Predictors of persistent pain after breast cancer surgery: a systematic review and meta-analysis of observational studies

What Does CATS Have to Do With Cancer? The Cognitive Activation Theory of Stress (CATS) Forms the SURGE Model of Chronic Post-surgical Pain in Women With Breast Cancer

Chronic post-surgical pain (CPSP) represents a highly prevalent and significant clinical problem. Both major and minor surgeries entail risks of developing CPSP, and cancer-related surgery is no exception. As an example, more than 40% of women undergoing breast cancer surgery struggle with CPSP years after surgery. While we do not fully understand the pathophysiology of CPSP, we know it is multifaceted with biological, social, and psychological factors contributing. The aim of this review is to advocate for the role of response outcome expectancies in the development of CPSP following breast cancer surgery. We propose the Cognitive Activation Theory of Stress (CATS) as an applicable theoretical framework detailing the potential role of cortisol regulation, inflammation, and inflammatory-induced sickness behavior in CPSP. Drawing on learning theory and activation theory, CATS offers psychobiological explanations for the relationship between stress and health, where acquired expectancies are crucial in determining the stress response and health outcomes. Based on existing knowledge about risk factors for CPSP, and in line with the CATS position, we propose the SURGEry outcome expectancy (SURGE) model of CPSP. According to SURGE, expectancies impact stress physiology, inflammation, and fear-based learning influencing the development and persistence of CPSP. SURGE further proposes that generalized response outcome expectancies drive adaptive or maladaptive stress responses in the time around surgery, where coping dampens the stress response, while helplessness and hopelessness sustains it. A sustained stress response may contribute to central sensitization, alterations in functional brain networks and excessive fear-based learning. This sets the stage for a prolonged state of inflammatory-induced sickness behavior - potentially driving and maintaining CPSP. Finally, as psychological factors are modifiable, robust and potent predictors of CPSP, we suggest hypnosis as an effective intervention strategy targeting response outcome expectancies. We here argue that presurgical clinical hypnosis has the potential of preventing CPSP in women with breast cancer.

Self-reported signs and symptoms of secondary upper limb lymphoedema related to breast cancer treatment: Systematic review

INTRODUCTION

Breast cancer survivors with secondary upper limb lymphoedema (ULL) may report a wide range of self-reported symptoms. At the moment, no overview of ULL-specific symptoms is available. The first aim, therefore, was to compare the prevalence rates of self-reported signs and symptoms in people with and without secondary ULL due to breast cancer treatment. The second aim was to determine whether symptoms of lymphoedema could be predictive for the development of ULL. The third aim was to describe the association between the presence/severity of symptoms and the presence/severity of ULL.

METHODS

A systematic search was conducted in Medline, Scopus, CINAHL and EMBASE databases, with key words related to breast cancer, symptoms and ULL.

RESULTS

Twenty-nine articles were eligible. The most frequently reported signs and symptoms were swelling (80.9%) and heaviness (66.7%) in the ULL group and tenderness (37%) and numbness (27%) in the non-ULL group. Perceived larger arm size, as well as feelings of arm tightness, stiffness, puffiness, pain, sensory disturbances and functional changes were predictive for the development of ULL. Moderate correlations were found between the presence of swelling, firmness in the past year and tightness now and severity of ULL. There was also moderate correlation between the presence of swelling and heaviness now and the presence of ULL.

CONCLUSIONS

Swelling and heaviness are the most commonly reported symptoms in patients with ULL. The presences of these two symptoms are moderately correlated with the presence and/or severity of ULL. Although limited information regarding the predictive self-reported symptoms for the development of ULL was found. Further research with standardised definitions of ULL and validated questionnaires for self-reported signs and symptoms are needed to confirm which signs and symptoms are related to ULL and which to other upper limb morbidities.

Pain Improvement After Healing Touch and Massage in Breast Cancer: an Observational Retrospective Study

BACKGROUND

Healing Touch (HT) and Oncology Massage (OM) are nonpharmacologic pain interventions, yet a comparative effectiveness study has not been conducted for pain in breast cancer.

PURPOSE

This breast cancer subgroup analysis compared the effectiveness of HT vs. OM on pain.

SETTING

The research occurred at an outpatient setting at an academic hybrid, multi-site, community-based cancer institute and Department of Supportive Oncology across four regional locations.

PARTICIPANTS

Breast cancer outpatients along the cancer continuum who experienced routine clinical, nonexperimentally manipulated HT or OM.

RESEARCH DESIGN

The study was an observational, retrospective, comparative effectiveness post hoc subanalysis of a larger dataset. Patients reporting pain < 2 were excluded. Pre- and posttherapy pain scores and differences were calculated. Logistic regression modeled posttherapy pain by modality, adjusting for pretherapy pain. The proportions experiencing ≥ 2-point (clinically significant) pain reduction were compared with chi-square tests.

INTERVENTION

The study focused on the first session of either HT or OM.

MAIN OUTCOME MEASURES

Pre- and posttherapy pain (range: 0 = no pain to 10 = worst possible pain).

RESULTS

A total of 407 patients reported pre- and posttherapy pain scores, comprised of 233 (57.3%) who received HT and 174 (42.8%) who received OM. Pretherapy mean pain was higher in HT (M=5.1, ± 2.3) than OM (M=4.3, ± 2.1) (p < .001); posttherapy mean pain remained higher in HT (M=2.7, ± 2.2) than OM (M=1.9, ± 1.7) (p < .001). Mean difference in pain reduction was 2.4 for both HT and OM. Both HT (p < .001) and OM (p < .001) were associated with reduced pain. Proportions of clinically significant pain reduction were similar (65.7% HT and 69.0% OM, p = .483). Modality was not associated with pain improvement (p = .072).

CONCLUSIONS

Both HT and OM were associated with clinically significant pain improvement. Future research should explore attitudes toward the modalities and potential influence of cancer stage and treatment status on modality self-selection.

Behavioral cancer pain intervention using videoconferencing and a mobile application for medically underserved patients: Rationale, design, and methods of a prospective multisite randomized controlled trial

BACKGROUND

Women with breast cancer in medically underserved areas are particularly vulnerable to persistent pain and disability. Behavioral pain interventions reduce pain and improve outcomes. Cancer patients in medically underserved areas receive limited adjunctive cancer care, as many lack access to pain therapists trained in behavioral interventions, face travel barriers to regional medical centers, and may have low literacy and limited resources. mHealth technologies have the potential to decrease barriers but must be carefully adapted for, and efficacy-tested with, medically underserved patients. We developed an mHealth behavioral pain coping skills training intervention (mPCST-Community). We now utilize a multisite randomized controlled trial to: 1) test the extent mPCST-Community reduces breast cancer patients' pain severity (primary outcome), pain interference, fatigue, physical disability, and psychological distress; 2) examine potential mediators of intervention effects; and 3) evaluate the intervention's cost and cost-effectiveness.

METHODS/DESIGN

Breast cancer patients (N = 180) will be randomized to mPCST-Community or an attention control. mPCST-Community's four-session protocol will be delivered via videoconferencing at an underserved community clinic by a remote pain therapist at a major medical center. Videoconference sessions will be supplemented with a mobile application. Participants will complete self-report measures at baseline, post-intervention, and 3- and 6-month follow-ups.

CONCLUSIONS

mPCST-Community has the potential to reduce pain and disability, and decrease barriers for cancer patients in medically underserved areas. This is one of the first trials to test an mHealth behavioral cancer pain intervention developed specifically for medically underserved communities. If successful, it could lead to widespread implementation and decreased health disparities.

Lymph Node Ratio Rather Than Positive Lymph Node Counts Has Better Prognostic Value in Patients With Testicular Germ Cell Tumors

Background:

Testicular cancer represents the most common malignancy in young adult men. In the current study, we sought to analyze and compare the prognostic value of lymph node ratio (LNR) as well as positive lymph node counts (LNC) to understand its clinical significance in testicular germ cell tumors.

Methods:

We employed eligibility criteria to recruit a total of 931 patients, with testicular cancer, from 2010 to 2015 from The Surveillance, Epidemiology, and End Results (SEER) database. We then used the X-Tile program to calculate LNR and LNC cutoff values and discriminate survival. We then calculated the overall and cancer specific survival rates and analyzed the association between LNR/LNC and clinical pathological characteristics using the χ² test. Finally, we assessed the relationships between clinical pathological factors and patient survival using univariate Cox proportional hazard analysis.

