Persistent Pain After Breast Cancer Treatment: A Critical Review of Risk Factors and Strategies for Prevention

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.

Poorly controlled postoperative pain: prevalence, consequences, and prevention

This review provides an overview of the clinical issue of poorly controlled postoperative pain and therapeutic approaches that may help to address this common unresolved health-care challenge. Postoperative pain is not adequately managed in greater than 80% of patients in the US, although rates vary depending on such factors as type of surgery performed, analgesic/anesthetic intervention used, and time elapsed after surgery. Poorly controlled acute postoperative pain is associated with increased morbidity, functional and quality-of-life impairment, delayed recovery time, prolonged duration of opioid use, and higher health-care costs. In addition, the presence and intensity of acute pain during or after surgery is predictive of the development of chronic pain. More effective analgesic/anesthetic measures in the perioperative period are needed to prevent the progression to persistent pain. Although clinical findings are inconsistent, some studies of local anesthetics and nonopioid analgesics have suggested potential benefits as preventive interventions. Conventional opioids remain the standard of care for the management of acute postoperative pain; however, the risk of opioid-related adverse events can limit optimal dosing for analgesia, leading to poorly controlled acute postoperative pain. Several new opioids have been developed that modulate μ-receptor activity by selectively engaging intracellular pathways associated with analgesia and not those associated with adverse events, creating a wider therapeutic window than unselective conventional opioids. In clinical studies, oliceridine (TRV130), a novel μ-receptor G-protein pathway-selective modulator, produced rapid postoperative analgesia with reduced prevalence of adverse events versus morphine.

Pectoralis and Serratus Fascial Plane Blocks Each Provide Early Analgesic Benefits Following Ambulatory Breast Cancer Surgery: A Retrospective Propensity-Matched Cohort Study

BACKGROUND

Pectoralis and serratus blocks have been described recently for use in breast surgery, but evidence supporting their analgesic benefits is limited. This cohort study evaluates the benefits of adding a pectoralis or serratus block to conventional opioid-based analgesia (control) in patients who underwent ambulatory breast cancer surgery at Women's College Hospital between July 2013 and May 2015. We tested the joint hypothesis that adding a pectoralis or serratus block reduced postoperative in-hospital (predischarge) opioid consumption and nausea and vomiting (PONV). We also examined the 2 block types for noninferiority.

METHODS

A total of 225 patients were propensity matched on 5 potential confounders among 3 study groups (75 per group): (1) pectoralis; (2) serratus; and (3) control. The propensity-matched cohort was used to evaluate the effect of the study group on postoperative in-hospital oral morphine equivalent consumption and PONV. We considered pectoralis noninferior to serratus block if it was noninferior for both outcomes, within 10 mg morphine and 17.5% in PONV incidence margins. Other outcomes included intraoperative fentanyl requirements, pain scores, time to first analgesic request, and duration of recovery room stay.

RESULTS

Both pectoralis and serratus blocks were each associated with reduced postoperative in-hospital opioid consumption and PONV compared with control. Pectoralis was noninferior to serratus block for these 2 outcomes. Pectoralis and serratus blocks were each associated with reduced intraoperative fentanyl requirements, prolonged time to first analgesic request, and expedited recovery room discharge compared with control; there were no differences for the remaining outcomes.

CONCLUSIONS

Pectoralis and serratus blocks were each associated with a reduction in postoperative in-hospital opioid consumption and PONV compared with conventional opioid-based analgesia after ambulatory breast cancer surgery.

Associations between genetic and epigenetic variations in cytokine genes and mild persistent breast pain in women following breast cancer surgery

Persistent pain following breast cancer surgery is a significant problem. Both inherited and acquired mechanisms of inflammation appear to play a role in the development and maintenance of persistent pain. In this longitudinal study, growth mixture modeling was used to identify persistent breast pain phenotypes based on pain assessments obtained prior to and monthly for 6months following breast cancer surgery. Associations between the "no pain" and "mild pain" phenotypes and single nucleotide polymorphisms (SNPs) spanning 15 cytokine genes were evaluated. The methylation status of the CpG sites found in the promoters of genes associated with pain group membership was determined using bisulfite sequencing. In the multivariate analysis, three SNPs (i.e., interleukin 6 (IL6) rs2069840, C-X-C motif chemokine ligand 8 (CXCL8) rs4073, tumor necrosis factor (TNF) rs1800610) and two TNF CpG sites (i.e., c.-350C, c.-344C) were associated with pain group membership. These findings suggest that variations in IL6, CXCL8, and TNF are associated with the development and maintenance of mild persistent breast pain. CpG methylation within the TNF promoter may provide an additional mechanism through which TNF alters the risk for mild persistent breast pain after breast cancer surgery. These genetic and epigenetic variations may help to identify individuals who are predisposed to the development of mild levels of persistent breast pain following breast cancer surgery.

Chronic postsurgical pain: is there a possible genetic link?

Persistent or chronic postsurgical pain (CPSP) has been defined as 'pain persisting beyond 2 months'. The cut-off limit of 2 months has been controversial, and some researchers argue for a 3-month period for the definition of CPSP. Multiple mechanisms, including both patient and surgical, have been shown to influence this transition. Patient factors include age, gender, anxiety, depression, somatisation, catastrophising, pre-existing pain anywhere and pain at the site of surgery. The various surgical factors include site and nature of surgery, infection, inflammation and repeat surgery. There is evidence that pre- or post-op chemotherapy and radiotherapy can also contribute towards the chronification of pain after surgery. The question of why pain following surgery or trauma persists long after the normal healing time is not yet fully explained by current evidence. This is frustrating to healthcare providers and intensely disappointing to the patients, many of whom suffer in silence for years. Genetics is now being shown to influence both the onset and the perpetuation of chronic pain in the susceptible patient. The main mechanisms are believed to be 'single nucleotide polymorphisms' (SNPs) and 'epigenetics', both of which will be discussed, with current and ongoing research and evidence, in this review. The influence of SNPs has not been replicated in recent studies and researchers advise caution in interpreting past studies. More research is needed to demonstrate the involvement of epigenetics as well as linking SNPs to the susceptible patient's journey.

