Predictors and consequences of multiple persistent postmastectomy pains

Neuropathic Pain Following Breast-conserving Surgery: A Systematic Review and Meta-Analysis

Background

Chronic pain after breast cancer surgery, affecting 25%-60% of patients, significantly impacts the survivors' quality of life. With improved survival rates, more individuals are experiencing this long-term complication. It is often overlooked that this chronic pain may stem from peripheral nerve injury, resulting in neuropathic pain characterized by burning sensations, electric shocks, and heightened sensitivity. Although neuropathic pain prevalence is reported at 24%-36% post-mastectomy, the data following breast-conserving surgery remain limited. This systematic review aimed to investigate the prevalence of neuropathic pain after breast-conserving surgery and its potential association with axillary procedures.

Methods

The electronic databases, Medline, Embase, Web of Science and Cochrane Central, were searched. Inclusion criteria were defined to include studies reporting on the prevalence of neuropathic pain following breast-conserving surgery and exploring associations with axillary procedures. A meta-analysis was performed to compute a pooled prevalence rate.

Results

Eight studies, covering 1,469 patients post-breast-conserving surgery, met the inclusion criteria. The meta-analysis revealed a pooled prevalence of 31% (95% confidence intervals [CI] 0.14-0.56) neuropathic pain among patients who underwent breast-conserving surgery. Six studies explored associations with axillary procedures; however, none suggested a correlation between axillary procedures and neuropathic pain after breast-conserving surgery.

Conclusion

This systematic review and meta-analysis indicated a pooled prevalence of 31% neuropathic pain following breast-conserving surgery of, with confidence interval ranging from 14% to 56%. The review did not provide conclusive evidence to suggest correlations between axillary procedures and neuropathic pain after breast-conserving surgery.

Effects of Physical Exercise and Motor Activity on Depression and Anxiety in Post-Mastectomy Pain Syndrome

BACKGROUND

Chronic post-surgical pain is a condition persisting for not less than 3 months after surgical intervention. It is evaluated that 25-60% of women who underwent breast cancer excision suffer from post-mastectomy pain syndrome, and anxiety, depression, sleep disturbance, and catastrophizing. Physical activity can reduce the risk of chronic diseases and has a good impact on mood and cognitive function. The aim of this study was to estimate the influence of physical activity on the intensity of pain, depression, and anxiety in women who underwent mastectomy for breast cancer removal.

METHODS

A prospective observational unicentric cohort study was performed. Patients were females who underwent unilateral or bilateral mastectomy. The Numerical Rating Scale (NRS) was used to measure pain intensity, Beck's Depression Inventory (BDI) for depression, and Generalized Anxiety Disorders-7 (GAD-7) for anxiety evaluation. Physical activity was assessed by the International Physical Activity Questionnaire (IPAQ). Interleukin (IL)-17, IL-1β, cortisol, adrenocorticotropic hormone (ACTH), and brain-derived neurotrophic factor (BDNF) were also evaluated in the blood of patients. All evaluations were assessed 3 and 6 months after the surgery.

RESULTS

Adequate physical activity reduced the intensity of pain, depression, and anxiety symptoms in women affected by post-mastectomy pain syndrome. Moreover, adequately active women showed a reduction in biomarkers of inflammation, cortisol, ACTH, and an increase of BDNF.

CONCLUSIONS

Our results suggest that physical activity can improve the quality of life, reduce the intensity of pain and inflammatory markers, and be useful in the reduction of associated anxiety and depression.

Changes in alpha, theta, and gamma oscillations in distinct cortical areas are associated with altered acute pain responses in chronic low back pain patients

Introduction

Chronic pain negatively impacts a range of sensory and affective behaviors. Previous studies have shown that the presence of chronic pain not only causes hypersensitivity at the site of injury but may also be associated with pain-aversive experiences at anatomically unrelated sites. While animal studies have indicated that the cingulate and prefrontal cortices are involved in this generalized hyperalgesia, the mechanisms distinguishing increased sensitivity at the site of injury from a generalized site-nonspecific enhancement in the aversive response to nociceptive inputs are not well known.