Results:

Univariate analysis revealed a significant association between prognosis with age (HR, 5.169; 95% CI, 1.758-15.200; P = 0.003), AJCC stage (III vs I: HR, 9.298; 95% CI, 2.691-32.131; P < 0.001), M stage (HR, 7.897; 95% CI, 3.417-18.251; P < 0.001) and LNR (HR, 3.009; 95% CI, 1.275-7.098; P = 0.012). On the other hand, LNC (HR, 1.743; 95% CI, 0.687-4.420; P = 0.242) was not significantly associated with prognosis. Analysis of the association between LNR/LNC and clinical pathological characteristics showed that high LNR patients tended to have significantly larger tumor sizes (χ² = 7.877, P = 0.005), as well as advanced T (χ² = 13.195, P = 0.004), N ( χ² = 86.775, P < 0.001), M (χ² = 19.948, P < 0.001) and 7th AJCC (χ² = 103.074, P < 0.001) stages. In addition, high LNC patients were significantly associated with T (χ² = 8.799, P = 0.032), N (χ² = 74.390, P < 0.001) and 7th AJCC (χ² = 111.759, P < 0.001) stages.

Conclusion:

LNR was a better predictor for long-term prognosis and was closely associated with clinical pathological characteristics than LNC in patients with testicular germ cell tumors.

Psychological and psychosocial predictors of chronic postsurgical pain: a systematic review and meta-analysis

Knowledge about psychological and psychosocial predictors of chronic postsurgical pain is important to identify patients at risk for poor outcomes. The objective of this systematic review with meta-analysis was to assess the effect of such predictors. A comprehensive search of the available literature on this topic was performed using the electronic databases PubMed, Scopus, Embase, and PsycInfo. Estimates of the effect of each predictor were extracted, and both a narrative synthesis and a quantitative synthesis of these estimates were performed. Multiple imputation was used to take into account the effect of nonsignificant estimates in case they were not reported by original studies. From a sample of 8322 records, 83 articles were included in the narrative synthesis and 41 studies were used to perform the meta-analyses. The narrative synthesis showed that evidence about the effect of psychological predictors is heterogeneous, with few expected predictors, such as optimism, state anxiety and psychological distress, consistently associated with chronic postsurgical pain. By contrast, the meta-analyses showed that state anxiety, trait anxiety, mental health, depression, catastrophizing and, to a lesser extent, kinesiophobia and self-efficacy have a weak but significant association with chronic postsurgical pain. In conclusion, this study showed that psychological predictors have a significant association with chronic postsurgical pain and that state anxiety is the most explicative one.

Characterization of Preoperative, Postsurgical, Acute and Chronic Pain in High Risk Breast Cancer Patients

Background: Pain after breast cancer surgery remains largely unexplained and inconsistently quantified. This study aims to describe the perioperative pain patterns in patients with breast cancer, up to two years after surgery. Methods: This is a pre-planned sub-study of the Ketorolac in Breast Cancer (KBC) trial. The KBC trial was a multicentre, prospective, double-blind, placebo-controlled, randomised trial of a single dose of 30 mg of ketorolac just before breast cancer surgery, aiming to test its effect on recurrences. This sub-study focuses only on pain outcomes. From 2013 to 2015, 203 patients were randomised to ketorolac (n = 96) or placebo (n = 107). Structured questionnaires were delivered by telephone after one and two years, exploring the presence, location, permanence, and frequency of pain. Patients’ perceptions of pain were captured by an open-ended question, the responses to which were coded and classified using hierarchical clustering. Results: There was no difference in pain between the ketorolac and the placebo group. The reported incidence of permanent pain was 67% and 45% at one and two years, respectively. The largest category was musculoskeletal pain. Permanent pain was mainly described in patients with musculoskeletal pain. The description of pain changed in most patients during the second postoperative year, i.e., moved from one category to another (no pain, permanent, or non-permanent pain, but also, the localisation). This phenomenon includes patients without pain at one year. Conclusions: Pain is a complex phenomenon, but also a fragile and unstable endpoint. Pain after breast cancer surgery does not necessarily mean breast pain but also musculoskeletal and other pains. The permanence of pain and the pain phenotype can change over time.

Chronic Post-Surgical Pain in the Frail Older Adult

Older adults are the fastest growing segment of the population and surgical procedures in this group increase each year. Chronic post-surgical pain is an important consideration in the older adult as it affects recovery, physical functioning, and overall quality of life. It is increasingly recognized as a public health issue but there is a need to improve our understanding of the disease process as well as the appropriate treatment and prevention. Frailty, delirium, and cognition influence post-operative outcomes in older adults and have been implicated in the development of chronic post-surgical pain. Further research must be conducted to fully understand the role they play in the occurrence of chronic post-surgical pain in the older adult. Additionally, careful attention must be given to the physiologic, cognitive, and comorbidity differences between the older adult and the general population. This is critical for elucidating the proper chronic post-surgical pain treatment and prevention strategies to ensure that the older adult undergoing surgical intervention will have an appropriate and desirable post-operative outcome.

Acute pain and side effects after tramadol in breast cancer patients: results of a prospective double-blind randomized study

The objective of this study was to evaluate the severity of acute pain and side effects in breast cancer patients postoperatively treated with two regimens of tramadol with paracetamol in a prospective double-blind study. Altogether 117 breast cancer patients who had axillary lymphadenectomy were randomized into two analgesic study groups and the analgesic treatment lasted 4 weeks. Stronger analgesia group received every 8 h 75/650 mg of tramadol with paracetamol, while weaker analgesia group received every 8 h 37.5/325 mg of tramadol with paracetamol. Patients with the higher dose of tramadol had less pain during the 1st and 4th week than patients with the lower dose. Frequency of nausea, vomiting, lymphedema or range of shoulder movement was not significantly different between the two groups of patients. Constipation was significantly more common in the group with stronger analgesia during the 2nd week in comparison to patients with weaker analgesia. The patients who were on 75/650 mg of tramadol with paracetamol had less pain in comparison to patients who were on 37.5/325 mg. Side effects were mild, but common in both groups of patients.

Ropivacaine infiltration analgesia of the drainage exit site enhanced analgesic effects after breast Cancer surgery: a randomized controlled trial

BACKGROUND

Postoperative pain after breast cancer surgery remains a major challenge in patient care. Local infiltration analgesia is a standard analgesic technique used for pain relief after surgery. Its application in patients who underwent mastectomy requires more clear elucidation. This study aimed to investigate the effect of ropivacaine infiltration of drainage exit site in ameliorating the postoperative pain after mastectomy.

METHODS

A prospective randomized controlled study was conducted in 74 patients who were scheduled for unilateral mastectomy by standardized general anesthesia. Both intervention group and control group were given infiltration of the two entry points of drainage catheters with 10 ml 0.5% ropivacaine (Group A) (n = 37) or 10 ml normal saline (Group B) (n = 37). Pain scores were recorded in post-anesthesia care unit (PACU), at 6 h, 12 h, 24 h and 36 h after operation by using a visual analogue scale (VAS). Postoperative nausea and vomiting (PONV) incidence, postoperative analgesic and antiemetic requirements, the incidence of chronic pain, as well as the quality of recovery were recorded.

RESULTS

The patients in Group A showed a significant reduction in postoperative pain in PACU (p < 0.0005), at 6 h (p < 0.0005), 12 h (p < 0.0005), and 24 h after surgery (p < 0.05) when compared to those in Group B. There were more postoperative analgesic requirements in Group B (p < 0.05). With regard to the quality of recovery, Group A was shown to be much superior over Group B (p < 0.05).

CONCLUSIONS

Ropivacaine infiltration of the two drainage exit sites decreased the degree of postoperative acute pain after mastectomy, and this approach improved patients' quality of recovery.

TRIAL REGISTRATION

retrospectively registered in Chictr.org.cn registry system on 24 February 2020 ( ChiCTR2000030139 ).

The influence of 12-week dance intervention on sleep quality and pain among women with breast cancer - Pilot study of a non-randomized clinical trial

BACKGROUND

Analyze the effects of a 12-week dance intervention on the sleep quality and the level of pain among women with breast cancer.

METHODS

Non-randomized clinical trial including 21 breast cancer survivors allocated in intervention group (n = 11) or control group (n = 10). Intervention group received a 12-week mix dance intervention and the control group maintained their routine activities. Data collection was realized through the application of a questionnaire before and after 12 weeks, involving pain (VAS) and sleep quality (Pittsburgh Sleep Quality Index). The Two-way ANOVA with repeated measures and Šidák correction, and multiple linear regression was used.