Complete Antethoracic Block for Analgesia After Modified Radical Mastectomy: A Case Report

Complete antethoracic block for modified radical mastectomy is a composite block comprising the antethoracic medial, antethoracic inferior, and antethoracic lateral blocks. The puncture targets of all components are easy to identify, and the risk of complications such as pneumothorax is low. Our patient was a 72-year-old woman undergoing modified radical mastectomy for breast cancer. After induction of general anesthesia, but before surgical incision, she received a complete antethoracic block for anesthesia, which also provided good analgesia postoperatively. We believe that complete antethoracic block is suitable for postoperative analgesia in patients undergoing this surgery.

The Relationship Between Sensory Loss and Persistent Pain 1 Year After Breast Cancer Surgery

Moderate to severe persistent pain after breast cancer surgery (PPBCS) affects 10 to 20% of the patients. Sensory dysfunction is often concomitantly present suggesting a neuropathic pain state. The relationship between various postoperative pain states and sensory dysfunction has been examined using quantitative sensory testing (QST), but only 2 smaller studies have examined PPBCS and sensory dysfunction in the surgical area. The purpose of this prospective study was to assess the relative importance of sensory function and PPBCS. QST consisted of sensory mapping, tactile detection threshold, mechanical pain threshold, and thermal thresholds. Two hundred ninety patients were enrolled and results showed that 38 (13%) had moderate to severe pain and 246 (85%) had hypoesthesia in the surgical area 1 year after surgery. Increased hypoesthesia areas were associated with pain at rest as well as during movement (P = .0001). Pain during movement was associated with a side-to-side difference of 140% (P = .001) for tactile detection threshold and 40% (P = .01) for mechanical pain threshold as well as increased thermal thresholds in the axilla (P > .001). Logistic regression models controlling for confounders showed larger areas of hypoesthesia as a significant risk factor, odds ratio 1.85 per 100 cm² for pain at rest and odds ratio 1.36 per 100 cm² for pain during movement.

PERSPECTIVE

PPBCS is associated with increasing areas of hypoesthesia as well as intraoperative nerve preservation. Thus, we hypothesize that PPBCS is associated with an interaction between a peripheral nociceptive drive in macroscopically preserved nerves and the central nervous system causing PPBCS as well as hypoesthesia. QST may identify patients suitable for intervention.

Pain, sensory disturbances and psychological distress are common sequelae after treatment of ductal carcinoma in situ: a cross-sectional study

Sequelae such as pain, sensory disturbances and psychological distress are well known after treatment for invasive breast cancer (IBC). Patients treated for ductal carcinoma in situ (DCIS) receive a similar treatment as low-risk IBC. The aim of this cross-sectional study was to describe prevalence of postoperative pain, sensory disturbances, psychological distress and rehabilitation needs among Danish women with DCIS.

METHODS

A total of 574 women treated for DCIS in Denmark in 2013 and 2014 were enrolled and 473 (82%) completed a detailed questionnaire on demographic factors, pain, sensory disturbances, psychological aspects and rehabilitation needs 1-3 years after surgery.

RESULTS

Median age was 60 years. A total of 33% of patients reported any pain and 12% reported moderate to severe pain in the area of surgery. Younger age (<50 years OR 4.7 (95% CI: 1.6-14.0, p = 0.006)), aged 50 to 65 years OR 2.8 (95% CI: 1.1-7.0, p = 0.02) and anxiety and depression (measured by HADS_total >15 OR of 3.1 (95% CI: 1.5-6.3, p = 0.003)) were significantly associated with moderate to severe pain. Approximately one-third of the patients reported sensory disturbances such as pins and needles (32%), numbness (37%) and painful itch (30%) and 94 women (20%) reported anxiety ≥8, 26 (6%) depression and 51 (11%) reported distress.

CONCLUSIONS

This cross-sectional study showed that women treated for DCIS suffered from pain, sensory disturbances and psychological impairment and had unmet rehabilitation needs. Further research is warranted, specifically addressing rehabilitation after diagnosis and treatment of DCIS.

Does expecting more pain make it more intense? Factors associated with the first week pain trajectories after breast cancer surgery

We studied postoperative pain trajectories and associated factors. Expectation of severe postoperative pain was associated with higher intensity of experimental and postoperative pain.

The aim of this study was to identify clinical risk factors for unfavorable pain trajectories after breast cancer surgery, to better understand the association between pain expectation, psychological distress, and acute postoperative pain. This prospective study included 563 women treated for breast cancer. Psychological data included questionnaires for depressive symptoms and anxiety. Experimental pain tests for heat and cold were performed before surgery. The amount of oxycodone needed for satisfactory pain relief after surgery was recorded. Pain intensity in the area of operation before surgery and during the first postoperative week and expected intensity of postoperative pain were recorded using the Numerical Rating Scale (NRS 0-10). Pain trajectories were formed to describe both initial intensity (the intercept) and the direction of the pain path (the slope). Factors associated with higher initial pain intensity (the intercept) were the amount of oxycodone needed for adequate analgesia, psychological distress, type of axillary surgery, preoperative pain in the area of the operation, and expectation of postoperative pain. The higher the pain initially was, the faster it resolved over the week. Expectation of severe postoperative pain was associated with higher scores of both experimental and clinical pain intensity and psychological factors. The results confirm that acute pain after breast cancer surgery is a multidimensional phenomenon. Psychological distress, pain expectation, and the patients' report of preoperative pain in the area to be operated should be recognized before surgery. Patients having axillary clearance need more efficient analgesic approaches.