Methods

We compared measured pain responses to peripheral mechanical stimuli applied to a site of chronic pain and at a pain-free site in participants suffering from chronic lower back pain (n = 15) versus pain-free control participants (n = 15) by analyzing behavioral and electroencephalographic (EEG) data.

Results

As expected, participants with chronic pain endorsed enhanced pain with mechanical stimuli in both back and hand. We further analyzed electroencephalographic (EEG) recordings during these evoked pain episodes. Brain oscillations in theta and alpha bands in the medial orbitofrontal cortex (mOFC) were associated with localized hypersensitivity, while increased gamma oscillations in the anterior cingulate cortex (ACC) and increased theta oscillations in the dorsolateral prefrontal cortex (dlPFC) were associated with generalized hyperalgesia.

Discussion

These findings indicate that chronic pain may disrupt multiple cortical circuits to impact nociceptive processing.

Incidence, risk factors, prevention and treatment of postmastectomy pain syndrome in breast cancer: A multicenter study

BACKGROUND

Postmastectomy pain syndrome (PMPS) is a common postoperative condition after breast cancer surgery.

PURPOSE

The aim of this study was to investigate the incidence rate and risk factors of PMPS, and to propose prevention and treatment methods.

METHODS

The study included 1790 postoperative breast cancer patients from three hospitals from 2017 to 2021, of which 302 (13.0%) patients with PMPS were included in the study.

RESULTS

Age, breast surgery type, axillary surgery type and radiotherapy are the risk factors of PMPS. Age, radiotherapy and chemotherapy affect the pain degree of PMPS during movement.

CONCLUSIONS

For breast cancer patients with high risk factors, pain should be actively prevented during perioperative period. Oral pharmacological agents, multidisciplinary combination therapy, local anesthetics and regional anesthesia are the most common treatment of PMPS.

Post-Mastectomy Pain Syndrome: An Up-to-Date Review of Treatment Outcomes

BACKGROUND

Post-mastectomy pain syndrome (PMPS) is a known debilitating surgical complication. While research on prevention, risk factors, and treatments have been conducted, there remains no cohesive treatment paradigm. The aim of our study is to synthesize the existing evidence on PMPS treatment, which may facilitate the implementation of standardized, effective management strategies.

METHODS

Using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, a comprehensive search was developed and translated for MEDLINE, Cochrane Library, EMBASE, CINAHL, PsycINFO, Web of Science, and ClinicalTrials.gov. The databases were searched using a combination of free terms, phrase searching, and database-specific controlled vocabulary related to PMPS. All unique records were by two independent reviewers. Publications on chronic (>3 months duration) pain after breast cancer-related surgery were included. Limited case series, case reports, and editorials were not included.

RESULTS

A total of 3402 articles from the years 1946-2019 resulted from the literature search after deduplication. Twenty-seven articles met final inclusion criteria for analysis, which revealed 10 major treatment modalities: fat grafting, neuroma surgery, lymphedema surgery, nerve blocks and neurolysis, laser, antidepressants, neuromodulators, physical therapy, mindfulness-based cognitive therapy, and capsaicin.

CONCLUSIONS

In this review, we present a comprehensive assessment of the treatments available for PMPS that may help guide breast surgeons and reconstructive surgeons to employ the most effective treatment strategies for these patients. This review supports the importance of multimodal, multidisciplinary care in improving the management of PMPS.

Choosing Mastectomy vs. Lumpectomy-With-Radiation: Experiences of Breast Cancer Survivors

Background

Annually about 280,000 women are diagnosed with breast cancer. Treatment options depend on age, comorbidities, tumor stage, grade, size, and other factors. Often, patients must decide between two surgical treatment options: mastectomy or lumpectomy-with-radiation herein simply called a lumpectomy. Since both offer similar survival outcomes, the choice ultimately is the patient’s. However, most rely on inputs from doctors, family, friends, personal research, and other actions. We believe decision-making processes for future patients will be aided if experiences of prior breast cancer survivors are known. This study’s aim is to provide such information.