RESULTS

No significant effects were found on sleep quality and pain after the 12-week intervention with a mix dance protocol. Also, no significant difference was found between intervention and control group during post-intervention. The multiple linear regression analysis, controlled by stage of treatment, did not present a significant relationship between sleep quality and pain. Additionally, some spontaneous reports provided by the participants demonstrated a subjective improvement in their social life and general well-being.

CONCLUSION

The 12-week mix dance intervention did not seem to directly influence the sleep quality and pain of breast cancer survivors in this study; however, no adverse events were reported. Perhaps, a dance protocol focusing only in one modality of dance may be more effective for breast cancer survivors on sleep quality and pain.

Acute pain after breast surgery and reconstruction: A two-institution study of surgical factors influencing short-term pain outcomes

BACKGROUND AND OBJECTIVES

Acute postoperative pain following surgery is known to be associated with chronic pain development and lower quality of life. We sought to analyze the relationship between differing breast cancer excisional procedures, reconstruction, and short-term pain outcomes.

METHODS

Women undergoing breast cancer excisional procedures with or without reconstruction at two systems: an academic hospital (AH) and Veterans Health Administration (VHA) were included. Average pain scores at the time of discharge and at 30-day follow-up were analyzed across demographic and clinical characteristics. Linear mixed effects modeling was used to assess the relationship between patient/clinical characteristics and interval pain scores with a random slope to account for differences in baseline pain.

RESULTS

Our study included 1402 patients at AH and 1435 at VHA, of which 426 AH and 165 patients with VHA underwent reconstruction. Pain scores improved over time and were found to be highest at discharge. Time at discharge, 30-day follow-up, and preoperative opioid use were the strongest predictors of high pain scores. Younger age and longer length of stay were independently associated with worse pain scores.

CONCLUSIONS

Younger age, preoperative opioid use, and longer length of stay were associated with higher levels of postoperative pain across both sites.

Kinesiophobia contributes to pain-related disability in breast cancer survivors: a cross-sectional study

PURPOSE

Pain is one of the most prevalent problems reported by breast cancer survivors. As this long-lasting complication can result in disabilities on all different domains of functioning, we aimed to clarify the contribution of different factors (pain-related factors, psychosocial factors, and fatigue) to pain-related disability in female breast cancer survivors.

METHODS

Seventy women who had completed their primary breast cancer treatment were included in this cross-sectional study. The following outcome measures were evaluated as independent variables for their contribution to pain-related disability (measured by the Pain Disability Index, with a maximum score of 70): pain intensity, self-reported symptoms of central sensitization, fatigue, illness beliefs, pain catastrophizing, and kinesiophobia. At first, bi- and multivariable regression methods were conducted. Secondly, a stepwise regression analysis was performed to determine the explained variance of the PDI.

RESULTS

Mean score on the PDI was 16 at 4.5 years post-surgery. Multivariable regression analysis revealed higher levels of kinesiophobia as the main contributor to pain-related disability. Ultimately, stepwise regression showed that up to 40% of variance in pain-related disability could be explained by kinesiophobia, negative perceptions related to illness consequences, and pain catastrophizing.

CONCLUSION

This study shows that breast cancer survivors portray moderate self-reported pain-related disability. Kinesiophobia emerged as the main contributor to pain-related disability at this time point, which could shine a light on the improvement of treatment modalities for pain management in this population.

Preventing pain after breast surgery: A systematic review with meta-analyses and trial-sequential analyses

BACKGROUND AND OBJECTIVE

The aim of this systematic review was to indirectly compare the efficacy of any intervention, administered perioperatively, on acute and persistent pain after breast surgery.

DATABASES AND DATA TREATMENT

We searched for randomized trials comparing analgesic interventions with placebo or no treatment in patients undergoing breast surgery under general anaesthesia. Primary outcome was intensity of acute pain (up to 6 hr postoperatively). Secondary outcomes were cumulative 24-hr morphine consumption, incidence of postoperative nausea and vomiting (PONV), and chronic pain. We used an original three-step approach. First, meta-analyses were performed when data from at least three trials could be combined; secondly, trial sequential analyses were used to separate conclusive from unclear evidence. And thirdly, the quality of evidence was rated with GRADE.

RESULTS

Seventy-three trials (5,512 patients) tested loco-regional blocks (paravertebral, pectoralis), local anaesthetic infiltrations, oral gabapentinoids or intravenous administration of glucocorticoids, lidocaine, N-methyl-D-aspartate antagonists or alpha2 agonists. With paravertebral blocks, pectoralis blocks and glucocorticoids, there was conclusive evidence of a clinically relevant reduction in acute pain (visual analogue scale > 1.0 cm). With pectoralis blocks, and gabapentinoids, there was conclusive evidence of a reduction in the cumulative 24-hr morphine consumption (> 30%). With paravertebral blocks and glucocorticoids, there was conclusive evidence of a relative reduction in the incidence of PONV of 70%. For chronic pain, insufficient data were available.

CONCLUSIONS

Mainly with loco-regional blocks, there is conclusive evidence of a reduction in acute pain intensity, morphine consumption and PONV incidence after breast surgery. For rational decision making, data on chronic pain are needed.

SIGNIFICANCE

This quantitative systematic review compares eight interventions, published across 73 trials, to prevent pain after breast surgery, and grades their degree of efficacy. The most efficient interventions are paravertebral blocks, pectoralis blocks and glucocorticoids, with moderate to low evidence for the blocks. Intravenous lidocaine and alpha2 agonists are efficacious to a lesser extent, but with a higher level of evidence. Data for chronic pain are lacking.

Pain Management in Breast Surgery: Recommendations of a Multidisciplinary Expert Panel-The American Society of Breast Surgeons

Opioid overdose accounted for more than 47,000 deaths in the United States in 2018. The risk of new persistent opioid use following breast cancer surgery is significant, with up to 10% of patients continuing to fill opioid prescriptions one year after surgery. Over prescription of opioids is far too common. A recent study suggested that up to 80% of patients receiving a prescription for opioids post-operatively do not need them (either do not fill the prescription or do not use the medication). In order to address this important issue, The American Society of Breast Surgeons empaneled an inter-disciplinary committee to develop a consensus statement on pain control for patients undergoing breast surgery. Representatives were nominated by the American College of Surgeons, the Society of Surgical Oncology, The American Society of Plastic Surgeons, and The American Society of Anesthesiologists. A broad literature review followed by a more focused review was performed by the inter-disciplinary panel which was comprised of 14 experts in the fields of breast surgery, anesthesiology, plastic surgery, rehabilitation medicine, and addiction medicine. Through a process of multiple revisions, a consensus was developed, resulting in the outline for decreased opioid use in patients undergoing breast surgery presented in this manuscript. The final document was reviewed and approved by the Board of Directors of the American Society of Breast Surgeons.

Ductal carcinoma in situ (DCIS): The importance of patient-reported outcomes (PRO)

Purpose

Patient reported outcomes (PROs) are an optimal method for assessing quality of life (QOL), including physical and psychosocial health. This review summarizes PROs frequently assessed in the setting of a DCIS diagnosis.

Recent findings

Health-related QOL has generally been found to be modestly affected in women with DCIS and similar to women with invasive breast cancer. Several studies reported a substantial negative impact on sexual health and body image, including some differences based on surgery type. Some patients experience pain after treatment, although many physical symptoms resolve. The prevalence of anxiety and depression varied based on assessment timing, with symptoms improving over time. Women with DCIS often overestimate the risks associated both with DCIS and invasive cancer.

Summary

PROs provide critical information regarding the experiences of women following a DCIS diagnosis. Continued inclusion of PROs in clinical trials is warranted, further informing treatment decisions and adequately preparing patients for what to expect following treatment.

Obese Patients Who Receive an Opioid-Sparing Enhanced Recovery After Surgery (ERAS) Protocol are at Increased Risk of Persistent Pain After Breast Surgery

BACKGROUND

Obese patients are at increased risk of persistent pain and chronic opioid dependence after surgery. We sought to evaluate the impact of an Enhanced Recovery After Surgery (ERAS) protocol in breast surgery patients to determine whether multimodal analgesia was effective for both obese and non-obese patients.

METHODS

A prospective cohort of patients undergoing breast surgery who received an opioid-sparing ERAS protocol was compared with patients who did not receive ERAS, including a historical cohort. Pain scores were compared with respect to body mass index (BMI). Obesity was defined as BMI ≥ 30, and moderate to severe pain was defined as 4-10 of a 10-point scale. Postoperative day one and week one pain scores were compared using the Kruskal-Wallis test.