Clinical Prediction Model and Tool for Assessing Risk of Persistent Pain After Breast Cancer Surgery

Purpose Persistent pain after breast cancer surgery is a well-recognized problem, with moderate to severe pain affecting 15% to 20% of women at 1 year from surgery. Several risk factors for persistent pain have been recognized, but tools to identify high-risk patients and preventive interventions are missing. The aim was to develop a clinically applicable risk prediction tool. Methods The prediction models were developed and tested using three prospective data sets from Finland (n = 860), Denmark (n = 453), and Scotland (n = 231). Prediction models for persistent pain of moderate to severe intensity at 1 year postoperatively were developed by logistic regression analyses in the Finnish patient cohort. The models were tested in two independent cohorts from Denmark and Scotland by assessing the areas under the receiver operating characteristics curves (ROC-AUCs). The outcome variable was moderate to severe persistent pain at 1 year from surgery in the Finnish and Danish cohorts and at 9 months in the Scottish cohort. Results Moderate to severe persistent pain occurred in 13.5%, 13.9%, and 20.3% of the patients in the three studies, respectively. Preoperative pain in the operative area ( P < .001), high body mass index ( P = .039), axillary lymph node dissection ( P = .008), and more severe acute postoperative pain intensity at the seventh postoperative day ( P = .003) predicted persistent pain in the final prediction model, which performed well in the Danish (ROC-AUC, 0.739) and Scottish (ROC-AUC, 0.740) cohorts. At the 20% risk level, the model had 32.8% and 47.4% sensitivity and 94.4% and 82.4% specificity in the Danish and Scottish cohorts, respectively. Conclusion Our validated prediction models and an online risk calculator provide clinicians and researchers with a simple tool to screen for patients at high risk of developing persistent pain after breast cancer surgery.

Variations in COMT and NTRK2 Influence Symptom Burden in Women Undergoing Breast Cancer Treatment

Women with breast cancer frequently report distressing symptoms during and after treatment that can significantly erode quality of life (QOL). Symptom burden among women with breast cancer is of complex etiology and is likely influenced by disease, treatment, and environmental factors as well as individual genetic differences. The purpose of the present study was to examine the relationships between genetic polymorphisms within Neurotrophic tyrosine kinase receptor 1 (NTRK1), Neurotrophic tyrosine kinase receptor 2 (NTRK2), and catechol-O-methyltransferase ( COMT) and patient symptom burden of QOL, pain, fatigue, anxiety, depression, and sleep disturbance before, during, and after treatment for breast cancer in a subset of participants ( N = 51) in a randomized clinical trial of a novel symptom-management modality for women with breast cancer undergoing chemotherapy. Patients were recruited at the time of initial breast cancer diagnosis and completed all survey measures at the time of recruitment, after the initiation of treatment (surgery and/or chemotherapy), and then following treatment conclusion. Multiple linear regression analyses revealed significant associations between NTRK2 and COMT single nucleotide polymorphism (SNP) genotype and symptom burden. Two COMT variants were associated with the specific symptoms of anxiety and QOL measures prior to the initiation of chemotherapy as well as pain interference and severity during and after treatment. Genotype at the NTRK2 SNP rs1212171 was associated with both sleep disturbance and fatigue. These findings, while exploratory, indicate that the genotypes of NTRK2 and COMT may contribute to relative risk for symptom burden during and shortly after the period of chemotherapy in women with early stage breast cancer.

Clinical and psychological moderators of the effect of mindfulness-based cognitive therapy on persistent pain in women treated for primary breast cancer - explorative analyses from a randomized controlled trial

BACKGROUND

Mindfulness-based intervention has been found efficacious in reducing persistent pain in women treated for breast cancer. Little, however, is known about possible moderators of the effect. We explored clinical and psychological moderators of the effect on pain intensity previously found in a randomized controlled trial of mindfulness-based cognitive therapy (MBCT) with women treated for breast cancer with persistent pain.

MATERIAL AND METHODS

A total of 129 women treated for breast cancer reporting persistent pain were randomized to MBCT or a wait-list control. The primary outcome of pain intensity (11-point numeric rating scale) was measured at baseline, post-intervention, three, and six months follow-up. Proposed clinical moderators included age, axillary lymph node dissection (ALND), radiotherapy, and endocrine treatment. Psychological moderators included psychological distress [the Hospital Anxiety and Depression Scale (HADS)], the adult attachment dimensions anxiety and avoidance [the Experiences in Close Relationships Short Form (the ECR-SF)], and alexithymia [the Toronto Alexithymia Scale (TAS-20)]. Multi-level models were used to test moderation effects over time, i.e. time × group × moderator.

RESULTS

Only attachment avoidance (p = 0.03, d = 0.36) emerged as a statistically significant moderator. Higher levels of attachment avoidance predicted a larger effect of MBCT in reducing pain intensity compared with lower levels attachment avoidance. None of the remaining psychological or clinical moderators reached statistical significance. However, based on the effect size, radiotherapy (p = 0.075, d = 0.49) was indicated as a possible clinical moderator of the effect, with radiotherapy being associated with a smaller effect of MBCT on pain intensity over time compared with no radiotherapy.

CONCLUSION

Attachment avoidance, and potentially radiotherapy, may be clinically relevant factors for identifying the patients who may benefit most from MBCT as a pain intervention. Due to the exploratory nature of the analyses, the results should be considered preliminary.

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.

Postmastectomy Pain: A Cross-sectional Study of Prevalence, Pain Characteristics, and Effects on Quality of Life

Background:

Postmastectomy pain syndrome (PMPS) is defined as a chronic (continuing for 3 or more months) neuropathic pain affecting the axilla, medial arm, breast, and chest wall after breast cancer surgery. The prevalence of PMPS has been reported to range from 20% to 68%. In this study, we aimed to determine the prevalence of PMPS among mastectomy patients, the severity of neuropathic pain in these patients, risk factors that contribute to pain becoming chronic, and the effect of PMPS on life quality.

Methods:

This cross-sectional study was approved by the Sakarya University, Medical Faculty Ethical Council and included 146 patients ranging in age from 18 to 85 years who visited the pain clinic, general surgery clinic, and oncology clinic and had breast surgery between 2012 and 2014. Patients were divided into two groups according to whether they met PMPS criteria: pain at axilla, arm, shoulder, chest wall, scar tissue, or breast at least 3 months after breast surgery. All patients gave informed consent prior to entry into the study. Patient medical records were collected, and pain and quality of life were evaluated by the visual analog scale (VAS) for pain, a short form of the McGill Pain Questionnaire (SF-MPQ), douleur neuropathique-4 (DN-4), and SF-36.

Results:

Patient mean age was 55.2 ± 11.8 years (33.0–83.0 years). PMPS prevalence was 36%. Mean scores on the VAS, SF-MPQ, and DN-4 in PMPS patients were 1.76 ± 2.38 (0–10), 1.73 ± 1.54 (0–5), and 1.64 ± 2.31 (0–8), respectively. Of these patients, 31 (23.7%) had neuropathic pain characteristics, and 12 (9.2%) had phantom pain according to the DN-4 survey. Patients who had modified radical mastectomy were significantly more likely to develop PMPS than patients who had breast-protective surgery (P = 0.028). Only 2 (2.4%) of PMPS patients had received proper treatment (anticonvulsants or opioids).