Methods

Feedback from prior breast cancer survivors was obtained using a 19-question survey distributed online to multiple breast cancer support groups. It focused on issues relevant to choosing between the two surgical options including, post-surgical complications, breast reconstruction, chronic pain, cosmetics, and surgery-choice satisfaction.

Results

Respondents (N=1606) had a median age of 49 years (range 26 to 88 years) and had a median body mass index (BMI) of 26.6 Kg/m². There were 978 mastectomy patients (60.9%) and 628 lumpectomy patients (39.1%). With regard to post-surgical reconstruction, 64.2% of mastectomy respondents and 13.5% of lumpectomy respondents decided to undergo breast cancer reconstruction following breast cancer surgery. Almost all (99.8%) of lumpectomy respondents had radiation side-effects; with skin irritation and thickening and chest wall tenderness being the most common. Among mastectomy patients, 94.3% had one or more complications; loss-or-changes in nipple or breast sensation, uneven breasts, chest wall tenderness, and breast swelling were the most common complications. Post-surgical pain lasting six months or more was experienced by a smaller percentage of mastectomy vs. lumpectomy patients (64.1% vs. 78%, p <0.00001). Mastectomy patients were also less likely to have pain that was persistent and present up to the time of the survey (35.4% vs. 46.0%, p=0.0002). With respect to cosmetic outcomes, mastectomy patients vs. lumpectomy patients were less likely to be either satisfied or very satisfied (52.2% vs. 62.7%, p=0.00004). Overall satisfaction of surgical treatment was 70.9% for mastectomy patients and 68.6% for lumpectomy patients.

Conclusion

Based on the experiences of these breast cancer survivors, mastectomy is associated with less chronic pain frequency and lower incidence of post-surgical side effects compared to lumpectomy. However, mastectomy is associated with lower cosmetic satisfaction. Breast cancer survivors that underwent a lumpectomy, reported being more satisfied with cosmetic outcomes but almost all reported radiation side-effects with skin thickening listed as the most common. Lumpectomy was also associated with higher chronic pain frequency compared to mastectomy.

The overall surgical treatment satisfaction reported by mastectomy and lumpectomy respondents was similar. The composite findings will provide information that will aid future breast cancer patients in making a decision between having a mastectomy or a lumpectomy.

Psychological Factors Are Associated with Pain at All Time Frames After Breast Cancer Surgery: A Systematic Review with Meta-Analyses

OBJECTIVE

This systematic review aimed to 1) assess associations between psychological factors and pain after breast cancer (BC) treatment and 2) determine which preoperative psychological factors predicted pain in the acute, subacute, and chronic time frames after BC surgery.

DESIGN

A systematic review with meta-analysis.

SUBJECTS

Women with early-stage BC.

METHODS

The Medline, EMBASE, CINAHL, and Web of Science databases were searched between 1990 and January 2019. Studies that evaluated psychological factors and pain after surgery for early-stage BC were included. Associations between psychological factors and pain, from early after surgery to >12 months after surgery, were extracted. Effect size correlations (r equivalents) were calculated and pooled by using random-effects meta-analysis models.

RESULTS

Of 4,137 studies, 47 were included (n = 15,987 participants; 26 studies ≤12 months after surgery and 22 studies >12 months after surgery). The majority of the studies had low to moderate risk of bias. Higher preoperative anxiety and depression were weak but significant predictors of pain at all time points up to 12 months (r equivalent: 0.15-0.22). Higher preoperative pain catastrophizing and distress were also weak but significant predictors of pain during the acute (0-7 days) and chronic (3-12 months) periods (r equivalent: 0.10-0.20). For the period >12 months after surgery, weak but significant cross-sectional associations with pain were identified for anxiety, depression, pain catastrophizing, and distress (r equivalents: 0.15, 0.17, 0.25, 0.14, respectively).