RESULTS

A combined contemporary and historical cohort of 1353 patients underwent lumpectomy and mastectomy without reconstruction. The present analysis comprises 622 patients with pain scores who did and did not receive ERAS between 2015 and 2018. The two groups were demographically similar. The day after surgery, those who received ERAS reported lower rates of moderate to severe pain, regardless of BMI (obese: 46.3% vs. 21.8%, p < 0.001; non-obese: 36.3% vs. 19.4%, p = 0.002). One week after surgery, obese patients who received ERAS had higher rates of persistent pain compared with non-obese patients (18.6% vs. 11.1%, p = 0.042).

CONCLUSIONS

An opioid-sparing ERAS protocol utilizing multimodal analgesia significantly improved postoperative pain control for obese and non-obese patients. However, it appears that obese patients are still at relatively greater risk for persistent pain after surgery.

Relationship of anxiety and depression symptoms with the different domains of physical activity in breast cancer survivors

Background Physical activity (PA) has shown benefits in the mental health of breast cancer (BC) survivors. However, it is unclear if different domains of PA are related to the emotional well-being of this population. The objective of this study was to verify the relationship between different domains of PA [occupational, exercise/sport participation and leisure time/commuting] with symptoms of anxiety and depression in BC survivors. Methods It is a cross-sectional study, composed of 128 women breast cancer survivor, in which the socioeconomic class was evaluated through the questionnaire of the Brazilian Association of Research Companies (ABEP), PA level was evaluated through the Baecke questionnaire, and, symptoms of anxiety and depression were evaluated through the Hospital Anxiety and Depression Scale (HADS). Results It was verified that occupational PA related to anxiety (B = 1.44 [95% CI: 0.11; 2.76]) and leisure time/commuting PA was negatively related to depression (B=-0.99 [95% CI: -1.64;-0.34]), even after adjustment of analysis by age, marital status, and socioeconomic status. There was no correlation between exercise/sport participation with scores of anxiety and depression in BC survivors. Physical activity at leisure time/commuting was negatively related with depression in BC survivors with mastectomy (B=-1.20 [95% CI:-1.92; -0.47). Limitations The difficulty of recruiting the studied population and the absence of subsidy for participation in the study are factors to be considerate. Conclusions Occupational PA may not to be indicated in the management of emotional disorders in BC survivors; however, leisure time/commuting may be recommended to contribute to the mental well-being of this population.

Modified Pectoral Nerve Block versus Serratus Block for Analgesia Following Modified Radical Mastectomy: A Randomized Controlled Trial

Background

Modified pectoral nerves (PECSII) and serratus blocks have been recently used for analgesia in breast surgery, but evidence comparing their analgesic benefits is limited. This prospective randomized, controlled study aims to examine the analgesic efficacy and safety profile of ultrasound-guided PECSII versus serratus blocks in patients undergoing modified radical mastectomy (MRM) for breast cancer.

Patients and Methods

One-hundred and eighty adult females scheduled for MRM were randomly allocated to three groups. PECS group patients received a PECSII block with 30mL of bupivacaine 0.25%, whereas SAPB group received a serratus anterior plane block (SAPB) using the same volume of bupivacaine 0.25% before induction of anesthesia. The control group received general anesthesia alone. Outcomes included 24 hours morphine consumption, intraoperative fentanyl requirements, visual analogue scale (VAS) scores for pain at rest and during movement, time to first rescue analgesia, postoperative nausea and vomiting (PONV), and sedation scores.

Results

Both PECSII and serratus blocks were associated with reduced postoperative morphine consumption compared to the control group (p<0.001). Both blocks were associated with reduced intraoperative fentanyl requirements, VAS scores, and PONV as compared with the control group. Also, they were associated with prolonged time to first rescue analgesia and better sedation scores in comparison with the control group. However, there were no differences between both blocks for all outcomes.

Conclusion

PECSII and serratus blocks provide similarly adequate analgesia following modified radical mastectomy.

Clinical Trial Registration

NCT02946294.

Analgesic Effectiveness of Ultrasound-Guided Pecs II Block in Central Venous Port Catheter Implantation

Background and Aim

In oncology patients, central venous port catheter (CVPC) implantation is generally preferred for venous route. However, in this procedure, postoperative pain is often observed. This study aimed to investigate the effectiveness of ultrasound-guided Pecs II block in the management of pain after CVPC placement.

Methods

One hundred and eighty-seven patients who underwent CVPC implantation between January 2017 and August 2018 were included in the study. Patients who underwent Pecs II block under ultrasound guidance were called as the Pecs group, and those who underwent local anesthesia (LA) were referred as the LA group. All procedural parameters were analyzed, including demographic characteristics of patients, visual analogue scores (VAS) at 2nd and 24th hours, and postoperative opioid, and non-steroidal anti-inflammatory drug (NSAID) consumption.

Results

The postoperative 2nd hour VAS scores were similar in both groups and were lower than the 24th hour VAS scores. VAS scores at the 24th hour in the Pecs group were significantly lower than the LA group (P = 0.001). While the number of fentanyl rescue doses administered in PACU was similar, the total NSAID consumption in the first 24 hours was higher in the LA group than in the Pecs group.

Conclusion

In CVPC placement, ultrasound-guided Pecs II block is a more reliable, easily applicable and longer-acting approach than LA infiltration for postoperative analgesia.

Chronic adverse effects after an axillary lymphadenectomy in breast cancer patients after administering weaker and stronger postoperative analgesia: results of a prospective double-blind randomized study

PURPOSE

The aim of this study was to compare the rate of chronic adverse effects after a weaker and stronger postoperative analgesia.

METHODS

A prospective double-blind randomized study included 117 breast cancer patients receiving tramadol for pain relief for 4 weeks after an axillary lymphadenectomy from 2015 to 2018. Patients with a larger dose received 75/650 mg of tramadol with paracetamol every 8 h and a group with a lower dose received 37.5/325 mg of tramadol with paracetamol every 8 h from the 2nd to the 29th postoperative day. 1 year after surgery, patients were evaluated for the presence of neuropathic pain, chronic pain, arm symptoms and lymphedema.

RESULTS

There was a trend for a lower rate of neuropathic pain after stronger analgesia in comparison to weaker analgesia (p = 0.059). Chronic pain was present in 18% of patients 1 year after the lymphadenectomy. There was no difference in the rate of chronic pain after stronger and weaker postoperative analgesia. Patients had less arm symptoms after a stronger analgesia than after a weaker analgesia (p = 0.02). Furthermore, there was a trend for a lower rate of lymphedema of the forearm after a stronger analgesia than after a lower analgesia (p = 0.078).

CONCLUSIONS

The patients who received a stronger postoperative analgesia had less arm symptoms and a better quality of life in comparison to patients who received a weaker analgesia. The patients who received a stronger postoperative analgesia had a statistical trend for less neuropathic pain in comparison to patients who received a weaker analgesia.

Incidence and Predictive Factors for Additional Opioid Prescription after Endoscopic Skull Base Surgery

Introduction  Postoperative pain management and opioid use following endoscopic skull base surgery (ESBS) is not well understood. A subset of patients requires additional opioid prescription (AOP) in the postoperative period. The objective of this study is to describe the incidence of AOP, as well as evaluate patient and surgical characteristics that may predict additional pain management requirements following ESBS. Methods  A retrospective review of cases undergoing ESBS between November 2016 and August 2018 was performed. We reviewed patients' sociodemographic and clinical data, and Controlled Substance Utilization Review and Evaluation System (CURES) records. Stepwise multivariable logistic regressions were performed to evaluate the factors associated with AOP within 60 days following surgery. Results  A total of 42 patients were identified. Indications for ESBS included intracranial mass (64.2%), sinonasal malignancy (23.8%), and skull base reconstruction (9.5%). AOP were recorded in nine patients (21.4%). There were no significant differences in operative factors, including approach, lesion location, or perioperative analgesia between the two cohorts. On multivariable logistic regression, we found that younger age (odds ratio [OR]: 0.891, 95% confidence interval [CI]: 0.79-1.00, p  = 0.050), comorbid depression (OR: 86.48, 95% CI: 1.40-5,379.07, p  = 0.034), and preoperative opioid use (OR: 104.45, 95% CI: 1.41-7,751.10, p  = 0.034) were associated with additional prescriptions postoperatively. Conclusion  The requirement for extended postoperative opioid pain control is common after ESBS. Patient demographics including age and psychosocial factors, such as depression may predict the need for AOP after ESBS. These results suggest that patient-driven factors, rather than surgical characteristics, may determine the need for prolonged pain control requirements after ESBS.