Conclusions:

PMPS seriously impacts patients’ emotional situation, daily activities, and social relationships and is a major economic burden for health systems. We conclude that the rate of PMPS among patients receiving breast cancer surgery in Turkey is 64.1% and that challenges to the proper treatment of these patients deserve further investigation.

Differences in demographic, clinical, and symptom characteristics and quality of life outcomes among oncology patients with different types of pain

The purposes of this study, in oncology outpatients receiving chemotherapy (n = 926), were to: describe the occurrence of different types of pain (ie, no pain, only noncancer pain [NCP], only cancer pain [CP], or both CP and NCP) and evaluate for differences in demographic, clinical, and symptom characteristics, and quality of life (QOL) among the 4 groups. Patients completed self-report questionnaires on demographic and symptom characteristics and QOL. Patients who had pain were asked to indicate if it was or was not related to their cancer or its treatment. Medical records were reviewed for information on cancer and its treatments. In this study, 72.5% of the patients reported pain. Of the 671 who reported pain, 21.5% reported only NCP, 37.0% only CP, and 41.5% both CP and NCP. Across the 3 pain groups, worst pain scores were in the moderate to severe range. Compared with the no pain group, patients with both CP and NCP were significantly younger, more likely to be female, have a higher level of comorbidity, and a poorer functional status. In addition, these patients reported: higher levels of depression, anxiety, fatigue, and sleep disturbance; lower levels of energy and attentional function; and poorer QOL. Patients with only NCP were significantly older than the other 3 groups. The most common comorbidities in the NCP group were back pain, hypertension, osteoarthritis, and depression. Unrelieved CP and NCP continue to be significant problems. Oncology outpatients need to be assessed for both CP and NCP conditions.

Cancer-related post-treatment pain and its impact on health-related quality of life in breast cancer patients: a cross sectional study in Palestine

BACKGROUND

Post-treatment pain has been suggested as an important indicator for health-related quality of life (HRQOL) in patients with breast cancer. Therefore, this study was performed to examine the association between pain and its impact on HRQOL among breast cancer patients in Palestine. Also, this study aimed to determine the QOL profile for breast cancer patients and stated the factors associated with QOL.

METHODS

A correlational cross-sectional study was conducted from May 2016 to November 2016 at Al-Watani Hospital and An-Najah National University Hospital in the Nablus district in Palestine. The five-level EuroQol five-dimensional instrument (EQ-5D-5L) was used to examine HRQOL. Pain severity and interference were assessed using the Brief Pain Inventory (BPI). Multiple linear regression analysis was performed to determine the most important variables related with HRQOL.

RESULTS

One hundred and seventy patients were involved in this study. Overall, all participants were female, with a mean ± SD for age of 51.71 ± 11.11 years. The reported HRQOL of this study was measured by using the median EQ-5D-5L index score, which was 0.67 (interquartile range: 0.51-0.84). There were moderate negative correlations between EQ-5D-5L index score and pain severity score (r = - 0.58, p value < 0.001), and pain interference score (r = - 0.604, p-value < 0.001). Furthermore, univariate analysis showed that age, marital status, employment status, income, current condition of cancer, and post-treatment pain were associated with quality of life (p-value < 0.05). Regression analysis revealed that patients with high income (p-value = 0.003), patients with lower pain severity score (p-value < 0.001), and lower pain interference score (p-value = 0.018) were independently associated with high QOL.

CONCLUSIONS

This is the first study to present important data regarding QOL by using the EQ-5D-5L instruments that may help healthcare providers to identify patients at risk of low QOL. Healthcare providers and health strategy makers should be alerted to low level HRQOL among breast cancer patients with low income level, patients with post-treatment pain, especially in the state of severe pain, and the state of pain interfering with daily life to improve their HRQOL.

Analgesic efficacy of ultrasound-guided paravertebral block versus serratus plane block for modified radical mastectomy: A randomised, controlled trial

Background and Aims:

Modified radical mastectomy (MRM) may be associated with severe post-operative pain, leading to chronic pain syndrome. We compared the post-operative analgesic profile of two ultrasound-guided nerve blocks: Paravertebral block (PVB) and serratus plane block (SPB).

Methods:

This double-blind, randomised study was conducted on fifty adult females, scheduled for MRM with axillary dissection. After inducing general anaesthesia with intravenous midazolam 1 mg, fentanyl 1.5 mcg/kg, propofol 1–2 mg/kg and vecuronium 0.1 mg/kg, patients were administered either ultrasound-guided thoracic PVB at T4 (n = 25) or SPB at 5^th rib (n = 25) with 20 ml of 0.5% bupivacaine, both as a single level injection. Time to first rescue analgesia and morphine consumption in 4, 6, 24, 48 and 72 h by PCA pump, visual analogue scale score and any adverse effects were recorded. Quantitative variables were compared using the unpaired t-test or the Mann–Whitney U test between the two groups. Qualitative variables were compared using the Chi-square test or Fisher's exact test.

Results:

The duration of analgesia (mean ± Standard deviation [SD]) was significantly longer in the PVB group compared to SPB group (346 ± 57 min vs. 245.6 ± 58 min, P < 0.001). The post-operative 24 h morphine consumption (mean ± SD) was significantly higher in the SPB group (9.7 ± 2.1 mg) compared to PVB group (6.5 ± 1.5 mg) (P < 0.001).

Conclusion:

Ultrasound-guided SPB is an alternative analgesic technique to thoracic PVB for MRM although PVB provides a longer duration of analgesia.

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.

Hyperalgesia and Persistent Pain after Breast Cancer Surgery: A Prospective Randomized Controlled Trial with Perioperative COX-2 Inhibition

Background

Persistent pain is a challenging clinical problem after breast cancer treatment. After surgery, inflammatory pain and nociceptive input from nerve injury induce central sensitization which may play a role in the genesis of persistent pain. Using quantitative sensory testing, we tested the hypothesis that adding COX-2 inhibition to standard treatment reduces hyperalgesia after breast cancer surgery. A secondary hypothesis was that patients developing persistent pain would exhibit more postoperative hyperalgesia.

