Management of Cancer-Induced Bone Pain in Hospice and Palliative Care

Cancer-induced bone pain (CIBP) is one of the most prevalent and disabling symptoms encountered in hospice and palliative care. Bone metastases are particularly common in patients with multiple myeloma, breast cancer, and prostate cancer, and may cause continuous background pain, movement-related breakthrough pain, pathologic fracture, malignant spinal cord compression, and hypercalcemia of malignancy. CIBP results from a complex interplay of nociceptive, inflammatory, and neuropathic mechanisms driven by tumor-stroma interactions and central sensitization. Effective management requires careful differentiation between continuous background pain and movement-related incident pain. In the hospice setting, treatment must be aligned with the patient's goals of care, with an emphasis on maximizing comfort while minimizing treatment burden. Management should be grounded in systematic assessment and the WHO analgesic ladder, while recognizing that many hospice patients require early initiation of strong opioids, opioid rotation, rescue dosing, and selected adjuvant analgesics such as corticosteroids, gabapentinoids, and ketamine. Bone-modifying agents, including zoledronic acid and denosumab, can reduce skeletal-related events. A patient-centered, interdisciplinary approach, informed by the concept of "total pain," remains the cornerstone of effective bone pain management at the end of life.