The postmastectomy pain syndrome: an epidemiological study on the prevalence of chronic pain after surgery for breast cancer

Low-Level Laser Treatment Is Ineffective for Capsular Contracture: Results of the LaTCon Randomized Controlled Trial

BACKGROUND

Breast reconstruction with implants can be complicated by symptomatic capsular contracture, especially after radiotherapy. A phase I, nonrandomized clinical trial demonstrated improvement in capsular contracture and avoidance of revision surgery with low-level laser therapy. This phase II, double-blind, randomized controlled trial assessed the efficacy of low-level laser for treating capsular contracture in women with breast reconstruction following mastectomy for breast cancer.

METHODS

Participants had completed their definitive implant-based reconstruction a minimum of 6 months previously and were randomized to weekly treatments over 6 weeks with either an active or inactive low-level laser handpiece (Riancorp LTU-904). Pain, tightness, arm movement, and appearance were assessed by patient questionnaires. Breast symmetry, shape, naturalness, softness, and grade of contracture were assessed by clinician reports. Participants were assessed at 1 and 6 months after completion of the treatments.

RESULTS

A total of 42 patients (intervention arm, n = 20; placebo, n = 22) were assessed in the trial. Thirty-two had postmastectomy radiotherapy. There was no significant difference in the change in any patient-reported outcomes or clinician-reported outcomes of breast symmetry, shape, or naturalness for the two groups. There was a significantly greater improvement in clinician-reported breast softness (p < 0.05) and degree of contracture (p < 0.05) in the placebo group at both 1- and 6-month follow-up.

CONCLUSION

Low-level laser is not an effective therapy for breast implant capsular contracture in reconstruction patients.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, I.

Single institution analysis of incidence and risk factors for post-mastectomy pain syndrome

Post Mastectomy Pain Syndrome (PMPS) is a common postoperative condition for breast cancer, but has been ignored. The aim of this study was to investigate the prevalence of PMPS and the risk factors in women submitted to surgical treatment for breast cancer. The study included 532 postoperative breast cancer patients in a hospital for five consecutive years period, of whom 473 were considered eligible and included in the study. A total of 420 people completed a questionnaire survey, which revealed that 152 (36.2%) had ever suffered from PMPS and 18 (11.8%) sought treatment. Of the patients with PMPS, 34 (22.4%) had a history of chronic pain. Patients with PMPS were younger than patients without PMPS (50.5 ± 10.4 vs 53.5 ± 11.1). Univariate analysis showed that age, history of chronic pain, tumor staging, number of lymphadenectomy were significantly different between the two groups. Multivariate analysis shows that age and history of chronic pain were independent risk factors. The incidence of PMPS in postoperative breast cancer patients can reach 36.2%, and age as well as previous history of pain are independent risk factors for PMPS. The combination of prevention and treatment may be an effective way to reduce PMPS.

Persistent Post-Mastectomy Pain: Risk Factors and Current Approaches to Treatment

Persistent Post-Mastectomy Pain (PPMP) is a common condition that can follow surgeries for breast cancer, the most common cancer in women. Because of the frequency of PPMP and its potential severity, it has received increasing research attention. This manuscript reviews the recent research literature, beginning with a brief history and then relevant medical, surgical, demographic, and psychosocial risk factors. Subsequently, social, psychological, and functional sequelae that have been linked to PPMPS are considered, as is research on current pharmacological, psychological, and rehabilitative approaches to treatment. The review concludes with a discussion of directions for future research and treatment that might reduce the incidence and impact of PPMP on breast cancer survivors. PERSPECTIVE: This article describes current research literature involving mechanisms, risks, and treatments related to persistent post-mastectomy pain. Implications of research findings also are discussed for pre- and post-surgical approaches to pain management, current treatments, and promising research directions.

Chronic postsurgical pain following breast reconstruction: a commentary and critique

In line with other major surgeries including breast cancer surgery (BCS), recent studies suggest a striking rate of chronic postsurgical pain (CPSP) following breast reconstruction. This commentary will critically examine evidence for the degree to which the prevalence of CPSP following breast reconstruction is directly attributable to reconstructive surgery. The discussion will trace similarities and distinctions between breast reconstruction and BCS in considering the risk for CPSP, and describe recent advances in the definition of CPSP, highlighting methodological limitations in the general investigation of CPSP, which also characterize the study of CPSP more specifically for breast reconstruction outcome. A convenience sample of relevant studies examining CPSP following breast reconstruction reveals inadequate evidence to support a serious concern for reconstruction-induced CPSP and further that these studies fail to adhere to recommended methodological standards to effectively isolate surgery as the etiology of persistent pain reported by women following reconstructive surgery. Suggestions for future exploration of problematic chronic pain after breast reconstruction are considered.

Persistent Breast Pain Among Women With Histories of Breast-conserving Surgery for Breast Cancer Compared With Women Without Histories of Breast Surgery or Cancer

OBJECTIVES

This study compared persistent breast pain among women who received breast-conserving surgery for breast cancer and women without a history of breast cancer.

METHODS

Breast cancer survivors (n=200) were recruited at their first postsurgical surveillance mammogram (6 to 15 mo postsurgery). Women without a breast cancer history (n=150) were recruited at the time of a routine screening mammogram. All women completed measures of breast pain, pain interference with daily activities and intimacy, worry about breast pain, anxiety symptoms, and depression symptoms. Demographic and medical information were also collected.

RESULTS

Persistent breast pain (duration ≥6 mo) was reported by 46.5% of breast cancer survivors and 12.7% of women without a breast cancer history (P<0.05). Breast cancer survivors also had significantly higher rates of clinically significant persistent breast pain (pain intensity score ≥3/10), as well as higher average breast pain intensity and unpleasantness scores. Breast cancer survivors with persistent breast pain had significantly higher levels of depressive symptoms, as well as pain worry and interference, compared with survivors without persistent breast pain or women without a breast cancer history. Anxiety symptoms were significantly higher in breast cancer survivors with persistent breast pain compared with women without a breast cancer history.

DISCUSSION

Results indicate that persistent breast pain negatively impacts women with a history of breast-conserving cancer surgery compared with women without that history. Strategies to ameliorate persistent breast pain and to improve adjustment among women with persistent breast pain should be explored for incorporation into standard care for breast cancer survivors.