Methods

138 women scheduled for lumpectomy/mastectomy under general anesthesia with paravertebral block were randomized to COX-2 inhibition (2x40mg parecoxib on day of surgery, thereafter 2x200mg celecoxib/day until day five) or placebo. Preoperatively and 1, 5, 15 days and 1, 3, 6, 12 months postoperatively, we determined electric and pressure pain tolerance thresholds in dermatomes C6/T4/L1 and a 100mm VAS score for pain. We calculated the sum of pain tolerance thresholds and analyzed change in these versus preoperatively using mixed models analysis with factor medication. To assess hyperalgesia in persistent pain patients we performed an additional analysis on patients reporting VAS>30 at 12 months.

Results

48 COX-2 inhibition and 46 placebo patients were analyzed in a modified intention to treat analysis. Contrary to our primary hypothesis, change in the sum of tolerance thresholds in the COX-2 inhibition group was not different versus placebo. COX-2 inhibition had an effect on pain on movement at postoperative day 5 (p<0.01). Consistent with our secondary hypothesis, change in sum of pressure pain tolerance thresholds in 11 patients that developed persistent pain was negative versus patients without pain (p<0.01) from day 5 to 1 year postoperatively.

Conclusions

Perioperative COX-2 inhibition has limited value in preventing sensitization and persistent pain after breast cancer surgery. Central sensitization may play a role in the genesis of persistent postsurgical pain.

Quality of postoperative recovery after breast surgery. General anaesthesia combined with paravertebral versus serratus-intercostal block

INTRODUCTION

The quality of postoperative recovery is one of the most important among all the quality indicators used in clinical situations. This is even more important after cancer surgery. Our aim was to evaluate this after non-reconstructive breast surgery under general anesthesia and paravertebral blockade or serratus-intercostal plane blockade, in the early and late post-operative period.

MATERIAL AND METHODS

A prospective observational study was conducted on 60 patients (25 paravertebral blockade group and 35 serratus-intercostal plane blockade group) scheduled for non-reconstructive breast surgery during a 6 month period. Every patient received general anaesthesia and were randomised to receive either paravertebral blockade or serratus-intercostal plane blockade. The quality of post-anaesthetic recovery was quantified by Postoperative Quality Recovery Scale, which is used to assess physiological, nociceptive, emotional, autonomy, cognitive and general state domains at different times: baseline (before surgery), 15min after the end of surgery, at discharge to home, and one month after surgery.

RESULTS

A total recovery of 95.93% was achieved in the early postoperative period (15min PACU), 99.07% at discharge to home, and 99.25% at one month after the intervention. No significant differences were found between groups in total score or in each evaluated area.

CONCLUSIONS

A progressive improvement was observed in the scores assessed with the Postoperative Quality Recovery Scale, reaching values that would allow the discharge to home and early return to usual active life from the immediate postoperative period, with no significant differences between the 2 analgesic techniques. Savings in opioid use and the excellent recovery were observed in all measured domains observed.

Accessory Joint and Neural Mobilizations for Shoulder Range of Motion Restriction After Breast Cancer Surgery: A Pilot Randomized Clinical Trial

OBJECTIVE

The aim of this study was to assess the methods to conduct a substantive clinical trial to evaluate the effects of accessory joint mobilization (AJM) vs neural mobilization (NM) techniques for shoulder motion restriction after breast cancer surgery.

METHODS

This pilot study was a prospective randomized and double-blind clinical trial in which 18 women who underwent unilateral breast cancer surgery and axillary lymph node dissection participated. The study was conducted at the Women's Health Research Group at the Physical Therapy Department of Alcalá University, Madrid, Spain. The intervention was AJM vs NM, with a 6-month follow-up. Primary outcomes included recruitment, adherence to treatment and retention rates, assessment procedures, and implementation of the 2 manual therapy techniques. Secondary outcomes included range of motion, sensory disturbance, pain, and upper limb functionality.

RESULTS

All participants accepted to be randomly assigned to study groups. One hundred percent retention was attained with all participants attending the 3-month and 6-month assessments. Adherence with treatment attendance was excellent. At 6-month follow-up, flexion range of motion had a mean change of 38.4° (±28.9) (P = .002) in the AJM group and a mean change of 36.8° (±21.8) (P = .002) in the NM group. Abduction range of motion had a median change of 52.4° (±43.6) (P = .004) in AJM group and a median change of 44° (±17.5) (P = .012).

CONCLUSIONS

These preliminary results of the effects of AJM and NM techniques in breast cancer survivors indicate that a full clinical trial will be worthwhile. The research methods tested and the modifications proposed within this pilot study offer a suitable foundation to conduct a substantive clinical trial.

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.

Women Treated for Breast Cancer Experiences of Chemotherapy-Induced Pain: Memories, Any Present Pain, and Future Reflections

BACKGROUND

Breast cancer survivors make up a growing population facing treatment that poses long-standing adverse effects including chemotherapy-related body function changes and/or pain. There is limited knowledge of patients' lived experiences of chemotherapy-induced pain (CHIP).

OBJECTIVE

The aim of this study was to explore CHIP and any long-standing pain experiences in the lifeworld of breast cancer survivors.

METHODS

Fifteen women participated in a follow-up interview a year after having experienced CHIP. They were interviewed from a lifeworld perspective; the interviews were analyzed through guided phenomenology reflection.

RESULTS

A past perspective: CHIP is often described in metaphors, leads to changes in a patient's lifeworld, and impacts lived time. The women become entirely dependent on others but at the same time feel isolated and alone. Existential pain was experienced as increased vulnerability. Present perspective: Pain engages same parts of the body, but at a lower intensity than during CHIP. The pain creates time awareness. Expected normality in relationships/daily life has not yet been achieved, and a painful existence emerges in-between health and illness. Future perspective: There are expectations of pain continuing, and there is insecurity regarding whom to turn to in such cases. A painful awareness emerges about one's own and others' fragile existence.

CONCLUSIONS

Experiencing CHIP can impact the lifeworld of women with a history of breast cancer. After CHIP, there are continued experiences of pain that trigger insecurity about whether one is healthy.