CONCLUSION

Significant pooled effect size correlations between psychological factors and pain were identified across all time frames. Though weak, these associations should encourage assessment of key psychological factors during preoperative screening and pain assessments at all postoperative time frames.

Patient-Reported Shoulder Morbidity and Fatigue among Breast Cancer Survivors: An Insight from a Tertiary Care Cancer Hospital

Context: Breast cancer is the most common cancer in Indian women with an annual mortality of around 87,000. Treatment for breast carcinoma may lead to swelling of the ipsilateral arm, shoulder stiffness, arm pain, and cancer-related fatigue. Very few centers in India have reported the arm and shoulder morbidity treated in their hospitals. Aims: The aim was to evaluate the predictive factors of arm and shoulder morbidity and fatigue among breast cancer survivors. Settings and Design: This was a retrospective analysis based on a prospectively maintained database. Materials and Methods: Early and locally advanced cases of breast cancer patients were screened for the study during 2015–2018. Eligible participants were invited to fill up the predetermined questionnaire, and their demographic and treatment-related information was accrued from a file archive. Follow-up period was estimated from the date of tissue diagnosis to last contact/time of interview. Results: Shoulder stiffness was the most common complaint followed by arm numbness. Obesity and diabetes played a crucial role in most of the morbidities and fatigue. The median fatigue score was 34, and the median time of appearance of lymphedema was 13 months. Modified radical mastectomy and radiotherapy to axilla were statistically significantly (P = 0.04 and 0.01, respectively) associated with greater shoulder stiffness and arm swelling. Conclusions: Obesity, diabetes, type of surgery, the extent of axillary dissection, and radiation plan are the major predictive factors of arm and shoulder morbidity. Further prospective validation is necessary for future breast cancer survivorship programs.

Postmastectomy Pain Syndrome: A Primer for Plastic Surgeons

Postmastectomy pain syndrome (PMPS) is defined as chronic pain after breast cancer surgery lasting greater than 3 months and has been shown to affect up to 60% of breast cancer patients. Substantial research has been performed to identify risk factors and potential treatment options, although the exact cause of PMPS remains elusive. As breast reconstruction becomes increasingly popular, plastic surgeons are likely to encounter more patients presenting with PMPS. This article summarizes current evidence on risk factors and treatment options for PMPS and highlights further areas of study.

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.

"Making Peace with Our Bodies": A Qualitative Analysis of Breast Cancer Survivors' Experiences with Qigong Mind-Body Exercise

Objectives: Breast cancer treatment leaves breast cancer survivors (BCS) with an array of lasting side effects, including persistent postsurgical pain (PPSP). In this study, we explored the perceptions of BCS with PPSP as they learned Qigong mind-body exercise (QMBE), a multimodal practice rooted in Traditional Chinese Medicine. Methods: Participants included 18 female BCS treated for stage 0-III breast cancer and experiencing PPSP. Participants were taught QMBE over 12 weeks. Semi-structured interviews were conducted before and after the intervention. Results: BCS disclosed a disconnect between mind and body that emerged during treatment. They perceived QMBE as moving meditation, which enabled them to reconnect mind and body, lessen their pain, and make peace with their bodies. Conclusion: These women's experiences both inform the promise of integrating QMBE and related mind-body exercise into PPSP clinical practice guidelines and suggest new areas of research regarding the role of multimodal interventions for holistic healing in BCS.

Pain Neuroscience Education in cancer survivors with persistent pain: A pilot study

PURPOSE

To describe the Pilot Study: Pain Neuroscience Education in Cancer Survivors and describe the innovative educational component of Pain Neuroscience Education (PNE).

DESIGN

Quasi experimental design.

METHOD

The PNE program, encompassing a one-on-one education session and an information leaflet was given to 30 cancer survivors. At baseline and two weeks after the PNE, participants were asked to fill out following outcome measures; pain intensity, pain catastrophizing, and HRQoL.

