually mild Loss of appetite Raised cholesterol levels in the blood – this is usually only slightly raised and you will have regular blood tests to check it

23. Medicines Used Feeling sleepy Being sick – you can have medicines to control this Liver changes that are very mild and  unlikely to cause symptoms – they will usually go back to normal when treatment is finished, but you will have regular blood tests to check how well your liver is working Diarrhoea – drink plenty of fluids and tell your doctor or nurse if diarrhoea becomes severe or continues for more than 3 days Dryness of the vagina – you can get vaginal moisturisers (lubricants) from your nurse or from the pharmacist Vaginal bleeding occurs in fewer than 1 in 20 women (5%) – this mainly happens in the first few weeks of treatment. Tell your doctor or nurse if the bleeding continues

24. Pain What pain means Pain is usually a sign that something is wrong – that you have an illness or injury to your body. When there is damage to any part of your body, your nervous system sends a message along nerves to your brain. When your brain receives these messages, you feel pain. Nerves transmit all pain in this way, including pain caused by your cancer.

25. Pain If you have a lot of pain it can be frightening and make you think that your cancer must be growing. But the amount of pain you have does not necessarily relate to how advanced your cancer might be. A very small tumour that is pressing on a nerve or your spinal cord can be extremely painful. Yet a very large tumour somewhere else may not cause you any pain at all.

26. Pain Having pain after successful treatment doesn't necessarily mean that your cancer has come back. Some people get pain after cancer treatment such as surgery or radiotherapy. This pain can start or get worse some months or years after treatment. It is due to the nervous system rewiring itself after nerves have been damaged. The nerves then send pain signals. This type of pain often does not respond to ordinary painkillers, and other ways of treating pain then need to be used. Pain may not be related to your cancer. It is understandable to worry about this. But remember that sometimes pain may be due to common causes of aches and pains, such as arthritis, headaches, constipation or digestive problems.

27. Pain Not all cancers cause pain Many people with cancer do not have pain. This is because cancers do not have any nerves of their own. A growing tumour can press on nerves near to where it is growing and that is what causes pain. How pain affects you Pain can affect you physically and emotionally. It is a very individual experience and feels different from one person to another. What is very painful and disturbing for one person may not affect another person so much.  Everyone’s pain is unique and needs to be treated individually. What works for you may not help someone else. So an individual treatment plan to control your pain is very important

28. Pain It is a good idea to keep a record of your pain What it feels like – stabbing, aching or burning Where it is – in one place, or spread around an area How it comes on – suddenly or gradually What relieves it – heat, cold, changing position, massage How often you have it – always, or does it come and go

29. Pain Getting help with pain The earlier you get treatment for pain, the easier it is to get it under control.

30. Pain Causes of cancer pain Most cancer pain is caused by the tumour pressing on bones, nerves or other organs in your body. Sometimes pain is related to your cancer treatment. For example, some chemotherapydrugs can cause numbness and tingling in your hands and feet or a burning sensation at the place where they are injected. Radiotherapy can cause skin redness and irritation.

31. Pain Acute and chronic pain Cancer pain can be acute or chronic. Acute pain is due to damage caused by an injury and tends to only last a short time. For example, having an operation can cause acute pain. The pain goes when the wound heals. In the meantime, painkillers will usually keep it under control. Chronic pain is pain caused by changes to nerves.

32. Pain Pain that is not well controlled can develop into chronic pain. So it is important to take painkillers that you are prescribed. Trying to put up with the pain can make it harder to control in the future If you have chronic cancer pain, you may have times when the pain is not controlled by the medicines you are taking. This is called breakthrough pain

33. Pain Types Nerve pain Bone pain Soft tissue pain Phantom pain Referred pain

34. Pain Types of painkillers Three main types Opioids Non opioid drugs Other drugs for pain control

35. Pain Opioids Opioids were first made from the juice of the opium poppy. But many are now manmade in a laboratory. There are different types of opioid painkillers. Some are used for mild or moderate pain and others for severe pain.  Opioids for severe pain include Morphine Diamorphine Fentanyl Buprenorphine Oxycodone These are commonly used to treat cancer pain. You can only get them on prescription from your doctor. Used properly, these drugs do not have many side effects.

36. Pain Opioids for mild to moderate pain include Codeine Tramadol Some types are available over the counter. You may worry that you will become addicted to morphine and other opioid drugs. This is a common fear, but it is unlikely you will get addicted to painkillers if you are taking them for cancer pain. You are usually started on a weaker opioid, and then move on to a stronger one if needed. Sometimes you might need very high doses of these drugs to control your pain. It is quite safe to take high doses if you need them. 

37. Pain Morphine There are lots of different preparations of morphine that can be given in different ways, including An immediate release liquid or tablet that you take every 2 to 4 hours Slow release tablets, capsules or powders that you take every 12 or 24 hours A liquid that can be injected into a vein or given through a drip A liquid that can be given through a small needle under the skin Suppositories inserted into your back passage Tablets you dissolve under your tongue (transmucosal tablets) Patches you stick on to the skin (transdermal patches)

38. Pain When you start taking morphine, you will normally be given the more short acting immediate release type. You may take it every 2 to 4 hours. That way your dose can be adjusted quickly and easily until your pain is controlled. Your doctor or nurse will give you instructions on how much morphine to take and when to take it. Their instructions will allow you some flexibility so that you can take enough to control your pain. If the dose you are taking is not enough for you, you will probably find that your pain comes back before the next dose of morphine is due. It is important to keep a note of how much morphine you take and when. Then your doctor or nurse can work out how much you need every 24 hours.