IMPLICATIONS FOR PRACTICE

Cancer survivors would likely benefit from communication and information about and evaluation of CHIP.

[Prevalence and management of pain in patients with metastatic cancer in Franche-Comté]

INTRODUCTION

Pain management is a major public health problem, especially in oncology. In order to assess professional practice, the IRFC-FC conducted a survey amongst patients with metastatic osteophilic solid tumor in Franche-Comté. The aims were to assess the pain prevalence, and its characteristics, its management and its impact on patients' quality of life in patients in pain.

METHODS

An observational, prospective and multicenter survey was conducted using a self-report questionnaire. Patients with metastatic breast or prostate cancer managed in 5 day-hospitals of the IRFC-FC over a period of three months were included.

RESULTS

Two hundred thirty-three questionnaires were analyzed. Pain prevalence rate was 48.5%. Three quarters of patients in pain had chronic background pain, moderate to severe, with or without breakthrough pain. Considering their pain intensity and their analgesic therapy, 42.0% of patients seem to have an inadequate treatment. Eighty-five percent of treated patients reported to be compliant and felt that their pain was well managed despite a strong impact on their quality of life.

CONCLUSION

The setting of a specific clinical pathway is essential to secure the standardized, optimal and efficient management of patients in pain. The assessment of patient satisfaction and quality of life must be integrated in clinical practice to identify patients in pain for which the treatment is inappropriate.

COMBIPECS, the single-injection technique of pectoral nerve blocks 1 and 2: a case series

Ultrasound-guided Pecs block can provide perioperative analgesia for breast surgery. A single-injection technique (COMBIPECS) combines both Pecs 1 and Pecs 2 blocks in a single needle pass. This technique saves time and is equally effective as the modified Pecs block which uses 2 needle passes. We present a case series of 21 patients who received the COMBIPECS block as a part of multimodal analgesia for breast cancer surgery. The block was administered before the surgery after induction of general anesthesia. The patients needed minimal intraoperative analgesics and remained pain free in the postoperative period up to 24 hours after surgery.

Efficacy of Mindfulness-Based Cognitive Therapy on Late Post-Treatment Pain in Women Treated for Primary Breast Cancer: A Randomized Controlled Trial

Purpose

To assess the efficacy of mindfulness-based cognitive therapy (MBCT) for late post-treatment pain in women treated for primary breast cancer.

Methods

A randomized wait list–controlled trial was conducted with 129 women treated for breast cancer reporting post-treatment pain (score ≥ 3 on pain intensity or pain burden assessed with 10-point numeric rating scales). Participants were randomly assigned to a manualized 8-week MBCT program or a wait-list control group. Pain was the primary outcome and was assessed with the Short Form McGill Pain Questionnaire 2 (SF-MPQ-2), the Present Pain Intensity subscale (the McGill Pain Questionnaire), and perceived pain intensity and pain burden (numeric rating scales). Secondary outcomes were quality of life (World Health Organization-5 Well-Being Index), psychological distress (the Hospital Depression and Anxiety Scale), and self-reported use of pain medication. All outcome measures were assessed at baseline, postintervention, and 3-month and 6-month follow-up. Treatment effects were evaluated with mixed linear models.

Results

Statistically significant time × group interactions were found for pain intensity (d = 0.61; P = .002), the Present Pain Intensity subscale (d = 0.26; P = .026), the SF-MPQ-2 neuropathic pain subscale (d = 0.24; P = .036), and SF-MPQ-2 total scores (d = 0.23; P = .036). Only pain intensity remained statistically significant after correction for multiple comparisons. Statistically significant effects were also observed for quality of life (d = 0.42; P = .028) and nonprescription pain medication use (d = 0.40; P = .038). None of the remaining outcomes reached statistical significance.

Conclusion

MBCT showed a statistically significant, robust, and durable effect on pain intensity, indicating that MBCT may be an efficacious pain rehabilitation strategy for women treated for breast cancer. In addition, the effect on neuropathic pain, a pain type reported by women treated for breast cancer, further suggests the potential of MBCT but should be considered preliminary.

Prevalence of persistent pain after breast cancer treatment by detection mode among participants in population-based screening programs

Background

To date, the study of the risks and benefits of breast cancer screening has not included the onset of persistent pain after breast cancer treatment within the context of population-based screening programs. Our purpose was to investigate the prevalence of persistent pain and associated factors in women diagnosed with breast cancer (screening or interval) in the context of a population-based breast cancer screening program in Spain.

Methods

A total of 1,057 women participating in a population-based breast cancer screening program were diagnosed with breast cancer between 2000 and 2008. The women were treated surgically and followed-up to 2013. The risk of developing persistent pain was estimated through multivariate logistic regression analysis.

Results

Breast cancer was detected during routine screening in 732 women (69.3 %) and emerged as an interval cancer between two screening rounds in 325 (30.7 %). Persistent pain was present in 118 women (11.3 %). Women diagnosed through routine screening reported a higher prevalence of persistent pain (12.9 %) than those with interval cancers (7.8 %)(P < 0.05). Multivariate logistic regression analysis identified two other variables associated with persistent pain: having a Charlson index > =2 (Odds Ratio [OR]: 4.5 95 % Confidence Interval [CI]: 2.1-9.5) versus no comorbidities, and having undergone an axillary lymph node dissection (OR: 2.0 95 % CI: 1.0-4.0) versus sentinel lymph node biopsy.

Conclusions

The prevalence of persistent pain was relatively low. The detection mode was not related to the onset of persistent pain. The factors associated with persistent pain were a Charlson index > =2 and the performance of axillary lymph node dissection. Women treated for breast cancer are at risk for developing persistent pain regardless of the detection mode, especially those with comorbidities and those who have undergone axillary lymph node dissection.

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

BACKGROUND

Persistent pain after breast cancer surgery affects up to 60% of patients. Early identification of those at higher risk could help inform optimal management. We conducted a systematic review and meta-analysis of observational studies to explore factors associated with persistent pain among women who have undergone surgery for breast cancer.

METHODS

We searched the MEDLINE, Embase, CINAHL and PsycINFO databases from inception to Mar. 12, 2015, to identify cohort or case-control studies that explored the association between risk factors and persistent pain (lasting ≥ 2 mo) after breast cancer surgery. We pooled estimates of association using random-effects models, when possible, for all independent variables reported by more than 1 study. We reported relative measures of association as pooled odds ratios (ORs) and absolute measures of association as the absolute risk increase.