Prolonged Opioid Use After Surgery for Early-Stage Breast Cancer

INTRODUCTION

This study examined the patterns of prolonged opioid use and the factors associated with higher risk of prolonged opioid use among opioid-naïve working-age patients with early-stage breast cancer.

METHODS

Using MarketScan data, the study identified 23,440 opioid-naïve patients who received surgery for breast cancer between January 2000 and December 2014 and filled at least one opioid prescription attributable to surgery. Prolonged opioid use was defined as one or more prescriptions for opioids within 90 to 180 days after surgery and defined extra-prolonged opioid use as one or more opioid prescriptions between 181 and 365 days after surgery. Multivariable logistic regressions were performed to ascertain factors associated with prolonged and extra-prolonged use of opioids.

FINDINGS

Of the 23,440 patients, 4,233 (18%) had prolonged opioid use, and 2,052 (9%) had extra-prolonged opioid use. Patients who received mastectomy plus reconstruction had the highest rate of prolonged opioid use (38%) followed by mastectomy alone (15%). A multivariable logistic regression confirmed that patients with mastectomy and reconstruction had the highest odds ratio of prolonged opioid use compared to lumpectomy and whole breast irradiation (adjusted odds ratio, 5.6; 95% confidence interval, 5.1-6.1). Mean daily opioid dose was consistently high without any obvious dosage reduction among patients with opioid use.

INTERPRETATION

This large observational study showed a high rate of prolonged opioid use among patients who received surgery for early-stage breast cancer and found significant difference in prolonged opioid use by treatment type.

IMPLICATIONS FOR PRACTICE

This large observational study found a high rate of prolonged opioid use among working-age patients with early-stage breast cancer who received curative surgery, especially among patients who received mastectomy. Among patients with opioid use, the mean daily opioid dose was consistently high without any obvious dosage tapering. This study highlights the need to emphasize appropriate opioid therapy and potential dosage reduction or discontinuation among patients with early-stage breast cancer who received surgical interventions.

Pain characteristics and quality of life of breast cancer survivors that return and do not return to work: an exploratory cross-sectional study

Purpose: the aim of this study is two-fold: 1) to explore the pain characteristics among breast cancer survivors that return to work and do not return to work; 2) to identify the factors associated with pain on the upper quadrant of the affected side.Materials and methods: Sixty-two breast cancer survivors were included. Quality of life was assessed using EORTC QLQ-C30 and QLQ-BR23. Pain characteristics were assessed with a body diagram and a numeric rating scale.Results: Thirty-five breast cancer survivors did not return to work. Ninety-one percent of women that did not return to work reported pain. The most frequent pain sites were the cervical spine and the axilla of the affected side. There were no significant differences in pain intensity between groups. The factors associated with pain on the upper quadrant of the affected side were perception of shoulder stiffness OR = 5.93 (1.38-44.87, 95%CI) and time since surgery of more than four years OR = 5.54 (1.36-20.97, 95% CI).Conclusions: Pain was highly prevalent among breast cancer survivors. Breast cancer survivors that returned to work presented better quality of life. Longer time since surgery and perception of shoulder stiffness were associated with pain on the upper quadrant of the affected side.Implications for rehabilitationPain is a major factor following breast cancer surgery preventing returning to work.This group reported more pain on the cervical spine and axilla of the affected side.Rehabilitation needs to focus specifically on pain management in order to improve quality of life.A multidisciplinary approach involving pain specialists and vocational support is recommended.

[Factors Related to Persistent Postoperative Pain after Cardiac Surgery: A Systematic Review and Meta-Analysis]

PURPOSE

This study aimed at identifying factors related to persistent postoperative pain after cardiac surgery and estimating their effect sizes.

METHODS

The literature search and selection was conducted in four different databases (CINAHL, Cochrane Library, PubMed, and PQDT) using the Preferred Reporting Items for Systematic Review and Meta-Analysis Statement. A total of 14 studies met the inclusion criteria and were systematically reviewed. For the meta-analysis, R was used to analyze 30 effect sizes of for both individual and operative factors as well as publication biases from a total of nine studies.

RESULTS

The meta-analysis revealed that persistent postoperative pain after cardiac surgery was related to one individual factor (gender) and two operative factors (acute postoperative pain and use of the internal mammary artery). Operative factors (OR=5.26) had a larger effect size than individual factors (OR=1.53).

CONCLUSION

Female gender, acute pain after surgery, and use of the internal mammary artery are related factors to persistent postoperative pain. The development of interventions focusing on modifiable related factors, such as acute postoperative pain, may help to minimize or prevent PPP after cardiac surgery.

Incidence of contralateral neurosensitive changes and persistent postoperative pain 6 months after mastectomy: A prospective, observational investigation

Mirror image sensory dysfunction (MISD) after breast surgery has not yet been studied. This prospective observational study aimed to determine the incidence of MISD, persistent postoperative pain (PPP) and mirror image pain (MIP) during 6 months after total unilateral mastectomy.Visual analogue scale (VAS), Neuropathic Pain Symptom Inventory (NPSI), Pain Catastrophizing Scale (PCS), Hospital Anxiety and Depression Scale (HADS), Life orientation test (LOT) and Quantitative Sensory Testing (QST) (in ipsi and contralateral breast, axilla and thigh) were recorded. VAS > 3 at 1, 3, and 6 postoperative months was considered PPP. Contralateral changes of QST at any time was considered indicative of MISD and spontaneous contralateral VAS ≥ 1 as MIP.Sixty-four patients were included. PPP at 1, 3 and 6 months was 18.8%, 56.2%, and 21.3%, respectively Ten patients presented MIP. MISD was detected in 79.7% patients in contralateral breast and 62.5% in contralateral axilla. Furthermore, changes in QST were present in 39.1% of patients in thigh. Electronic Von Frey (EVF) changes in both contralateral breast and axilla, and in thigh significantly diminished at all postoperative times. Changes of postoperative EVF ≥ 20% in contralateral breast were associated to higher VAS values. NPSI scores were significantly higher at all postoperative times. At 1 month, PCS, depression HADS subscale and LOT scores were significantly worse than all the other periods.MISD incidence was almost 80%, and 15.6% of patients showed spontaneous contralateral VAS ≥ 1. At 6 months 21.3% of patients manifested PPP. The worst alteration of factors related to PPP occurred at 1 postoperative month. Most consistent QST was EVF.

Is Xbox 360 Kinect-based virtual reality training as effective as standard physiotherapy in patients undergoing breast cancer surgery?

PURPOSE

Breast cancer surgery may be associated with pain and physical symptoms in the upper limbs. Functional impairment and pain-related avoidance of movement may further increase disability level. This study aimed to investigate the potential effects of early postoperative virtual reality (VR) therapy on pain, range of motion (ROM), muscle strength, functionality, and fear of movement.

METHODS

Forty women with breast cancer who had undergone unilateral mastectomy with axillary lymph node dissection and who were receiving adjuvant therapy were included in the study and randomly assigned to two groups: the Kinect-based rehabilitation group (KBRG) and the standardized physical therapy group (SPTG). The KBRG (n = 20) received VR therapy using Xbox Kinect-based games and the SPTG (n = 20) received standard physiotherapy. Study subjects were assessed at baseline and after the 6-week treatment. Outcome measures were pain (visual analogue scale), grip strength (dynamometer), functionality (disabilities of the arm shoulder and hand questionnaire), muscle strength (handheld dynamometer), ROM (digital goniometer), and fear of movement (Tampa kinesiophobia scale (TKS)).

RESULTS

Both groups detected significant changes in pain, ROM, muscle strength, grip strength, functionality, and TKS scores after the treatment (p < 0.01). Fear of movement was significantly improved in the KBRG and the SPTG displayed more improvement in functionality (p < 0.05). There were no differences in ROM, muscle strength, grip strength, and pain between the groups after the treatment (p > 0.05).

CONCLUSION

Kinect-based VR therapy resulted in significant outcomes that were comparable to those obtained under standard physiotherapy in the early postoperative phase in patients who had undergone breast cancer surgery.

TRIAL REGISTRATION

This study is registered at ClinicalTrials.gov ( ClinicalTrials.gov identifier: NCT03618433).