Surgical Outcome and Cosmetic Results of Autologous Fat Grafting After Breast Conserving Surgery and Radiotherapy for Breast Cancer: A Retrospective Cohort Study of 222 Fat Grafting Sessions in 109 Patients

BACKGROUND

Breast conserving surgery (BCS) and radiotherapy (RT) often lead to breast deformity. Reconstruction of these defects is a surgical challenge. Lately, the popularity of autologous fat grafting in these patients is growing. The purpose of this study was to assess clinical outcomes and aesthetic results of autologous fat grafting after BCS and RT.

MATERIALS AND METHODS

A database of all patients who underwent fat grafting after BCS and RT was prospectively maintained. Patient demographics, clinical and surgical characteristics and intra- and postoperative complications were analysed. Preoperative and 6-month postoperative photographs were evaluated by a four-member expert-panel assessing the aesthetic outcome (Harvard scale, five-point aesthetic scale and an overall score).

RESULTS

Between June 2008 and January 2016, 109 consecutive patients (114 breasts) underwent 222 fat grafting procedures. The mean clinical postoperative follow-up was 26 ± 19 months (range 10-97). The median number of fat grafting sessions sufficient for a satisfactory surgical result was two (range 1-6). Localized infections occurred in four patients, all treated effectively with oral antibiotics. Fat necrosis that required excision under local anaesthesia occurred once. The overall cosmetic appearance was rated 5.1/10 before and 7.2/10 after reconstruction (p < 0.01). A significant improvement was noted in breast symmetry, volume, shape and scarring.

CONCLUSION

Fat grafting after BCS and RT provides significant aesthetic improvement of the breast. It has a positive effect on the postsurgical scar and irradiated tissue and helps to restore the volume deficit, which makes it suitable as a reconstructive approach in this patient group.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Is chronic postsurgical pain surgery-induced? A study of persistent postoperative pain following breast reconstruction

BACKGROUND

Chronic postsurgical pain (CPSP) is a reported risk for women undergoing breast reconstruction, but it remains unclear that such persistent pain is induced by reconstructive surgery. To address this concern, this prospective cohort study examined the prevalence of and risk factors associated with CPSP among women undergoing breast reconstruction.

MATERIALS AND METHODS

Women (n = 1996) recruited for the Mastectomy Reconstruction Outcomes Consortium (MROC) Study were assessed preoperatively and at two-years postoperatively for relevant medical/.surgical variables, pain experience, body physical well-being, anxiety, depression, and reconstruction procedure type and characteristics.

RESULTS

Nearly half of the entire sample reported some level of preoperative pain. At two years there were statistically significant but not clinically meaningful increases in both pain intensity and chest/upper body discomfort but a decrease in affective pain rating. Average clinical pain severity was strikingly similar for preoperative and postoperative assessments. Preoperative levels of pain, acute postoperative pain, and (marginally) level of depression held consistent relationship at two-year follow-up with all outcome measures. Autologous flap reconstruction was associated with more severe CPSP compared to TE/I reconstruction. Older age, higher BMI, bilateral reconstruction, and adjuvant radiation and chemotherapy were associated with CPSP and chest/upper body discomfort for at least one outcome measure at two years.

CONCLUSIONS

The substantial rate of preoperative pain and comparable prevalence of preoperative and postoperative pain ratings suggest that persistent pain after breast reconstruction may not necessarily reflect surgery-induced pain. Future research will need to determine those factors that contribute to long-term pain following breast reconstruction.

Post-breast surgery pain syndrome: establishing a consensus for the definition of post-mastectomy pain syndrome to provide a standardized clinical and research approach - a review of the literature and discussion

BACKGROUND

Post-mastectomy pain syndrome (PMPS) is a frequent complication of breast surgery. There is currently no standard definition for this chronic pain syndrome. The purpose of this review was to establish a consensus for defining PMPS by identifying the various elements included in the definitions and how they vary across the literature, determining how these definitions affect the methodological components therein, and proposing a definition that appropriately encompasses all of the appropriate elements.

METHODS

We searched PubMed to retrieve all studies and case reports on PMPS, and we analyzed definitions of PMPS, inclusion/exclusion criteria, and methods of measuring PMPS.

RESULTS

Twenty-three studies were included in this review. We identified 7 independent domains for defining PMPS: surgical breast procedure, neuropathic nature, pain of at least moderate intensity, protracted duration, frequent symptoms, appropriate location of the symptoms and exacerbation with movement. These domains were used with varying frequency. Inclusion/exclusion criteria and methods for assessing PMPS also varied markedly.

CONCLUSION

To prevent future discrepancies in both the clinical and research settings, we propose a new and complete definition based on the results of our review: PMPS is pain that occurs after any breast surgery; is of at least moderate severity; possesses neuropathic qualities; is located in the ipsilateral breast/chest wall, axilla, and/or arm; lasts at least 6 months; occurs at least 50% of the time; and may be exacerbated by movements of the shoulder girdle.

The Post-mastectomy Pain Syndrome-A Systematic Review of the Treatment Modalities

Post-mastectomy pain syndrome (PMPS) is a chronic neuropathic pain condition, affecting many women who have undergone breast cancer surgery. The development of PMPS is complex and the treatment options are limited. In this systematic review, we have analyzed the existing treatment modalities of PMPS. Six studies on five treatments were carefully selected, critically evaluated, and presented. The treatments were: antidepressants, anti-epileptics, topical capsaicin, and autologous fat grafting. Four of these treatments had a significant effect on PMPS. However, most of the studies had several flaws and therefore larger studies of high quality should be performed in the future.