FINDINGS

Following PNE, a significant decrease on pain intensity (p = 0.001), on the SF-36 subscale pain (p = 0.003) and for the following PCS subscales: Helplessness (p < 0.001), Rumination (p = 0.002) and Total score (p < 0.001) was found compared to baseline.

CONCLUSIONS

Although the current results need to be verified in a larger randomized, controlled trial, preliminary evidence shows a decrease in pain intensity and pain catastrophizing following PNE in cancer survivors with persistent pain.

The effects of poloxamer and sodium alginate mixture (Guardix-SG®) on range of motion after axillary lymph node dissection: A single-center, prospective, randomized, double-blind pilot study

PURPOSE

Restricted shoulder mobility is a major upper extremity dysfunction associated with lower quality of life and disability after breast cancer surgery. We hypothesized that a poloxamer and sodium alginate mixture (Guardix-SG®) applied after axillary lymph node dissection (ALND) would significantly improve shoulder range of motion (ROM) in patients with breast cancer.

METHODS

We conducted a double-blind, randomized, prospective study to evaluate the clinical efficacy and safety of Guardix-SG® for the prevention of upper extremity dysfunction after ALND. The primary outcome measure was shoulder ROM at baseline (T0) and 3 (T1), 6 (T2), and 12 months (T3) after surgery. Secondary outcome measures were the Disabilities of the Arm, Shoulder, and Hand score(DASH), pain associated with movement, which was assessed using a numeric rating scale, and lymphedema assessed using body composition analyzer.

RESULTS

A total of 83 women with breast cancer were randomly assigned to either the Guardix-SG® group or the control group. In the Guardix-SG® group (n = 37), Guardix-SG® was applied to the axillary region after ALND. In the control group (n = 46), ALND was performed without using Guardix-SG®. Comparing ROM for shoulder flexion before surgery (178.2°) and 12 months after surgery (172.3°), that was restored 12 months after surgery in the Guardix-SG® group, and there was no statistically significant difference between that at before surgery and 12 months after surgery (p = 0.182). No adverse effect was observed in either group.

CONCLUSIONS

The results of this study have shown that Guardix-SG® help improve shoulder ROM without causing adverse effects in patients who underwent breast cancer surgery. However, there was no statistically significant difference from the control group. A further large-scale study is needed to obtain a more conclusive conclusion.

TRIAL REGISTRATION

CRISKCT0003386; https://cris.nih.go.kr (20181207).

Ketamine normalizes high-gamma power in the anterior cingulate cortex in a rat chronic pain model

Chronic pain alters cortical and subcortical plasticity, causing enhanced sensory and affective responses to peripheral nociceptive inputs. Previous studies have shown that ketamine had the potential to inhibit abnormally amplified affective responses of single neurons by suppressing hyperactivity in the anterior cingulate cortex (ACC). However, the mechanism of this enduring effect has yet to be understood at the network level. In this study, we recorded local field potentials from the ACC of freely moving rats. Animals were injected with complete Freund’s adjuvant (CFA) to induce persistent inflammatory pain. Mechanical stimulations were administered to the hind paw before and after CFA administration. We found a significant increase in the high-gamma band (60–100 Hz) power in response to evoked pain after CFA treatment. Ketamine, however, reduced the high-gamma band power in response to evoked pain in CFA-treated rats. In addition, ketamine had a sustained effect on the high-gamma band power lasting up to five days after a single dose administration. These results demonstrate that ketamine has the potential to alter maladaptive neural responses in the ACC induced by chronic pain.

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.