Improving the therapeutic window of conventional opioids: novel differential signaling modulators

Conventional opioids are widely used for acute pain management in the postoperative setting. However, a primary concern with conventional opioids is their therapeutic window-the range between doses that produce the desired therapeutic effect (analgesia) and doses that produce unwanted opioid-related adverse events (ORAEs). Conventional µ receptor opioids have a narrow therapeutic window in part because of their mechanism of action (MoA): they bind to µ receptors and non-selectively activate two intracellular signaling pathways, leading to analgesia and to ORAEs. This review explores the clinical potential of µ receptor ligands with differential signaling. Agents with a 'differential signaling" MoA represent an innovative approach that may enhance the therapeutic window. These agents modulate µ receptor activity to selectively engage downstream signaling pathways associated with analgesia while limiting activity in downstream signaling pathways that lead to ORAEs. Differential signaling may fulfill an unmet need in the management of postoperative pain.

Clinical Analysis of the Effects of Different Anesthesia and Analgesia Methods on Chronic Postsurgical Pain in Patients With Uniportal Video-Assisted Lung Surgery

OBJECTIVES

To understand whether different anesthesia and analgesia methods affected the incidence of chronic postsurgical pain (CPSP) in patients who underwent uniportal video-assisted lung surgery and to explore the influence factors of CPSP.

DESIGN

Retrospective study.

SETTING AND PARTICIPANTS

A total of 120 patients, who underwent selective uniportal video-assisted lung surgery at Zhongshan Hospital from March to June 2018, were enrolled.

INTERVENTIONS

The visual analog scale was used to assess the degree of pain on the first and second postoperative days. At the third and sixth months after surgery, the telephone follow-up was conducted for the survey of the numerical rating scale. The incidence of acute and chronic pain in different anesthesia methods was analyzed, and the relevant factors of CPSP were statistically analyzed.

RESULTS

Among the 111 patients who completed follow-up, no significant difference was noted in the incidences of acute and chronic postsurgical pain between patients who received different anesthesia and analgesia methods (p > 0.05). The incidence of CPSP was 29.7% at 3 months after surgery and 9.0% at 6 months after surgery. The degree of pain within 48 hours after surgery was a risk factor for CPSP (odds ratio [OR] = 2.39, p < 0.05).

CONCLUSION

CPSP accounted for a specific proportion of patients after uniportal video-assisted lung surgery; however, it was significantly lower than that of patients with conventional thoracotomy. The incidence did not differ significantly among anesthesia and analgesia methods. Active and effective control of acute postsurgical pain might reduce the incidence of CPSP.

The Physiotherapy Intervention for Shoulder Pain in Patients Treated for Breast Cancer: Systematic Review

Pain and joint dysfunction of the upper limb following treatment for mammary carcinoma are defined as the most frequent side effects of surgery for mammary carcinoma by calculating a prevalence range in the USA that varies between 12% and 51% with regard to pain and between 1.5% and 50% for joint dysfunction. This objective of this study was to describe physiotherapy interventions that demonstrate efficacy based on the type of pain present in patients with shoulder pain who have been treated for breast cancer.

We conducted a search for relevant publications in the last 10 years (2009-2019) on the PubMed, Medline, CINAHL, and Cochrane databases. The articles obtained were selected on the basis of correlation criteria, with themes concerning shoulder pain after mammary carcinoma and physiotherapy performed to treat this pain.

Studies suggest treating musculoskeletal pain through active exercises, joint and tissue mobilization techniques, with accessory joint mobilization and neurodynamics performed by experienced physiotherapists. In order to treat radio-induced and drug-induced neuropathic pain, both aerobic and strengthening exercises are supervised by an experienced physiotherapist and carried out twice weekly for a total of 150 minutes of exercise. Finally, the treatment suggested to deal with chronic pain uses a multidisciplinary approach, including pain education interventions, pharmacological interventions, psychological interventions, and physiotherapy interventions.

To conclude. the classification of different types of shoulder pain following mammary carcinoma treatments requires specific and targeted physiotherapy interventions in which active therapeutic exercise has a central role.

The effectiveness of physiotherapy interventions on pain and quality of life in adults with persistent post-surgical pain compared to usual care: A systematic review

Background

Persistent post-surgical pain (PPSP) is a common condition following surgery, resulting in persistent pain and reduced quality of life (QoL). While pharmacological management is common, its effectiveness remains equivocal. This systematic review investigated the effectiveness of physiotherapy management in adults with PPSP in comparison to usual care.

Methods

A systematic search of six electronic databases was conducted. Studies of human adults (>18 years) with PPSP localised or directly referred from the surgical site, pain persisting for at least two months post-surgery and with physiotherapy as the intervention were included. This review was conducted and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The McMaster critical review form for quantitative studies was utilised to assess the methodological quality. A descriptive synthesis was undertaken due to the heterogeneity of the included studies.

Results

Of the 1395 articles that were screened, eight studies met the inclusion criteria. A diverse range of physiotherapy interventions were utilised, and effectiveness was measured through diverse outcomes and measures. Summarised findings from the heterogenous evidence base indicated that physiotherapy interventions for PPSP has a positive impact across a range of outcomes, including pain, quality of life (QoL), physical function and depression. While these are encouraging findings, the current evidence base lacks uniformity with regards to participant characteristics, time periods since diagnosis, interventions delivered, and its parameters, and outcomes measured.

Conclusion

Due to ongoing challenges in the management of PPSP, alternate treatment strategies such as physiotherapy are being trialled. Despite a number of methodological constraints, current evidence indicates that physiotherapy could play a role in the management of PPSP.

PROSPERO registration

CRD42019129580

The role of physical, cognitive and social factors in pain interference with activities of daily living among individuals with chronic cancer pain

OBJECTIVES

The aim of this study was to better understand the role that physical, cognitive and social factors play in pain interference with activities of daily living among individuals with cancer and chronic pain.

METHOD

In this cross-sectional study, interviews with 156 patients with chronic cancer pain were conducted across five tertiary level hospitals in the province of Tarragona (Spain). Participants were interviewed individually and provided information about the presence and characteristics of pain, fatigue, catastrophic thinking, social support and the impact of pain on their daily activities.

RESULTS

Pain intensity (β = 0.23, p = .003), fatigue (β = 0.26, p < .001) and pain catastrophising (β = 0.39, p < .001) were significantly and positively associated with pain interference in daily activities. Pain interference scores were not explained by social support (β = 0.12 p = .090) or socio-demographic factors (R²  = .005; p = .94).

CONCLUSION

This study provides important new findings regarding the association between physical, cognitive and social factors and function of individuals with cancer and chronic pain, thus supporting a biopsychosocial approach to the management of chronic pain in individuals with cancer.

Treating Persistent Pain After Breast Cancer Surgery

Breast cancer is one of the most commonly diagnosed cancers among women, and since the prognosis of breast cancer has substantially improved in past decades, complications of management are becoming increasingly apparent. Persistent pain lasting greater than 3 months after breast cancer surgery is unfortunately a common complication affecting approximately 30% of patients after tumour resection. Persistent breast cancer pain has neuropathic features and is typically mild-to-moderate in intensity, with approximately 10% suffering from severe pain. There is an increasing need to prevent persistent pain through the use of transitional pain programmes and perioperative interventions, and to identify novel treatment modalities to reduce suffering in those who unfortunately develop persistent pain. This review serves to provide an overview on persistent pain after breast cancer surgery, its pathophysiology, and current management strategies.

Erector Spinae Plane Block Decreases Pain and Opioid Consumption in Breast Surgery: Systematic Review

Adequate control of acute postoperative pain is crucial in breast surgeries, as it is a significant factor in the development of persistent chronic pain. Inadequate postoperative pain control increases length of hospital stays and risk of severe complications. Erector spinae plane block (ESPB) is a novel regional block that has the ability to sufficiently block unilateral multidermatomal sensation from T1 to L3. By reviewing the literature on ESPB, this paper aimed to elucidate its efficacy in breast surgery analgesia and its role in addressing the opioid crisis in North America.

Recurrence of breast cancer after regional or general anaesthesia: a randomised controlled trial

BACKGROUND

Three perioperative factors impair host defence against recurrence during cancer surgery: the surgical stress response, use of volatile anaesthetic, and opioids for analgesia. All factors are ameliorated by regional anaesthesia-analgesia. We tested the primary hypothesis that breast cancer recurrence after potentially curative surgery is lower with regional anaesthesia-analgesia using paravertebral blocks and the anaesthetic propofol than with general anaesthesia with the volatile anaesthetic sevoflurane and opioid analgesia. A second hypothesis was that regional anaesthesia-analgesia reduces persistent incisional pain.