TENS effects on dysesthesia and quality of life after breast cancer surgery with axilectomy: randomized controlled trial

Abstract Introduction: After breast cancer surgery, many women may present quality of life (QOL) impairment due to the presence of discomfort as dysesthesia in the anterolateral region of the chest, armpit and/or medial part of the arm caused by intercostobrachial nerve injury (ICBN). Objective: To investigate the effects of Transcutaneous Electrical Nerve Stimulation (TENS) on dysesthesia intensity at the intercostobrachial nerve (ICBN) dermatome and QOL in women after breast cancer surgery. Methods: A randomized, double-blinded, placebo controlled clinical trial was conducted. Women undergoing axillary lymphadenectomy (AL), with dysesthesia on ICBN dermatome were included. Patients were divided into active and placebo TENS groups. TENS was applied with a frequency of 100 Hz, pulse duration of 100 µs and amplitude at the highest sensory intensity tolerable for 20 minutes during 20 sessions, three times a week, on alternating days. In the placebo TENS group, electrical current was delivered only during the first 45 seconds of application. Skin sensitivity was assessed by esthesiometry. Dysesthesia intensity was assessed with a visual analogue scale (VAS) and QOL with the EORTC QLQ-C30 and the specific EORTC QLQ-BR23 which is the Breast Cancer Module. Results: VAS decreased significantly over the 20 sessions in the active TENS group (p<0.006) and no difference was found between groups. There weren’t significant differences in EORTC QLQ-C30 and EORTC QLQ-BR23 after 20 sessions or between groups. Conclusion: TENS decreased dysesthesia intensity in the ICBN dermatome after breast cancer surgery, but did not improve quality of life.

The effect of kinesio taping with exercise compared with exercise alone on pain, range of motion, and disability of the shoulder in postmastectomy females: a randomized control trial

[Purpose] The aim of the study was to investigate the effect of kinesio tape on pain, range of motion, and disability of the shoulder. [Subjects and Methods] Seventy-four female patients who underwent modified radical mastectomy participated in this study. They were randomly divided into two groups, an experimental group that received kinesio tape for the shoulder joint in addition to a conventional physiotherapy program and a control group that received the physiotherapy program only. Outcome measures included the Visual Analogue Scale, shoulder range of motion, and Shoulder Pain and Disability Index. [Results] The experimental group showed significant differences in all outcome measures both within and between groups. The control group only showed a significant within group difference in shoulder flexion. [Conclusion] Clinicians should be able to recognize the benefits achieved through the use of adjunct treatment options such as kinesio tape in comparison with benefits that can be obtained through the use of individual modalities in physical therapy. Kinesio tape can be suggested and recommended for postmastectomy patients, especially for shoulder pain, range of motion, and disability.

Persistent Pain after Breast Cancer Treatment: A Questionnaire-Based Study on the Prevalence, Associated Treatment Variables, and Pain Type

Purpose

Persistent pain is a common side effect of breast cancer treatment. The present study aimed to assess the prevalence, associated treatment-related factors, and the type of pain (neuropathic or nociceptive) in patients who had undergone a unilateral mastectomy.

Methods

All women who underwent a unilateral mastectomy at a University Hospital between 2009 and 2013 were eligible for inclusion. Women with breast reconstruction or active cancer were excluded. Participants were mailed a questionnaire evaluating the prevalence, location, intensity, and frequency of surgical site pain. Additionally, the painDETECT®, a validated instrument to evaluate neuropathic pain, was mailed to all participants.

Results

A total of 305 women were included, and of them, 261 (85.6%) completed the study questionnaire. After a median follow-up period of 3.0 years, 100 women (38.3%) reported experiencing pain at the surgical site. Body mass index ≥30 kg/m², radiation therapy, and axillary lymph node dissection were significantly associated with persistent pain in univariate models. However, only body mass index ≥30 kg/m² was independently associated with persistent pain (odds ratio, 2.13; 95% confidence interval, 1.06–4.27; p=0.034) in a multivariate analysis. Of the patients reporting pain, 71.0% were unlikely to have a neuropathic pain component. A moderate, but highly significant, positive correlation was observed between the pain intensity and the painDETECT® score (rs=0.47, p<0.001).

Conclusion

Persistent pain after breast cancer treatment continues to have a high prevalence. Our results indicate that the largest proportion of patients experiencing persistent pain after breast cancer treatment do not have a clear neuropathic pain component.

A review of postoperative analgesia for breast cancer surgery

An online database search with subsequent article review was performed in order to review the various analgesic modalities for breast cancer surgery. Of 514 abstracts, 284 full-length manuscripts were reviewed. The effect of pharmacologic interventions is varied (NSAIDS, opioids, anticonvulsants, ketamine, lidocaine). Likewise, data from high-quality randomized, controlled studies on wound infiltration (including liposome encapsulated) and infusion of local anesthetic are minimal and conflicting. Conversely, abundant evidence demonstrates paravertebral blocks and thoracic epidural infusions provide effective analgesia and minimize opioid requirements, while decreasing opioid-related side effects in the immediate postoperative period. Other techniques with promising – but extremely limited – data include cervical epidural infusion, brachial plexus, interfascial plane and interpleural blocks. In conclusion, procedural interventions involving regional blocks are more conclusively effective than pharmacologic modalities in providing analgesia to patients following surgery for breast cancer.

Hyperbaric oxygen therapy for late radiation-induced tissue toxicity: prospectively patient-reported outcome measures in breast cancer patients

Introduction

This study examines patient reported outcome measures of women undergoing hyperbaric oxygen treatment (HBOT) after breast-conserving therapy.

Method

Included were 57 women treated with HBOT for late radiation-induced tissue toxicity (LRITT) referred in the period January 2014-December 2015. HBOT consisted of (on average) 47 sessions. In total, 80 min of 100 % O₂ was administered under increased pressure of 2.4 ATA. Quality of life was assessed before and after treatment using the European Organization for Research and Treatment of Cancer (EORTC) QLQ-BR23, and a NRS pain score.

Results

Fifty-seven women were available for evaluation before and after treatment. Before HBOT, patients had severe complaints of pain in the arm/shoulder (46 %), swollen arm/hand (14 %), difficulty to raise arm or move it sideways (45 %), pain in the area of the affected breast (67 %), swollen area of the affected breast (45 %), oversensitivity of the affected breast (54 %), and skin problems on/in the area of the affected breast (32 %); post HBOT, severe complaints were still experienced in 17, 7, 22, 15, 13, 15, and 11 % of the women, respectively. Differences were all significant. The NRS pain score improved at least 1 point (range 0–10) in 81 % of the patients (p < 0.05).

