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Chronic Pain Following Breast Cancer Surgery

Chronic Pain Following Breast Cancer Surgery. Eric J. Visser, Churack Chair, UNDA. Chronic pain following breast surgery. Pain is common, but (thankfully) usually not severe We don’t see many cases in the pain clinic Patients may be learning to live with it? Grateful to have survived?

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Chronic Pain Following Breast Cancer Surgery

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  1. Chronic Pain Following Breast Cancer Surgery Eric J. Visser, Churack Chair, UNDA

  2. Chronic pain following breast surgery • Pain is common, but (thankfully) usually not severe • We don’t see many cases in the pain clinic • Patients may be learning to live with it? • Grateful to have survived? • Worried about the pain (recurrence)? Meretoja, Tuomo J., et al. "Pain at 12 months after surgery for breast cancer." JAMA 311.1 (2014): 90-92; Gartner R et al. JAMA 2009.

  3. Chronic pain following breast surgery • Breast cancer surgery (overall): ~50% • Mastectomy: ~50% • Breast conserving surgery: ~50% • Breast augmentation: 10-40% • Abnormal sensory (neuropathic) symptoms: ~80% • Phantom breast pain: ~5-10% Meretoja, Tuomo J., et al. "Pain at 12 months after surgery for breast cancer." JAMA 311.1 (2014): 90-92; Gartner R et al. JAMA 2009.

  4. Features of chronic pain after breast surgery Gartner R et al. JAMA 2009 • Daily pain 50% • Moderate-mild (≤4/10) 90% • Severe 10% • Site: -Breast or chest wall 70% -Axilla or arm 60% -Regional (neck & shoulder) 50% -Other sites (widespread) 40%

  5. Chronic pain syndromes • Post-mastectomy syndrome (‘neuropathic pain’) -Inter-costo-brachial neuralgia (axillary dissection) -‘Scar pain’ (neuroma) • Reconstructive (flap/implant) surgery -No difference in pain; mastectomy alone ± plastics • Phantom breast pain

  6. Chronic pain syndromes • Secondary pain syndromes (arm, shoulder) -‘Frozen shoulder’ -Neck & shoulder myofascial pain (trigger points) -Lymphoedema -Complex Regional Pain Syndrome • Cancer pain syndromes -Local invasion, metastases -Treatment effects (chemo-neuropathies)

  7. Neuropathic pain (nerve pain) Pain due to a lesion or disease of the nervous system (IASP 2015)

  8. Neuropathic pain (nerve pain) Neuropathic pain descriptors • ‘Electrical’ • Burning, shooting, stabbing ‘Positive’ signs & symptoms • Allodynia (touch, pressure, cold pain) • Dysesthesiae • Phantom sensations ‘Negative’ signs & symptoms • Numbness • Anaesthesia dolorosa

  9. Allodynia (touch pain) & neuropathic pain

  10. Post-mastectomy pain syndrome Jung BF et al. Pain 2003 • A neuropathic pain syndrome • Pain & altered sensation in breast, axilla, chest wall • Inter-costo-brachial neuralgia • Dissection of the axilla • Scar pain (neuroma) ~30-50%

  11. Risk factors for chronic pain • High BMI • Younger age • Pre-op pain (breast, widespread pain, fibromyalgia) • Severe acute post-operative pain (>6/10) • Complex surgery: revision, reconstruction • Nerve injury: axillary dissection vs sentinel node • Radiotherapy (chemotherapy) • Limb immobilization (frozen shoulder, CRPS) • Lymphoedema Andersen, Kenneth Geving, and Henrik Kehlet. "Persistent pain after breast cancer treatment: a critical review of risk factors and strategies for prevention." The Journal of Pain 12.7 (2011): 725-746.

  12. Risk factors for chronic pain: Psychosocial ‘Yellow Flags’ • C.H.A.M.P.S • Catastrophic thinking (hypervigilance, ruminating) • Anxiety, depression • Medically-focused • Passive coping style • Single (poor social support)

  13. Risk factors with breast pain: ‘Red Flags’ • T.I.N.T • Tumour: cancer recurrence • Infection/inflammation: seroma • Neuropathic pain • Trauma: lymphoedema

  14. Prevention of chronic pain • Avoid ‘unnecessary’ surgery & re-operations (cosmetic?) • Surgical technique (minimally invasive, nerve sparing) • Screen & monitor at ‘risk patients’ • ‘Preventive analgesia’ techniques • Multidisciplinary rehabilitation

  15. Preventive analgesia techniques • Multimodal analgesia • Paracetamol (5/7) • Parecoxib or celecoxib (5/7) • Neuropathic pain drugs • Pregabalin (10/7) • Tramadol or tapentadol

  16. Preventive analgesia techniques • Local anaesthetic infiltration • EMLA cream (5/7)? • Paravertebral block??? • Epidural??? • IV Lignocaine infusion? • IV Dexmedetomidine?

  17. Breast pain management checklist • Provide education & information about breast pain • Always ask about neuropathic pain & phantom sensations • Test for allodynia, DN4Q • Check for lymphoedema • Check for shoulder pain & stiffness • Check for Complex Regional Pain Syndrome (CRPS)

  18. Breast pain management checklist • Check for ‘red flags’ (TINT) (infection, cancer) • Check ‘yellow flags’ (CHAMPS) • Indentify those at risk of chronic pain & disability • Early referral to a pain management clinic • Start multimodal analgesia (paracetamol, coxibs) • Tramadol or tapentadol & pregabalin

  19. Breast pain management checklist • Start Vitamin C 1000 mg/d & Vitamin E 500IU/d for 2M • Physiotherapy (TENS, trigger points) • Keep shoulder & arm moving • Scar or neuroma injections • Shoulder injections • Lignocaine patches • Behavioural pain management & social support

  20. What’s new? • Genetic risk • Catecholamine (COMT) enzyme • Potassium channel in nerves • Cancer recurrence and analgesia technique • Opioids?

  21. Chronic Pain Following Breast Cancer SurgeryThank you Eric J. Visser, Churack Chair, UNDA

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