RESULTS

Thirty studies, involving a total of 19 813 patients, reported the association of 77 independent variables with persistent pain. High-quality evidence showed increased odds of persistent pain with younger age (OR for every 10-yr decrement 1.36, 95% confidence interval [CI] 1.24-1.48), radiotherapy (OR 1.35, 95% CI 1.16-1.57), axillary lymph node dissection (OR 2.41, 95% CI 1.73-3.35) and greater acute postoperative pain (OR for every 1 cm on a 10-cm visual analogue scale 1.16, 95% CI 1.03-1.30). Moderate-quality evidence suggested an association with the presence of preoperative pain (OR 1.29, 95% CI 1.01-1.64). Given the 30% risk of pain in the absence of risk factors, the absolute risk increase corresponding to these ORs ranged from 3% (acute postoperative pain) to 21% (axillary lymph node dissection). High-quality evidence showed no association with body mass index, type of breast surgery, chemotherapy or endocrine therapy.

INTERPRETATION

Development of persistent pain after breast cancer surgery was associated with younger age, radiotherapy, axillary lymph node dissection, greater acute postoperative pain and preoperative pain. Axillary lymph node dissection provides the only high-yield target for a modifiable risk factor to prevent the development of persistent pain after breast cancer surgery.

New approach for treatment of prolonged postoperative pain: APS Out-Patient Clinic

Background and aims

Persistent postoperative pain (PPP) is a significant clinical problem. Several patient-related risk factors for PPP have been identified, including a previous chronic pain problem, young age, female gender and psychological vulnerability. Intra- and postoperative risk factors include surgical complications such as infections, haematoma, nerve damage and repeated surgery. As the length of hospital stay has been shortened, some patients may be discharged despite ongoing pain and insufficient analgesic medication. The challenge is to identify patients at high risk of developing PPP and to create a targeted care pathway to ensure effective and safe pain treatment especially in the subacute postoperative phase at home. This observational study describes the first two years of the Acute Pain Service Out-Patient Clinic (APS-OPC) at the Helsinki University Hospital.

Methods

Patient characteristics, known risk factors, and details of treatment of PPP for the first 200 patients referred to our APS-OPC were retrospectively collected from the medical records. The APS-OPC clinic functions in close collaboration with the Multidisciplinary Pain Clinic (MPC), and the number of patients in need of physiotherapist, psychologist or psychiatrist counselling was recorded, as well as the number of patients referred to the MPC for further PPP management.

Results

Patients were referred to the APS-OPC from different surgical specialities, the two most common being thoracic and orthopaedic surgery. Seventy per cent of the patients (139/200) presented symptoms indicating neuropathic postsurgical pain. The patients had, on average, five risk factors for PPP. The median time from surgery to the first contact to the APS-OPC was two months, and the median duration of follow-up was 2.8 months (0–16 months). The median number of contacts with APS-OPC was 3 (range 1–14). Every fourth patient needed only one contact to the APS-OPC. Nineteen per cent of the patients had an appointment with the physiotherapist and 20% with a psychologist or psychiatrist. At discharge after surgery, 54% of the patients were using weak opioids, 32% strong opioids and 71% gabapentinoids; at discharge from the APS-OPC, these numbers were 20%, 6% and 43%, respectively. Twenty-two per cent of the patients were referred to the MPC for further pain management.

Conclusions

The APS-OPC provides a fluent fast-track method of ensuring effective multimodal analgesia in the subacute recovery phase after surgery. Even strong opioids can be safely used after discharge and then tapered off in close supervision of the APS-OPC anaesthesiologist. As the APS-OPC was implemented in close collaboration with the MPC, the multidisciplinary resources are easily available during the course of the APS-OPC treatment.

Implications

The first two years of the APS-OPC have shown that a significant number of surgical patients benefit from continuing active pain management after discharge from hospital. This fast-track service provides physician-supervised titration of analgesics to improve pain relief in the subacute phase. An important task of the APS-OPC is to ensure that strong opioids are not inappropriately continued after recovery. Another goal of the APS-OPC is to identify patients in need of multidisciplinary pain management services to prevent chronification.

Prevalence and risk factors associated with pain 21 months following surgery for breast cancer

PURPOSE

This study investigated (1) the prevalence of pain following breast cancer treatment including moderate-to-severe persistent pain and (2) the association of risk factors, present 1 month following surgery, with pain at 21 months following surgery. This information may aid the development of clinical guidelines for early pain assessment and intervention in this population.

METHODS

This study was a retrospective analysis of core and breast modules of the European Organisation for Research and Treatment of Cancer (EORTC) questionnaire from 121 participants with early breast cancer. The relationships between potential risk factors (subscales derived from the EORTC), measured within 1 month following surgery, and pain at 21 months following surgery were analysed using univariable and multi-variable logistic regression.

RESULTS

At 21 months following surgery, 46.3 % of participants reported pain, with 24 % categorised as having moderate or severe pain. Prevalence of pain was similar between those who underwent axillary lymph node dissection versus biopsy. Univariate logistic regression identified baseline pain (odds ratio (95 % CI): 2.7 (1.1 to 6.4)); baseline arm symptoms (11.2 (1.4 to 89.8)); emotional function (0.4 (0.1 to 0.8)) and insomnia (2.3 (1.1 to 4.7) as significantly associated with pain at 21 months. In multi-variable analysis, two factors were independently associated with pain at 21 months-baseline arm symptoms and emotional subscale scores.

CONCLUSION

Pain is a significant problem following breast cancer treatment in both the early post-operative period and months following surgery. Risk factors for pain at long-term follow-up included arm symptoms and higher emotional subscale scores at baseline.

Persistent posthysterectomy pain: A prospective, observational study

BACKGROUND

There is a large variation in the prevalence of persistent postsurgical pain depending on the type of surgery. It is unclear how common persistent postsurgical pain is after vaginal or laparoscopic hysterectomy.

OBJECTIVES

The objective of this study was to define the prevalence of persistent postsurgical pain 6 months after laparoscopic or vaginal hysterectomy for benign causes and to ascertain the intensity of the pain and its possible predictors.