Conclusion

In these breast cancer patients treated with HBOT for LRITT, the patient-reported outcomes were positive and improvements were observed. HBOT was a well-tolerated treatment for LRITT and its side-effects were both minimal and reversible.

Concerns about Breast Cancer, Pain, and Fatigue in Non-Metastatic Breast Cancer Patients Undergoing Primary Treatment

Women diagnosed with breast cancer often endorse psychosocial concerns prior to treatment, which may influence symptom experiences. Among these, low perceived social support relates to elevated fatigue. Those with low social support perceptions may also experience a greater sense of rejection. We sought to determine if social rejection concerns post-surgery predict fatigue interference 12 months later in women with non-metastatic breast cancer. Depressive symptoms and pain severity after completion of adjuvant therapy (six months post-surgery) were examined as potential mediators. Women (N = 240) with non-metastatic breast cancer were recruited 2–10 weeks post-surgery. Multiple regression analyses examined relationships among variables adjusting for relevant covariates. Greater rejection concerns at study entry predicted greater fatigue interference 12 months later (p < 0.01). Pain severity after adjuvant therapy partially mediated the relationship between social rejection concerns and fatigue interference, with significant indirect (β = 0.06, 95% CI (0.009, 0.176)) and direct effects (β = 0.18, SE = 0.07, t(146) = 2.78, p < 0.01, 95% CI (0.053, 0.311)). Therefore, pain levels post-treatment may affect how concerns of social rejection relate to subsequent fatigue interference. Interventions targeting fears of social rejection and interpersonal skills early in treatment may reduce physical symptom burden during treatment and into survivorship.

Cancer treatment and survivorship statistics, 2016

The number of cancer survivors continues to increase because of both advances in early detection and treatment and the aging and growth of the population. For the public health community to better serve these survivors, the American Cancer Society and the National Cancer Institute collaborate to estimate the number of current and future cancer survivors using data from the Surveillance, Epidemiology, and End Results cancer registries. In addition, current treatment patterns for the most prevalent cancer types are presented based on information in the National Cancer Data Base and treatment-related side effects are briefly described. More than 15.5 million Americans with a history of cancer were alive on January 1, 2016, and this number is projected to reach more than 20 million by January 1, 2026. The 3 most prevalent cancers are prostate (3,306,760), colon and rectum (724,690), and melanoma (614,460) among males and breast (3,560,570), uterine corpus (757,190), and colon and rectum (727,350) among females. More than one-half (56%) of survivors were diagnosed within the past 10 years, and almost one-half (47%) are aged 70 years or older. People with a history of cancer have unique medical and psychosocial needs that require proactive assessment and management by primary care providers. Although there are a growing number of tools that can assist patients, caregivers, and clinicians in navigating the various phases of cancer survivorship, further evidence-based resources are needed to optimize care. CA Cancer J Clin 2016;66:271-289. © 2016 American Cancer Society.

Clinical and neurophysiological evaluation of persistent sensory disturbances in breast cancer women after mastectomy with or without radiotherapy

PURPOSE

Breast cancer surgery or radiotherapy (RT) are potential causes of persistent pain syndrome. It remains to be clarified whether numbness or pain reported by patients after mastectomy and RT are conditioned by changes in nerve transmission. The aim of this study was to examine the potential relationship between subjective sensory complications and neurophysiological examinations in breast cancer survivors with post-mastectomy pain syndrome.

METHODS

Sixty breast cancer survivors (30 patients only after mastectomy - group A; and 30 after mastectomy with RT - group B) complaining of pain and sensory disturbances in the brachial plexus area and 20 healthy women (group C) were studied with regard to sensory perception and pain intensity using the Visual Analogue Scale and electroneurography (ENG).

RESULTS

There was a statistically significant decrease in the amplitudes in SCV recordings following stimulation of the ulnar (p = 0.04) and lateral cutaneous antebrachii nerves (p = 0.02) in group B in comparison to group C. Additionally, a significant decrease in the amplitude and conduction velocity parameters was detected in the sensory fibers of the median and medial cutaneous antebrachii nerves in group A (p = 0.00 and p = 0.02, respectively) in comparison to group C.

CONCLUSIONS

The results of this pilot study suggest persistent post-mastectomy pain syndrome sometimes appears as a result of nerve injury in course of breast cancer surgery and RT. Therefore studies in nerve conduction may be added to the comprehensive patient assessment used in planning breast cancer patients' rehabilitation after oncological treatment has finished.

Breast cancer survivors suffer from persistent postmastectomy pain syndrome and posttraumatic stress disorder (ORTHUS study): a study of the palliative care working committee of the Turkish Oncology Group (TOG)

PURPOSE

Persistent postmastectomy pain syndrome (PMPS) is one of the most important disturbing symptoms. Posttraumatic stress disorder (PTSD) is an anxiety disorder which is characterized by reactions to reminders of the trauma that has been experienced. The purpose of this study is to evaluate the predictors of PMPS and PTSD in Turkish breast cancer survivors and the correlation between PMPS and PTSD.

METHOD

The study is designed as a multicenter survey study. Breast cancer patients in remission were evaluated. Patients were evaluated with structured questionnaires to assess the PMPS and clinical parameters associated with it. The Turkish version of the posttraumatic stress disorder checklist-civilian version (PCL-C) was used.

RESULTS

Between February 2015 and October 2015, 614 breast cancer survivors in outpatient clinics were evaluated. The incidence of PMPS documented is 45.1 %. In the multivariate analysis low income, presence of PTSD and <46 months after surgery were associated with increased risk of PMPS. PTSD was documented in 75 %, and the mean PCL-C score was 32.4 ± 11.1. PMPS and being married at the time of the evaluation were linked with PTSD.

CONCLUSIONS

It is the first data about the association between PMPS and PTSD. The clinicians should be aware of PMPS and PTSD in breast cancer survivors.

An exploratory study on the effectiveness of "Calmare therapy" in patients with cancer-related neuropathic pain: A pilot study

PURPOSE

Calmare therapy (CT) has been suggested as a novel treatment for managing chronic pain. Recently, it was reported to show a positive therapeutic outcome for managing neuropathic pain condition. We performed an exploratory prospective study on the effectiveness of CT in patients with various types of cancer-related neuropathic pain (CNP).