A Review of Breast Pain: Causes, Imaging Recommendations, and Treatment

Over two-thirds of women will experience breast pain in their lifetime. As one of the leading breast symptoms for which women seek medical attention, breast pain is suspected to be underreported and under-studied. Cyclical breast pain is related to hormonal changes. Noncyclical breast pain is independent of the menstrual cycle and can be idiopathic and related to chronic pain syndromes, infections, ill-fitting bras, musculoskeletal abnormalities, pregnancy, perimenopause, and postsurgical causes. Breast pain can also present in transgender patients and may require additional considerations as to the underlying cause. Imaging of mastalgia depends upon the suspected etiology. Inappropriate imaging for breast pain is associated with significant utilization of health care resources. Cyclical breast pain does not require an imaging work-up. The work-up of focal, noncyclical breast pain includes ultrasound for women aged younger than 40 years, and mammography and ultrasound for women aged 40 years and older. Management of breast pain is often supportive, as most breast pain resolves spontaneously. If pain persists, imaging and management should follow a step-wise approach. If conservative measures fail, second-line therapy is topical nonsteroidal anti-inflammatory drugs. If breast pain is severe and resistant to conservative methods, additional third-line therapies can be added by breast care specialists with specific knowledge of the potential deleterious side effects of these medications. While the causes of mastalgia are overwhelmingly benign, breast pain can significantly impact quality of life, and the breast radiologist should be familiar with causes, management, and treatment recommendations from a multidisciplinary approach.

The Jacki Jacket after mastectomy with reconstruction: a randomized pilot study

BACKGROUND

Breast cancer patients undergoing mastectomy with reconstruction (TM + R) often experience post-operative discomfort from surgical drains. Despite a variety of garment options for use in the post-operative period, high-quality data assessing the impact of specific garments on post-operative pain are lacking. We report the results of a prospective randomized trial assessing the impact of the Jacki Jacket (JJ), a long-sleeve jacket with inner drain receptacle pockets, on post-discharge pain and quality of life (QOL) after TM + R.

METHODS

Breast cancer patients undergoing TM + R at a single institution were randomized post-operatively to receive a JJ or usual care (UC). Participant-reported demographics, pain intensity, and QOL were collected on post-operative day 1 (T1). Following discharge, participants completed a daily pain and medication dairy (T2); on day of drain(s) removal (T3), participants again completed pain and QOL questionnaires. Linear models were used to evaluate associations between JJ use, post-operative pain, and QOL.

RESULTS

From 3/8/17 to 12/20/17, 139 women were randomized. All participants completed T1 measures, 102 returned the T2 diary, and 118 (84.9%) completed T3 questionnaires. There was no significant difference in pain scores between JJ and UC arms at any timepoint. Adjusting for surgery type, age, marital status, depression, and obesity, participants randomized to JJ reported significantly better body image scores (estimate = 12.94, p = 0.009). There were no adverse events.

CONCLUSIONS

Although JJ garment use did not impact post-operative pain intensity scores, the significant impact of JJ use on body image supports consideration for inclusion of such garments in post-operative care for patients undergoing TM + R.

CLINICAL TRIAL REGISTRATION INFORMATION

Registered with ClinicalTrials.gov, NCT number NCT02976103, November 18, 2016.

Scaling Up Cortical Control Inhibits Pain

Acute pain evokes protective neural and behavioral responses. Chronic pain, however, disrupts normal nociceptive processing. The prefrontal cortex (PFC) is known to exert top-down regulation of sensory inputs; unfortunately, how individual PFC neurons respond to an acute pain signal is not well characterized. We found that neurons in the prelimbic region of the PFC increased firing rates of the neurons after noxious stimulations in free-moving rats. Chronic pain, however, suppressed both basal spontaneous and pain-evoked firing rates. Furthermore, we identified a linear correlation between basal and evoked firing rates of PFC neurons, whereby a decrease in basal firing leads to a nearly 2-fold reduction in pain-evoked response in chronic pain states. In contrast, enhancing basal PFC activity with low-frequency optogenetic stimulation scaled up prefrontal outputs to inhibit pain. These results demonstrate a cortical gain control system for nociceptive regulation and establish scaling up prefrontal outputs as an effective neuromodulation strategy to inhibit pain.