DESING

A prospective, observational study.

SETTING

Pirkanmaa Hospital District between October 2008 and September 2013.

PATIENTS

Two hundred and forty-two women who underwent laparoscopic (150) or vaginal (92) hysterectomy for benign causes and who also participated in our earlier studies concerning acute pain.

INTERVENTIONS

A pain questionnaire and a prestamped return envelope were mailed to all women 6 months after surgery. If the questionnaire had not been returned within 4 weeks, a reminder was sent. Data regarding preoperative pain and acute postoperative pain were collected from the records of our earlier studies concerning acute pain. The patient characteristics and surgical outcomes were collected from the patients' medical records.

MAIN OUTCOME MEASURE

The prevalence of persistent postsurgical pain 6 months after hysterectomy.

RESULTS

The response rate was 94% (227 respondents). Twenty-seven (18.9%) of 143 patients who had no pain preoperatively had persistent pain after surgery. Overall, 26.0% of patients had persistent pelvic pain 6 months after surgery. On an 11-point numeric rating scale (NRS), most of the patients rated their average pain as mild (NRS 0 to 3) and only 6.9% rated their worst pain as severe (NRS 7 to 10). Smoking, acute postoperative pain at 4 h after surgery and a laparoscopic approach were significantly associated with persistent pain in a multivariable analysis.

CONCLUSION

Persistent posthysterectomy pain is common, but pain is mild and does not interfere with daily activities for most of the patients 6 months after surgery. Smoking is the strongest predictor for persistent pain.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT 01537731.

A longitudinal analysis of chronic arm morbidity following breast cancer surgery

Arm morbidity (AM) arising from breast cancer (BC) treatment can detrimentally impact quality of life; often limiting a survivor's ability to participate in valued activities. The present study explored (a) the developmental time course of AM [restricted range of motion (ROM), pain, and arm volume changes], negative affect, and perceived disability in the immediate years post-surgery, and (b) the mediating role of perceived disability on the relationship between AM and negative affect over time. In this 5-year longitudinal study, BC survivors from four Canadian oncology clinics (n = 431) completed five annual clinical assessments, where differences in ROM (shoulder abduction, external rotation) and arm volume between the affected and non-affected arm were measured. The profile of mood states (POMS), disability of arm, shoulder, hand, and McGill Pain Questionnaire-Short form were completed. Results from general linear modeling showed that AM, negative affect, and perceived disability were greatest 1-year post-surgery, declined, and with the exception of arm volume changes, were significantly lower 5 years later. Negative affect was significantly associated with restrictions in shoulder abduction and external rotation (average r = -0.15; p < 0.05) and present arm pain (average r = 0.28, p < 0.01) at most assessments. The mediating role of perceived disability on the relationship between AM and negative affect was statistically significant in a majority of assessments. Perceived disability is the underlying factor driving the relationship between AM and mood disturbance over time. Rehabilitative therapy to improve survivors' functional well-being might mitigate the negative impacts of AM on emotional health.

Chronic pain in the pelvic area or lower extremities after rectal cancer treatment and its impact on quality of life: a population-based cross-sectional study

The aim of this investigation was to examine the prevalence of and factors associated with chronic pain in the pelvic area or lower extremities after rectal cancer treatment and its impact on quality of life (QoL). This is a population-based cross-sectional study of chronic pain and QoL in patients treated for rectal cancer from 2001 to 2007. A modified version of the Brief Descriptive Danish Pain Questionnaire and the European Organization for Research and Treatment of Cancer QLQ-C30 questionnaire were mailed to 1713 Danish patients. Informative answers were obtained from 1369 patients (80%). A total of 426 patients (31%) reported chronic pain in the pelvic area or lower extremities, 173 (41%) of whom had daily pain. Pain in other parts of the body was associated with the presence of pain in the pelvic region (odds ratio [OR] 4.81 [3.63-6.38], P < 0.001). Multivariate logistic regression analysis showed an association with chronic pain in female patients (OR 1.91 [1.51-2.43], P < 0.001) and in those who received radio(chemo)therapy (OR 1.31 [1.01-1.7], P = 0.041) or underwent abdominoperineal excision (OR 1.71 [1.19-2.44], P = 0.003), total mesorectal excision (OR 1.39 [1.01-1.90], P = 0.041), and Hartmann procedure (OR 1.72 [1.04-2.84], P = 0.33) compared with partial mesorectal excision. Ordinal regression analysis showed a strong association between all QoL subgroups and pelvic pain. Chronic pain in the pelvic region or lower extremities after rectal cancer treatment is a common but largely neglected problem that is associated with female gender, type of surgery, radio(chemo)therapy, and young age, all of which impact the patient's QoL.

Pressure Pain Sensitivity Maps of the Neck-Shoulder Region in Breast Cancer Survivors

OBJECTIVE

The aim of the present study was to report pressure pain sensitivity topographical maps of the frontal and dorsal parts of the shoulder region, and locate the pressure pain sensitive areas in breast cancer survivors compared with matched healthy control subjects.

METHODS

Twenty-two breast cancer survivors (BCS) and 22 matched control subjects participated. A numeric pain rating scale of the neck-shoulder area and pressure pain thresholds (PPTs) was assessed bilaterally over 28 points in the frontal and dorsal neck-shoulder area. Topographical pain sensitivity maps of the upper trapezius, pectoral, and anterior deltoid areas were computed.

RESULTS

A three-way analysis of variance was carried out to evaluate the differences in PPTs. The BCS reported spontaneous neck pain (mean ± SD 3.6 ± 2.8), pain in the affected shoulder (4.3 ± 2.7), and pain in the non-affected shoulder (0.9 ± 1.8). Additionally, the BCS exhibited bilaterally lower PPTs in all the measurement points as compared with the control subjects (P < 0.05). The PPTs were lower at the superior part of the trapezius muscle (P < 0.001), the musculotendinous insertion, the anterior part of the deltoid muscle (P < 0.001), and the tendon of the pectoral muscle (P < 0.001) as compared with the control subjects.

CONCLUSIONS

The results suggest the sensitization processes in the BCS and give preliminary evidence to most sensitive areas in the superior part of the upper trapezius and musculotendinous insertion of the pectoral muscle.