METHOD

We performed an open-labeled, single-arm, exploratory study on the effectiveness of CT in patients with various types of cancer-related neuropathic pain (CNP). The primary endpoint was a comparison of the 11-point Numerical Rating Scale (NRS) pain score at one month with the baseline score in each patient. Brief Pain Inventory (BPI) and consumption of opioid were also evaluated during follow-up period.

RESULTS

CT significantly decreased NRS pain score at one month from baseline (p < 0.001) in 20 patients with chemotherapy-induced peripheral neuropathy (n = 6), metastatic bone pain (n = 7), and post-surgical neuropathic pain (n = 7). It also improved overall BPI scores, decreased consumption of rescue opioid (p = 0.050), and was found satisfactory by a half of patients (n = 10, 50.0%).

CONCLUSIONS

Our preliminary results suggest that CT may be considered for cancer patients with various types of CNP. Large studies are necessary to confirm our findings and ascertain which additional CNP show positive response to CT.

Pain in cancer survivors

Cancer and its treatment exert a heavy psychological and physical toll. Of the myriad symptoms which result, pain is common, encountered in between 30% and 60% of cancer survivors. Pain in cancer survivors is a major and growing problem, impeding the recovery and rehabilitation of patients who have beaten cancer and negatively impacting on cancer patients' quality of life, work prospects and mental health. Persistent pain in cancer survivors remains challenging to treat successfully. Pain can arise both due to the underlying disease and the various treatments the patient has been subjected to. Chemotherapy causes painful chemotherapy-induced peripheral neuropathy (CIPN), radiotherapy can produce late effect radiation toxicity and surgery may lead to the development of persistent post-surgical pain syndromes. This review explores a selection of the common causes of persistent pain in cancer survivors, detailing our current understanding of the pathophysiology and outlining both the clinical manifestations of individual pain states and the treatment options available.

Thoracic paravertebral block reduced the incidence of chronic postoperative pain for more than 1 year after breast cancer surgery

Background

Thoracic paravertebral block (TPVB) is used to reduce pain after breast cancer surgery (BCS), but the pain-reduction effects more than 1 year after surgery are unclear.

Findings

Fifty-one patients underwent BCS at the Niigata City General Hospital from December 2009 through March 2010. To evaluate the long-term effects of TPVB in the reduction of chronic pain after BCS, we retrospectively reviewed the anesthesia charts and medical records of these patients and conducted telephone surveys regarding postoperative pain 13–17 months after surgery in 46 of these patients. Among the 46 patients enrolled in this study, 17 experienced chronic pain. There was a significant difference in the percentage of patients that received TPVB among those with and without chronic pain (patients with chronic pain 5/17 (29.4 %), patients without chronic pain 18/29 (62.1 %), p = 0.039). The pain score 3–6 h after surgery was significantly higher in the patients with chronic pain than without (p = 0.016). Bivariate logistic regression revealed that TPVB and pain score 3–6 h after surgery were independent predictive factors of chronic pain after BCS.

Conclusions

These results indicate that TPVB has the potential to reduce chronic pain for more than 1 year after BCS.

Long-term effect of pulsed high-intensity laser therapy in the treatment of post-mastectomy pain syndrome: a double blind, placebo-control, randomized study

We assess the long-term effect of pulsed high-intensity laser therapy (HILT) in the treatment of the post-mastectomy pain syndrome (PMPS). A total of 61 women participated in this study (30 in the laser group and 31 in the placebo laser group), with a mean age of 53.56 ± 1.11 years. Patients who were randomly assigned to the laser group received HILT three times per week for 4 weeks, plus a routine physical therapy program (RPTP). The placebo laser group received placebo HILT plus RPTP. The outcomes measured were pain level by visual analog scale (VAS), shoulder range of motion (ROM), and quality of life (QOL). Statistical analysis was performed by ANOVA with repeated measures to compare the differences between baseline and post-treatment measurements and after 12 weeks of follow-up for both groups. The level of statistical significance was set at P < 0.05. Shoulder ROM significantly increased in the laser group after 4 weeks of treatment and after 12 weeks of follow-up compared with the placebo group. VAS results showed a significant decrease post-treatment in the laser group relative to the placebo group, and QOL results showed a significant improvement in the laser group compared with the placebo group and still improved after 12 weeks of follow-up. HILT combined with an RPTP appears to be more effective in patients with PMPS than a placebo laser procedure with RPTP.

Cancer treatment-related neuropathic pain syndromes--epidemiology and treatment: an update

Cancer treatment-related chronic neuropathic pain (NP) is a pervasive and distressing problem that negatively influences function and quality of life for countless cancer survivors. It occurs because of cancer treatment-induced damage to peripheral and central nervous system structures. NP becomes chronic when pain signal transmission persists, eventually sensitizing neurons in the dorsal horn and other pain-processing regions in the central nervous system. Frequently overlooked, NP due to cancer treatment has been understudied. Consequently, only a few pharmacologic interventions have been shown to be effective based on the results of randomized controlled trials. Future research designed to explore pathophysiologic mechanisms and effective mechanism-targeted interventions is sorely needed.

High Body Mass Index and Young Age Are not Associated with Post-Mastectomy Pain Syndrome in Breast Cancer Survivors: A Case-Control Study

BACKGROUND

Surgery is usually the first treatment for breast cancer which is followed by some complications such as chronic pain. Post mastectomy pain syndrome (PMPS) is a common complication among breast cancer survivors and is considered as a chronic neuropathic pain in the side of surgery which persists more than three months. The exact mechanisms and related risk factors of the chronic pain after breast surgery are unknown. The aim of this study was to investigate the association of body mass index (BMI) and age with PMPS.

METHODS

In this case-control study, a total of 122 women were assessed; of these, 61 women were diagnosed with PMPS and selected as cases and 61 pain-free patients were selected as controls. The demographic and clinical characteristics of participants were collected through questionnaires and medical record of patients. Logistic regression model was used to determine the association of BMI and age with PMPS, adjusted for demographic and clinical characteristics.

