A 31-year-old patient with a history of breast cancer undergoing chemotherapy presents with new back pain; what are the next steps in management?

Urgent Evaluation for Spinal Metastases is the Immediate Priority

In a 31-year-old breast cancer patient on active chemotherapy presenting with new back pain, you must immediately obtain MRI of the entire spine to rule out spinal metastases, as breast cancer is the most common cause of spinal metastasis and can present with back pain as the initial symptom. 1, 2, 3

Immediate Red Flag Assessment

Your first priority is determining whether this represents metastatic disease requiring urgent intervention:

• Order MRI of the entire spine immediately – do not wait for plain radiographs, as they miss early metastatic lesions and can falsely reassure you (one case showed what appeared to be a benign hemangioma on X-ray that was actually metastasis on advanced imaging) 1, 3

• Assess for spinal cord compression symptoms urgently: Ask specifically about bilateral leg weakness, saddle anesthesia, bowel/bladder dysfunction, or progressive neurological deficits – these require emergency neurosurgical consultation within hours 1

• Examine for localized tenderness over vertebrae and perform a complete neurological examination including motor strength, sensation, and reflexes in both lower extremities 1, 2

Critical Clinical Context

Breast cancer patients can develop spinal metastases months to years after initial diagnosis, and 75% of breast cancer patients who present with metastatic recurrence have vertebral involvement 2, 3. The median time to recurrence in documented cases is 5 years, but this can occur at any point 2, 3.

If imaging confirms metastatic disease:

• Refer immediately to oncology and radiation oncology 2
• If pathological fracture is present or imminent, obtain orthopedic surgery consultation for surgical stabilization followed by radiation therapy 1
• Emergency radiation therapy is indicated if surgical decompression is not feasible 1

If Metastases Are Ruled Out: Chemotherapy-Related Pain Management

Once you have definitively excluded metastatic disease with MRI, then consider chemotherapy-induced pain:

Assessment Protocol

• Use a standardized pain scale (0-10 numeric rating) and obtain comprehensive pain characteristics: location, quality, radiation pattern, timing, aggravating/relieving factors 1

• Distinguish between neuropathic and musculoskeletal pain: Ask about numbness, tingling, burning sensations in a stocking-glove distribution (suggests chemotherapy-induced peripheral neuropathy) versus mechanical, movement-related pain 1, 4

Evidence-Based Treatment Algorithm

For neuropathic pain (numbness, tingling, burning):

• Start duloxetine 30 mg daily for 1 week, then increase to 60 mg daily – this is the ONLY medication with Level 1 evidence showing 30-50% pain reduction in chemotherapy-induced neuropathy 1, 4
• Prescribe physical activity/exercise program – multiple RCTs demonstrate improvement in neuropathy symptoms 1, 4
• Consider acupuncture as adjunctive therapy 1

For musculoskeletal/mechanical back pain:

• Offer acetaminophen or NSAIDs (use NSAIDs cautiously given chemotherapy-related risks of thrombocytopenia, renal toxicity, and GI bleeding – verify recent CBC and renal function first) 1
• Prescribe physical therapy with stretching and strengthening exercises 1
• Consider acupuncture for pain intensity reduction 1

Common Pitfalls to Avoid

Do not assume this is "just chemotherapy side effects" without imaging – 88% of breast cancer patients presenting with spinal metastases had known prior breast cancer history, and clinicians initially misdiagnosed them with benign conditions like lumbar spondylosis 2, 3

Do not use plain radiographs as your definitive imaging – they miss early metastatic lesions and can show incidental findings (like hemangiomas) that mask underlying metastasis 3

Do not prescribe NSAIDs without checking recent labs – chemotherapy causes hematologic, renal, and hepatic toxicities that are potentiated by NSAIDs 1

Coordination and Follow-Up

• Communicate with the patient's oncologist before initiating any new therapy, as any intervention affecting immune function or drug metabolism requires oncology input 5

• Schedule reassessment within 1-2 weeks to evaluate treatment response and adjust management 1

• Educate the patient that new or worsening pain requires immediate reporting, as it may signal disease progression 1