METHODS

We did a randomised controlled trial at 13 hospitals in Argentina, Austria, China, Germany, Ireland, New Zealand, Singapore, and the USA. Women (age <85 years) having potentially curative primary breast cancer resections were randomised by computer to either regional anaesthesia-analgesia (paravertebral blocks and propofol) or general anaesthesia (sevoflurane) and opioid analgesia. The primary outcome was local or metastatic breast cancer recurrence. The secondary outcome was incisional pain at 6 months and 12 months. Primary analyses were done under intention-to-treat principles. This trial is registered with ClinicalTrials.gov, NCT00418457. The study was stopped after a preplanned futility boundary was crossed.

FINDINGS

Between Jan 30, 2007, and Jan 18, 2018, 2132 women were enrolled to the study, of whom 24 were excluded before surgery. 1043 were assigned to regional anaesthesia-analgesia and 1065 were allocated to general anaesthesia. Baseline characteristics were well balanced between study groups. Median follow-up was 36 (IQR 24-49) months. Among women assigned regional anaesthesia-analgesia, 102 (10%) recurrences were reported, compared with 111 (10%) recurrences among those allocated general anaesthesia (hazard ratio 0·97, 95% CI 0·74-1·28; p=0·84). Incisional pain was reported by 442 (52%) of 856 patients assigned to regional anaesthesia-analgesia and 456 (52%) of 872 patients allocated to general anaesthesia at 6 months, and by 239 (28%) of 854 patients and 232 (27%) of 852 patients, respectively, at 12 months (overall interim-adjusted odds ratio 1·00, 95% CI 0·85-1·17; p=0·99). Neuropathic breast pain did not differ by anaesthetic technique and was reported by 87 (10%) of 859 patients assigned to regional anaesthesia-analgesia and 89 (10%) of 870 patients allocated to general anaesthesia at 6 months, and by 57 (7%) of 857 patients and 57 (7%) of 854 patients, respectively, at 12 months.

INTERPRETATION

In our study population, regional anaesthesia-analgesia (paravertebral block and propofol) did not reduce breast cancer recurrence after potentially curative surgery compared with volatile anaesthesia (sevoflurane) and opioids. The frequency and severity of persistent incisional breast pain was unaffected by anaesthetic technique. Clinicians can use regional or general anaesthesia with respect to breast cancer recurrence and persistent incisional pain.

FUNDING

Sisk Healthcare Foundation (Ireland), Eccles Breast Cancer Research Fund, British Journal of Anaesthesia International, College of Anaesthetists of Ireland, Peking Union Medical College Hospital, Science Fund for Junior Faculty 2016, Central Bank of Austria, and National Healthcare Group.

The serratus plane block for postoperative analgesia in breast and thoracic surgery: a systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

The serratus plane block (SPB) is a novel chest wall interfascial plane block. Its analgesic efficacy compared with non-block care and paravertebral block (PVB) is unestablished.

METHODS

We conducted a random-effects meta-analysis of randomized controlled trials (RCTs) recruiting adult surgical patients that compared a SPB to non-block care or PVB for postoperative analgesia. Visual analog scale pain scores were the primary outcome. Database sources were Medline, Embase, the Cochrane Library, and Google Scholar searched up to July 29, 2019 without language restriction. Risk of bias was assessed using Cochrane methodology.

RESULTS

Nineteen RCTs that comprised 1260 patients were included. Six trials involved thoracic surgery patients and 13 studied breast surgery patients. SPB reduced pain scores 0 hour postoperatively (-1.62 cm; 99% CI -2.43 to -0.81; p<0.001; I2=92%), at 2-4 hours (-1.29 cm; 99% CI -2.08 to -0.49; p<0.001; I2=92%), at 6 hours (-1.69 cm; 99% CI -3.19 to -0.20; p=0.004; I2=99%), and up to 24 hours compared with non-block care. SPB also prolonged the time to first analgesic request (193.2 min; 95% CI 7.2 to 379.2 min; p=0.04; I2=99%), reduced 24-hour postoperative opioid consumption (-11.27 mg of IV morphine equivalent; -17.36 to -5.18 mg; p<0.001), and reduced postoperative nausea and vomiting (RR 0.51; 95% CI 0.38 to 0.68; p<0.001; I2=12%). In contrast, no meaningful differences were detected in any of the outcomes for the SPB versus PVB data.

CONCLUSIONS

SPB reduced postoperative pain scores (Grading of Recommendations Assessment, Development, and Evaluation rating: low; due to heterogeneity and deficiencies in blinding) in breast and thoracic surgery patients compared with non-block care. Based on five trials only, SPB was not appreciably different from PVB.

Aerobic and Resistance Exercise Improves Shoulder Function in Women Who Are Overweight or Obese and Have Breast Cancer: A Randomized Controlled Trial

BACKGROUND

Adverse upper limb musculoskeletal effects occur after surgical procedures and radiotherapy for breast cancer and can interfere with activities of daily living.

OBJECTIVE

The objective of this study was to examine the effects of a 16-week exercise intervention on shoulder function in women who are overweight or obese and have breast cancer.

DESIGN

This study was a randomized controlled trial.

SETTING

The study was performed at the Division of Biokinesiology and Physical Therapy at the University of Southern California.

PARTICIPANTS

One hundred women with breast cancer were randomly allocated to exercise or usual-care groups. The mean (SD) age of the women was 53.5 (10.4) years, 55% were Hispanic white, and their mean (SD) body mass index was 33.5 (5.5) kg/m2.

INTERVENTION

The 16-week exercise intervention consisted of supervised, progressive, moderate to vigorous aerobic and resistance exercise 3 times per week.

MEASUREMENTS

Shoulder active range of motion, isometric muscular strength, and patient-reported outcome measures (including Disabilities of the Arm, Shoulder, and Hand and the Penn Shoulder Scale) were assessed at baseline, after the intervention, and at the 3-month follow-up (exercise group only). Differences in mean changes for outcomes were evaluated using mixed-model repeated-measures analysis.

RESULTS

Compared with the usual-care group, the exercise group experienced significant increases in shoulder active range of motion (the mean between-group differences and 95% confidence intervals (CIs) were as follows: shoulder flexion = 36.6° [95% CI = 55.2-20.7°], external rotation at 0° = 23.4° [95% CI = 31.1-12.5°], and external rotation at 90° = 34.3° [95% CI = 45.9-26.2°]), improved upper extremity isometric strength, and improved Disabilities of the Arm, Shoulder, and Hand and Penn Shoulder Scale scores.

LIMITATIONS

Limitations include a lack of masking of assessors after the intervention, an attention control group, and statistical robustness (shoulder function was a secondary end point).

CONCLUSIONS

A 16-week exercise intervention effectively improved shoulder function following breast cancer treatment in women who were overweight or obese, who were ethnically diverse, and who had breast cancer.

[For which patients could we consider de-escalation in the management of ductal carcinomas in situ?]

Ductal carcinomas in situ (DCIS) of the breast account for 85% to 90% of breast cancer in situ. Current recommendations for the management of DCIS in France are based on surgical excision of the lesions, lumpectomy in healthy margins (margins of excision≥2mm) or mastectomy in case of extensive lesions. Radiation therapy is recommended after conservative surgical treatment. However, it seems relevant for some patients to discuss the benefit of a therapeutic de-escalation. Indeed, it has been reported that radiotherapy has no major impact on overall survival and that its interest could be discussed in the low-risk situations of invasive recurrence for which surgery alone could be sufficient, subject to sufficient margins. These questions call for the precise definition of low risk populations and to clarify the importance of taking into account decision support tools and new molecular markers. The place of scores like that of the University of Southern California - Van Nuys, and that of genomic tests such as the Oncotype test© DX DCIS (DCIS score) need to be specified. The expected results of several prospective studies could go in the direction of a significant therapeutic de-escalation for the management of DCIS in the years to come. In the meantime, however, it is advisable to remain cautious and the inclusion of patients in clinical trials should be favored.

Impact of chemotherapy on symptoms and symptom clusters in postmenopausal women with breast cancer prior to aromatase inhibitor therapy

AIMS AND OBJECTIVES

To examine and compare the differences in symptoms and symptom clusters between postmenopausal women with early-stage breast cancer who did and did not receive chemotherapy prior to aromatase inhibitor (AI) therapy.

BACKGROUND

Women with breast cancer often experience multiple concurrent symptoms during AI therapy. The burden of symptoms prior to AI is associated with nonadherence to cancer treatment. To date, few studies have comprehensively explored the symptoms and symptom clusters occurring prior to AI therapy.