RESULTS

No significant differences were found in means of weight (68.02±8.80 vs. 68.67±11.82, p=0.726), BMI (26.38±3.28 vs. 27.10±6.03, p=0.410), and age (46.34±11.67 vs. 48.54±12.57, p=0.319) between those with PMPS and those not reporting PMPS. A non-significant slight increase in odds ratio of PMPS was observed in obese category compared to normal weight category [OR=1.152 (95% CI 0.405-3.275), p=0.908], but after adjusting the confounding factors, the risk of pain development was attenuated in obese subjects [OR=0.748 (95% CI 0.228-2.459), p=0.633]. Also, non-significant decrease in odds ratios of PMPS was found in 20-39 y, 40-49 y, and 50-59 y ages categories compared to oldest age category [adjusted OR= 0.781 (95% CI 0.213-2.866), p=0.576; adjusted OR=0.485 (95% CI 0.152- 1.554), p=0.183; adjusted OR=0.735 (95% CI 0.206-2.627), p=0.628; respectively].

CONCLUSION

In contrast with some observational studies, present study showed that high BMI and younger age might not be associated with increased risk of PMPS development. Further research is necessary to determine the main risk factors and directionality and causal mechanisms for associations of these risk factors with chronic pain after mastectomy.

Chronic pain in breast cancer survivors: comparison of psychosocial, surgical, and medical characteristics between survivors with and without pain

CONTEXT

According to the literature, 25%-60% of women treated for breast cancer, regardless of the stage, experience pain. Many risk factors have been suggested, with many possible confounding factors.

OBJECTIVES

The aim was to investigate psychosocial, surgical, and medical factors associated with chronic pain by comparing breast cancer survivors with chronic pain with survivors without chronic pain. In addition, we investigated the prevalence, intensity, and body location of chronic pain after breast cancer treatment nationwide.

METHODS

A nationwide postal survey of 1332 women who received surgery and adjuvant therapy for breast cancer in Norway two to six years before the onset of this study.

RESULTS

A total of 832 women (63%) returned the questionnaires, and 41% reported pain, of which 51% had mild, 41% moderate, and 8% severe pain. Among the women who experienced pain, 33.8% reported symptoms and signs of neuropathic pain. Young age (odds ratio [OR], 0.95; 95% CI, 0.93-0.98; P < 0.0001), axillary lymph node dissection with subsequent chemotherapy and radiotherapy (OR, 1.69; 95% CI, 1.07-2.67; P = 0.02), other illness that caused pain (OR, 2.37; 95% CI, 1.72-3.26; P < 0.0001), depression (OR, 2.07; 95% CI, 1.25-3.40; P = 0.004), and anxiety (OR, 1.83; 95% CI, 1.26-2.66; P = 0.002) were associated with chronic pain.

CONCLUSION

Young age, previous comorbidities (such as back pain, arthritis, arthrosis, and fibromyalgia), and combined treatment with axillary lymph node dissection, chemotherapy, and radiotherapy were risk factors for chronic pain. Whether depression or anxiety is a risk factor for chronic pain remains unclear.

Neurological complications of breast cancer: study protocol of a prospective cohort study

INTRODUCTION

The improvement in breast cancer survival rates, along with the expected overdiagnosis and overtreatment associated with breast cancer screening, requires a comprehensive assessment of its burden. Neurological complications can have a devastating impact on these patients; neuropathic pain and chemotherapy-induced peripheral neuropathy are among the most frequently reported. This project aims to understand the burden of neurological complications of breast cancer treatment in Northern Portugal, and their role as mediator of the impact of the treatment in different dimensions of the patients' quality of life.

METHODS AND ANALYSIS

A prospective cohort study was designed to include 500 patients with breast cancer, to be followed for 3 years. The patients were recruited at the Portuguese Oncology Institute of Porto and evaluations were planned at different stages: pretreatment, after surgery, after chemotherapy (whenever applicable) and at 1 and 3 years after enrolment. Patients diagnosed with neuropathic pain or chemotherapy-induced peripheral neuropathy (subcohorts), were also evaluated at the moment of confirmation of clinical diagnosis of the neurological complication and 6 months later. In each of the follow-up periods, a neurological examination has been performed by a neurologist. Data were collected on sociodemographic and clinical characteristics, quality of life, sleep quality, and anxiety and depression. Between January and December 2012, we recruited and conducted the baseline evaluation of 506 participants. The end of the follow-up period is scheduled for December 2015.

ETHICS AND DISSEMINATION

The study protocol was approved by the Ethics Committee of the Portuguese Oncology Institute of Porto and all patients provided written informed consent. All study procedures were developed in order to assure data protection and confidentiality. Results from this project will be disseminated in international peer-reviewed journals and presented in relevant conferences.

Immediate breast reconstruction does not increase postmastectomy pain

BACKGROUND

Postmastectomy pain syndrome (PMPS) is a recognized complication of breast surgery, with a reported prevalence of 20–52 %. We investigated whether patients having immediate reconstruction (IR) reported more long-term pain compared to those having mastectomy alone (MA). We also investigated treatment factors influencing PMPS.

METHODS

In a single center, all patients who underwent MA or IR between January 2009 and June 2011 and attended for follow-up between February 2012 and July 2012 were identified. Patients were invited to complete two questionnaires, a pain intensity visual analog scale (VAS, scored 0 to 10) and the PainDetect screening tool for neuropathic pain.

RESULTS

Of 318 patients due to attend, 272 (86 %) submitted complete questionnaires. Of these, 134 (49 %) women had IR (implant based n = 93, pedicled flaps n = 33, free flaps n = 8). The overall point prevalence pain was low, with 221 (81 %) reporting VAS current pain as zero. Only 8 (3 %) patients reported a VAS score above 4. Six (2 %) patients had a positive PainDetect score. The percentage of patients reporting VAS scores greater than zero and positive or borderline PainDetect scores was similar for MA and IR (VAS: 13 and 14 %, respectively; PainDetect: 6 and 11 %, respectively). Radiotherapy was the strongest predictor of neuropathic pain.

CONCLUSIONS

In this cohort, the prevalence of PMPS was lower than historic reports. We find no evidence of increased overall pain intensity or chronic neuropathic pain after IR compared to MA despite additional tissue dissection and potential donor site morbidity. This adds support to the positive benefits of breast reconstruction.