39. Pain Remember that you must take slow release tablets regularly or they won't work. When you start taking them, it can take up to 48 hours for the dose to steady in your bloodstream. They are not the sort of tablets that you can take now and again. You should also have a supply of the immediate release type morphine to take, in case you have any extra pain while you are taking slow release tablets. The extra pain may be breakthrough pain or incident pain

40. Pain Diamorphine Diamorphine is a form of morphine that is very easy to dissolve in very small amounts of water. So it may be used when morphine needs to be given by injection, especially in a syringe driver. This is a battery operated or clockwork pump. It gives liquid from a syringe through a small fine tube placed just under the skin. The pump can give small amounts continuously. So it is used when good regular pain control is needed for people who have sickness or find it difficult to swallow tablets. It may be used for people who are terminally ill, but being cared for at home. A nurse changes the syringe every 24 or 48 hours.

41. Pain Fentanyl Fentanyl is a manmade (synthetic), slow release opioid. You can have it as a patch (called Durogesic) stuck onto your skin that releases the drug slowly. So you don't have to take any tablets or have any injections. When you start fentanyl, it can take up to 72 hours to get the right level of drug in your bloodstream.

42. Pain While you have a fentanyl patch, you should also have a supply of the immediate release type morphine or oxycodone to take, in case you have any extra pain. When you've had a fentanyl patch, it takes up to 72 hours to get the fentanyl out of your system once you stop using it. So any other painkiller you move onto will need to be phased in gradually as the fentanyl is phased out.

43. Pain Oxycodone This opioid can be useful if you have both bone and nerve pain. Particularly if morphine has not helped your pain or has given you unpleasant side effects. Oxycodone is available as an injectable liquid, a liquid that you drink or as capsules to swallow. These preparations are called OxyNorm. There is a slow release tablet called OxyContin. You should have a supply of the immediate release type oxycodone to take, in case you have any extra pain while you are taking the slow release tablets.

44. Pain Codeine Codeine is a weak opioid and is usually the first choice of drug if non opioid drugs are not enough to control your pain. A number of tablets combine codeine and paracetamol, for example co-codamol or co-dydramol. Tramadol Tramadol is a weak opioid and is available as Tablets or capsules (Tramacet or Zamadol) Slow release tablets or capsules that you take every 12 hours (Dromadol, Nobligan or Tradorec) Tablets that dissolve on your tongue (Zamadol melt)

45. Pain These include drugs such as paracetamol and anti inflammatory drugs. Anti inflammatories are often called non steroidal anti inflammatory drugs (NSAIDs for short). These drugs are very good for relieving bone and muscle pain. They can help improve pain relief when you take them with stronger painkillers. There are many different non steroidal anti inflammatory drugs. They include Aspirin Ibuprofen Diclofenac (Voltarol) You can have these drugs in different ways including As a liquid or tablet every 4 to 8 hours As slow release tablets that you take every 12 hours As an injection As a suppository (into your back passage)

46. Pain Other drugs for pain control Your doctor may give you other drugs to help relieve your pain. These are sometimes called co analgesics or adjuvant analgesics because they are given alongside other painkillers (analgesics). They can mean that you can take a lower dose of opioid painkillers than you otherwise would. So you are less likely to have side effects. Co analgesics include

47. Pain Steroids Steroids reduce swelling. These are useful for pain control because swelling around a tumour increases pressure on surrounding tissues and so may increase pain. Steroids are made naturally in the body and can also be made artificially and used as drugs. Doctors prescribe steroids for many different reasons and for many different illnesses and conditions. They can be tablets or injections. In cancer care, you are most likely to have either prednisolone or dexamethasone.

48. Pain Bisphosphonates Cancer that has spread to the bone can cause pain. This can be a problem in advanced cancer, especially with breast cancer, prostate cancer and myeloma. Bisphosphonates are a group of drugs that may help to Control bone pain and so lower the amount of painkillers you need to take Slow down or prevent damage caused by cancer spread to the bones

49. Pain Anti depressants Some types of anti depressant can help to relieve nerve pain that is not controlled by other painkillers. They can also help with depression that may be caused by long term chronic pain. Drugs to prevent fits (anticonvulsants) This group of drugs is usually used to control fits (seizures). But they can often help to relieve burning or tingling pain (nerve pain). The anticonvulsant drugs used include gabapentin (Neurontin), topiramate (Topamax), lamotrigine (Lamictal) and pregabalin (Lyrica).

50. Pain Local anaesthetics These drugs are used for pain problems in a specific part of the body. Some local anaesthetic drugs can relieve pain from mouth ulcers. Your doctor may suggest gel that forms a protective coating over the ulcer such as Gelclair (Orabase). Or they may suggest mouthwashes such as benzydamine (Difflam), Gelclair, MuGard or Caphosol. These drugs coat the lining of your mouth and can relieve pain from mouth ulcerscaused by chemotherapy or pain caused by radiotherapy.