DESIGN

Secondary analysis of a prospective repeated-measures study.

METHODS

The sample comprised postmenopausal women (N = 339) with breast cancer who would receive AI therapy with or without chemotherapy. We collected information on 48 symptoms after surgery or chemotherapy but before AI therapy using different symptom assessment tools. Mann-Whitney U tests were used to compare the differences in the severity of symptoms between groups. Exploratory factor analysis (EFA) was conducted to determine symptom clusters. This study followed STROBE guidelines.

RESULTS

The most severe symptoms among women with breast cancer prior to AI therapy were breast sensitivity, unhappy with the appearance of my body, general aches and pain, joint pain and muscle stiffness. Women who received chemotherapy prior to AI therapy experienced significantly higher severity of 22 symptoms than women who did not receive chemotherapy. Through EFA seven distinct symptom clusters were revealed in both groups: cognitive, musculoskeletal, psychological, vasomotor, weight, sexual and urinary, with additional gastrointestinal symptom cluster been identified in women who received chemotherapy.

CONCLUSIONS

This study indicates the presence of symptoms among women with breast cancer prior to AI therapy, with higher severity of symptoms and greater number of symptom clusters for women who received chemotherapy.

RELEVANCE TO CLINICAL PRACTICE

Nurses should assess and be aware of symptoms and symptom clusters existed prior to AI therapy and manage them in advance.

Cancer treatment and survivorship statistics, 2019

The number of cancer survivors continues to increase in the United States because of the growth and aging of the population as well as advances in early detection and treatment. To assist the public health community in better serving these individuals, the American Cancer Society and the National Cancer Institute collaborate every 3 years to estimate cancer prevalence in the United States using incidence and survival data from the Surveillance, Epidemiology, and End Results cancer registries; vital statistics from the Centers for Disease Control and Prevention's National Center for Health Statistics; and population projections from the US Census Bureau. Current treatment patterns based on information in the National Cancer Data Base are presented for the most prevalent cancer types. Cancer-related and treatment-related short-term, long-term, and late health effects are also briefly described. More than 16.9 million Americans (8.1 million males and 8.8 million females) with a history of cancer were alive on January 1, 2019; this number is projected to reach more than 22.1 million by January 1, 2030 based on the growth and aging of the population alone. The 3 most prevalent cancers in 2019 are prostate (3,650,030), colon and rectum (776,120), and melanoma of the skin (684,470) among males, and breast (3,861,520), uterine corpus (807,860), and colon and rectum (768,650) among females. More than one-half (56%) of survivors were diagnosed within the past 10 years, and almost two-thirds (64%) are aged 65 years or older. People with a history of cancer have unique medical and psychosocial needs that require proactive assessment and management by follow-up care providers. Although there are growing numbers 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.

The Prevalence, Impact, and Risk Factors for Persistent Pain After Breast Cancer Surgery in a New Zealand Population

OBJECTIVE

Few Australasian studies have assessed persistent pain after breast cancer surgery. This study aims to evaluate the prevalence, impact, and risk factors of moderate to severe persistent pain after breast cancer surgery in a New Zealand population.

METHODS

Retrospective cross-sectional study of patients who underwent breast cancer surgery between six and 48 months previously. Validated questionnaires were used to assess pain prevalence and impact, psychological distress, and upper limb function. Patients' clinical records were assessed for potential risk factors.

RESULTS

Of the 375 patients who were sent questionnaires, 201 were included in the study. More than half of the patients (N = 111, 55%) reported breast surgery related-persistent pain, with 46 (23%) rating the pain as moderate to severe. Neuropathic pain was reported by 21 (46%) patients with moderate to severe pain. Pain interference, upper limb dysfunction, and psychological distress were significantly higher in patients with moderate to severe pain (P < 0.001). Non-European ethnicity (odds ratio [OR] = 5.02, 95% confidence interval [CI] = 2.05-12.25, P < 0.001), reconstruction surgery (OR = 4.10, 95% CI = 1.30-13.00, P = 0.02), and axillary node dissection (OR = 4.33, 95% CI = 1.19-15.73, P < 0.03) were identified as risk factors for moderate to severe pain by multivariate logistic regression analysis.

CONCLUSIONS

Moderate to severe persistent pain after breast cancer surgery affects many New Zealand patients, and is associated with impaired daily life activities, physical disability, and psychological distress. Large numbers of patients undergo breast cancer surgery annually. This study emphasizes the importance of identification and management of these patients perioperatively.

Development of a Simple Preoperative Risk Score for Persistent Pain After Breast Cancer Surgery: A Prospective Observational Cohort Study

OBJECTIVES

Persistent postoperative pain is reported by 30% to 50% of patients following breast cancer surgery. Studies testing preventive measures, however, have so far failed to produce consistent positive results. If preventive measures could be targeted to a subgroup of patients at high risk of persistent pain, positive results would be more likely. Our aim was to develop a simple risk score predicting persistent pain after breast cancer surgery.

MATERIALS AND METHODS

In a prospective observational cohort study, we tested the predictive ability of a 4 simple items score for persistent pain in 200 patients scheduled for breast cancer surgery. A multivariable logistic regression model was created for the outcome of clinically important pain at 4 months.

RESULTS

On the basis of literature review and univariable analysis of our data, 4 parameters were selected: preoperative pain at the surgical site, history of depression, age below 50 years and expected pain of high intensity (>6/10). Points for the score are based on the coefficients of the logistic regression model. A total score ≥2 points/5 predicts a risk of developing clinically important pain at 4 months >30%, with an area under the curve-receiver operating characteristic of 0.81.

DISCUSSION

We studied known risk factors for persistent pain in patients scheduled for breast cancer surgery and constructed a preoperative risk score simple enough to select high-risk patients in future prevention studies.

Predictors of persistent postsurgical pain following total knee arthroplasty: A protocol for systematic review and meta-analysis

Background: Total knee arthroplasty (TKA) is a commonly performed procedure, primarily when knee joints have been damaged by progressive arthritis; however, over 20% of surgical patients develop persistent postsurgical pain (PPSP). We plan to conduct a systematic review and meta-analysis of factors associated with the development of PPSP following TKA. Methods: We will include peer-reviewed cohort or case-control studies that explore, in an adjusted model, factors associated with the development of PPSP after TKA. We will identify eligible studies, in any language, by a systematic search of MEDLINE, EMBASE, CINAHL, AMED, Scopus, SPORTDiscus, and PsycINFO, from inception of each database. Pairs of reviewers will, independently and in duplicate, screen titles and abstracts of identified citations, review the full texts of potentially eligible studies, and extract information from eligible studies. When possible, we will pool estimates of association for all independent variables reported by more than one study and report both an adjusted odds ratio and the absolute risk increase and associated 95% confidence intervals (Cis). We will use the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to summarize the quality of evidence for all meta-analyses as high, moderate, low, or very low. Discussion: Our results will facilitate identification of patients at risk for the development of PPSP following TKA, highlight promising predictors for further study, and help guide the design of interventional studies to improve prognosis of high-risk patients.

Chronic postsurgical pain: From risk factor identification to multidisciplinary management at the Toronto General Hospital Transitional Pain Service

Background: Chronic postsurgical pain is a highly prevalent public health problem associated with substantial emotional, social, and economic costs. Aims: (1) To review the major risk factors for chronic postsurgical pain (CPSP); (2) to describe the implementation of the Transitional Pain Service (TPS) at the Toronto General Hospital, a multiprofessional, multimodal preventive approach to CPSP involving intensive, perioperative psychological, physical, and pharmacological management aimed at preventing and treating the factors that increase the risk of CPSP and related disability; and (3) to present recent empirical evidence for the efficacy of the TPS. Methods: The Toronto General Hospital TPS was specifically developed to target patients at high risk of developing CPSP. The major known risk factors for CPSP are perioperative pain, opioid use, and negative affect, including depression, anxiety, pain catastrophizing, and posttraumatic stress disorder-like symptoms. At-risk patients are identified early and provided comprehensive care by a multidisciplinary team consisting of pain physicians, advanced practice nurses, psychologists, and physical therapists. Results: Preliminary results from two nonrandomized, clinical practice-based trials indicate that TPS treatment is associated with improvements in pain, pain interference, pain catastrophizing, symptoms of anxiety and depression, and opioid use. Almost half of opioid-naïve patients and one in four opioid-experienced patients were opioid free by the 6-month point. Conclusions: These promising results suggest that the TPS benefits patients at risk of CPSP. A multicenter randomized controlled trial of the TPS in several Ontario hospitals is currently underway.