Neuropathic pain in people with cancer (part 1): incidence, manifestation, and assessment

Many patients with cancer are at risk of experiencing neuropathic pain. This type of pain is complex and therefore requires complex assessment with a focus on impact on quality-of-life issues such as sleep and depression. Nurses are well placed to identify patients with possible signs and symptoms of neuropathic pain and so it is important for nurses to understand neuropathic pain and its manifestation, impact on quality of life, and management. Part 1 of this paper provides an overview of neuropathic cancer pain incidence, manifestation, and assessment; part 2 will address management.

Cancer treatment and survivorship statistics, 2014

The number of cancer survivors continues to increase due to the aging and growth of the population and improvements in early detection and treatment. In order for the public health community to better serve these survivors, the American Cancer Society and the National Cancer Institute collaborated to estimate the number of current and future cancer survivors using data from the Surveillance, Epidemiology, and End Results (SEER) program registries. In addition, current treatment patterns for the most common cancer types are described based on information in the National Cancer Data Base and the SEER and SEER-Medicare linked databases; treatment-related side effects are also briefly described. Nearly 14.5 million Americans with a history of cancer were alive on January 1, 2014; by January 1, 2024, that number will increase to nearly 19 million. The 3 most common prevalent cancers among males are prostate cancer (43%), colorectal cancer (9%), and melanoma (8%), and those among females are cancers of the breast (41%), uterine corpus (8%), and colon and rectum (8%). The age distribution of survivors varies substantially by cancer type. For example, the majority of prostate cancer survivors (62%) are aged 70 years or older, whereas less than one-third (32%) of melanoma survivors are in this older age group. It is important for clinicians to understand the unique medical and psychosocial needs of cancer survivors and to proactively assess and manage these issues. There are a growing number of resources that can assist patients, caregivers, and health care providers in navigating the various phases of cancer survivorship.

Identification of patient subgroups and risk factors for persistent arm/shoulder pain following breast cancer surgery

PURPOSE

In this prospective, longitudinal study, we extend our findings on persistent breast pain in patients (n = 398) following breast cancer surgery and evaluate the prevalence and characteristics of persistent pain in the arm/shoulder. In addition, differences in the severity of common symptoms and quality of life outcomes measured prior to surgery, among the arm pain classes, were evaluated.

METHODS AND SAMPLE

Patients were recruited from Breast Care Centers located in a Comprehensive Cancer Center, two public hospitals, and four community practices. Patients were assessed prior to and monthly for six months following breast cancer surgery.

RESULTS

Using growth mixture modeling, patients were classified into no (41.6%), mild (23.6%), and moderate (34.8%) arm pain classes based on ratings of worst arm/shoulder pain. Compared to the no pain class, patients in the moderate pain class were significantly younger, had a higher body mass index, and were more likely to report preoperative breast pain and swelling in the affected breast. In addition, patients in the moderate pain class reported higher levels of depression, anxiety, and sleep disturbance than the no pain class.

CONCLUSIONS

Findings suggest that approximately 35% of women experience persistent levels of moderate arm/shoulder pain in the first six months following breast cancer surgery. Moderate arm/shoulder pain is associated with clinically meaningful decrements in functional status and quality of life.

Functionality in Women with Breast Cancer: The Use of International Classification of Functioning, Disability and Health (ICF) in Clinical Practice

[Purpose] The aim of this study was to evaluate the functionality of women diagnosed with breast cancer according to the International Classification of Functioning, Disability and Health (ICF). [Subjects and Methods] This was a cross-sectional study. We applied instruments consistent with the summary of ICF codes for breast cancer: quality of life questionnaire (WHOQOL), upper limb symptoms and function (DASH), social support, physical examination and functional medical record data. [Results] The study included 105 women who were 55 years old and subjected to surgical treatment within an average of 1.63 year previously. The 'function' component considered in the WHOQOL, the DASH and physical examination. There were high prevalences of positive responses for most codes, and only b130, d430, d445, d640, d650, d920 and codes of environmental factors considered by the Social Support Questionnaire showed high prevalences of negative responses (47.6%, 61%, 43.8%, 63.8%, 56.2%, 52.4%, and 35.2%, respectively). [Conclusion] There was a lower prevalence of disability, with the exception of issues related to strenuous activity and load. Some findings showed conflicting results between different instruments that measure the same code, and studies that propose more accurate tools and are able to consider the ICF codes specific to this pathology are necessary.

Chronic pain following abdominal free flap breast reconstruction: a prospective pilot analysis

BACKGROUND

Chronic pain after breast reconstruction is an ill-defined process which can generate significant patient morbidity and disability. The purpose of this study was to examine chronic, persistent pain in a prospective study of free flap breast reconstruction patients, in an effort to identify possible points of intervention and counseling.

METHODS

We performed a prospective study evaluating function, quality of life, and satisfaction in patients undergoing abdominally based autologous reconstruction between 2006 and 2010. Using the short form 36, we examined the presence of chronic body pain (>4 months) as well as overall mental and physical health. Patients with debilitating pain were compared to those without in a post hoc analysis.

RESULTS

Overall, 399 women underwent reconstruction during the study period, with 149 enrolling and having long-term follow-up in this portion of the prospective study. Twenty-six (17%) of 149 patients experienced chronic body pain that was moderately debilitating after autologous reconstruction, making it one of the most common complications experienced in this cohort. No differences were noted in demographics, medical history, procedure type, history of axillary surgery, radiation treatment, surgical outcomes, or follow-up time between the cohorts. However, patients with chronic pain were found to have higher preoperative pain scores (P < 0.0001) and lower physical, mental, and overall health scores across time points. All scores significantly worsened with time in comparison to the cohort without pain, who, in contrast showed score improvement across all areas. Although pain issues trended toward being noted in postoperative visits more frequently in the chronic pain cohort (37% vs 19%, P = 0.051), only 1 (4.2%) patient was referred for pain service consultation. Additionally, satisfaction with reconstruction was significantly lower in patients who demonstrated chronic pain (P = 0.03).

CONCLUSIONS

Factors contributing to chronic pain continue to be elusive and understudied. Our data demonstrate the importance of screening for chronic pain, as we determined that preoperative pain is linked to increased, moderately debilitating postoperative chronic pain. Persistent chronic pain, in turn, is associated with significant morbidity, disability, and dissatisfaction. Such patients with pain issues may benefit from additional preoperative counseling and early involvement of the pain service.

Pain in 1,000 women treated for breast cancer: a prospective study of pain sensitivity and postoperative pain

BACKGROUND

This article describes the methods and results of the early part (experimental pain tests and postoperative analgesia) of a study that assesses genetic and other factors related to acute pain and persistent pain after treatment of breast cancer in a prospective cohort of 1,000 women.

METHODS

One thousand consenting patients were recruited to the study. Before surgery (breast resection or mastectomy with axillary surgery), the patients filled in questionnaires about health, life style, depression (Beck Depression Inventory), and anxiety (State-Trait Anxiety Inventory). They were also exposed to experimental tests measuring heat (43° and 48°C, 5 s) and cold (2-4°C) pain intensity and tolerance. Anesthesia was standardized with propofol and remifentanil, and postoperative analgesia was optimized with i.v. oxycodone.

RESULTS

The patients showed significant interindividual variation in heat and cold pain sensitivity and cold pain tolerance. There was a strong correlation between the experimental pain measures across the tests. Presence of chronic pain, the number of previous operations, and particularly state anxiety were related to increased pain sensitivity. Previous smoking correlated with decreased heat pain sensitivity. These factors explained 4-5% of the total variance in pain sensitivity in these tests. Oxycodone consumption during 20 h was significantly higher in patients who had axillary clearance. Oxycodone consumption had only a weak correlation with the experimental pain measures.

CONCLUSIONS

Contact heat and cold pressure tests identify variability in pain sensitivity which is modified by factors such as anxiety, chronic pain, previous surgery, and smoking. High levels of anxiety are connected to increased pain sensitivity in experimental and acute postoperative pain.

Associations between cytokine gene variations and severe persistent breast pain in women following breast cancer surgery

Persistent pain following breast cancer surgery is a significant clinical problem. Although immune mechanisms may play a role in the development and maintenance of persistent pain, few studies have evaluated for associations between persistent breast pain following breast cancer surgery and variations in cytokine genes. In this study, associations between previously identified extreme persistent breast pain phenotypes (ie, no pain vs severe pain) and single nucleotide polymorphisms (SNPs) spanning 15 cytokine genes were evaluated. In unadjusted analyses, the frequency of 13 SNPs and 3 haplotypes in 7 genes differed significantly between the no pain and severe pain classes. After adjustment for preoperative breast pain and the severity of average postoperative pain, 1 SNP (ie, interleukin [IL] 1 receptor 2 rs11674595) and 1 haplotype (ie, IL10 haplotype A8) were associated with pain group membership. These findings suggest a role for cytokine gene polymorphisms in the development of persistent breast pain following breast cancer surgery.

PERSPECTIVE

This study evaluated for associations between cytokine gene variations and the severity of persistent breast pain in women following breast cancer surgery. Variations in 2 cytokine genes were associated with severe breast pain. The results suggest that cytokines play a role in the development of persistent postsurgical pain.

Persistent postsurgical pain: evidence from breast cancer surgery, groin hernia repair, and lung cancer surgery

The prevalences of severe persistent postsurgical pain (PPP) following breast cancer surgery (BCS), groin hernia repair (GHR), and lung cancer surgery (LCS) are 13, 2, and 4-12 %, respectively. Estimates indicate that 80,000 patients each year in the U.S.A. are affected by severe pain and debilitating impairment in the aftermath of BCS, GHR, and LCS. Data across the three surgical procedures indicate a 35-65 % decrease in prevalence of PPP at 4-6 years follow-up. However, this is outweighed by late-onset PPP, which appears following a pain-free interval. The consequences of PPP include severe impairments of physical, psychological, and socioeconomic aspects of life. The pathophysiology underlying PPP consists of a continuing inflammatory response, a neuropathic component, and/or a late reinstatement of postsurgical inflammatory pain. While the sensory profiles of PPP-patients and pain-free controls are comparable with hypofunction on the surgical side, this seems to be accentuated in PPP-patients. In BCS-patients and GHR-patients, the sensory profiles indicate inflammatory and neuropathic components with contribution of central sensitization. A number of surgical factors including increased duration of surgery, repeat surgery, more invasive surgical techniques, and intraoperative nerve lesion have been associated with PPP. One of the most consistent predictive factors for PPP is high intensity acute postsurgical pain, but also psychological factors including anxiety, catastrophizing trait, depression, and psychological vulnerability have been identified as significant predictors of PPP. The quest to identify improved surgical and anesthesiological techniques to prevent severe pain and functional impairment in patients after surgery continues.

A retrospective study of postmastectomy pain syndrome: incidence, characteristics, risk factors, and influence on quality of life

Objective. The underlying cause for postmastectomy pain syndrome (PMPS) and its impact on quality of life remain unclear. The objective of this study aims to determine retrospectively the prevalence of PMPS, its predicting risk factors, and its impact on quality of life. Method. In this survey, 225 women completed a battery of questionnaires. The questionnaires comprised the short form of the McGill Pain Questionnaire (SF-MPQ) exploring the characteristics and the description of the pain, and a Short Form-36 (SF-36) Health Survey evaluating quality of life. Logistic regression analyses were subsequently performed to identify risk factors for PMPS. Results. 62 women (27.6%) reported PMPS as a consequence of surgery, and the pain was generally mild, mostly localized in breast area and intermittent. The pain was mainly described as aching (62.9%). 144 women reported sensory disturbance. We found that only the younger age is the predictive factor for PMPS (P < 0.05). Compared to the patients who did not experience PMPS, those who suffered from PMPS had significantly worse scores in role limitations due to physical problems (role physical, RP), body pain (BP), general health (GH), vitality (VT), role limitations due to emotional problems (role emotional, RE), and mental health (MH) (P < 0.05). Conclusion. PMPS is a significant problem, and the possible risk factors should be further explored. Patients with PMPS have significant worse quality of life, suggesting that patients should be well informed about the likelihood of experiencing the pain, and they may be afforded greater predictability and higher perceived control to enhance their quality of life.