A single-session acceptance and commitment therapy intervention among women undergoing surgery for breast cancer: A randomized pilot trial to reduce persistent postsurgical pain

OBJECTIVE

Oncologic breast surgeries carry a risk for persistent postsurgical pain. This study was a randomized pilot and feasibility study of a single-session Acceptance and Commitment Therapy (ACT) intervention compared with treatment as usual among women undergoing surgery for breast cancer or ductal carcinoma in situ.

METHODS

Participants were recruited via letter of invitation and follow-up phone call from a single site in the United States from 2015 to 2017. Participants were at risk for persistent postsurgical pain, based on young age (<50), a preexisting chronic pain condition, or elevated anxiety, depression, or pain catastrophizing.

RESULTS

The 54 participants were female with a mean age of 52.91 years (SD=11.80). At 3-month postsurgery, 11% of the sample reported moderate-severe pain (>3 on a 0-10 numeric rating scale) in the operative breast or with arm movement. Written qualitative responses indicated that the majority of participants who received the intervention understood the concepts presented and reported continued practice of exercises learned in the session. The between group effect sizes for moderate-severe pain and elevated anxiety at 3-month post-surgery were small (Phi=0.08 and 0.16, respectively). The between group effect sizes for depression, pain acceptance, and pain catastrophizing at 3-month postsurgery were minimal.

CONCLUSIONS

This study found small positive effects on postsurgical pain and anxiety for a single-session ACT intervention among women with breast cancer. This study supports the use of ACT with this population.

EduCan trial: study protocol for a randomised controlled trial on the effectiveness of pain neuroscience education after breast cancer surgery on pain, physical, emotional and work-related functioning

INTRODUCTION

Over the past decades, awareness on the importance of educational interventions in cancer pain management has increased. However, education is often restricted to biomedical pain management instructions. A more modern educational approach, also known as pain neuroscience education (PNE), explains pain from a biopsychosocial perspective. We hypothesise that this more comprehensive educational approach in the early treatment phase of breast cancer will lead to more beneficial effects for cancer pain management. Therefore, the aim of the present study is to investigate the effectiveness of this PNE intervention, in addition to best evidence physical therapy modalities for treatment and prevention of pain, physical, emotional and work-related functioning after breast cancer surgery, compared with a traditional biomedical educational intervention.

METHODS

A double-blinded randomised controlled trial has been started in November 2017 at the University Hospitals of Leuven. Immediately after breast cancer surgery, all participants (n=184) receive a 12-week intensive standard physical therapy programme. They receive three additional refresher sessions at 6, 8 and 12 months postsurgery. In addition, participants receive three educational sessions during the first-month postsurgery and three 'booster sessions' at 6, 8 and 12 months postsurgery. In the intervention group, the content of the education sessions is based on the modern PNE approach. Whereas in the control group, the education is based on the traditional biomedical approach. The primary outcome parameter is pain-related disability 1 year after surgery. Secondary outcomes related to other dimensions of pain, physical, emotional and work-related functioning at 1-week, 4, 6, 8, 12 and 18 months postsurgery.

ETHICS AND DISSEMINATION

The study will be conducted in accordance with the Declaration of Helsinki. This protocol has been approved by the ethical committee of the University Hospitals of Leuven. Results will be disseminated via peer-reviewed scientific journals and presentations at congresses.

TRIAL REGISTRATION NUMBER

NCT03351075.

Ketamine reduces aversion in rodent pain models by suppressing hyperactivity of the anterior cingulate cortex

Chronic pain is known to induce an amplified aversive reaction to peripheral nociceptive inputs. This enhanced affective response constitutes a key pathologic feature of chronic pain syndromes such as fibromyalgia. However, the neural mechanisms that underlie this important aspect of pain processing remain poorly understood, hindering the development of treatments. Here, we show that a single dose of ketamine can produce a persistent reduction in the aversive response to noxious stimuli in rodent chronic pain models, long after the termination of its anti-nociceptive effects. Furthermore, we demonstrated that this anti-aversive property is mediated by prolonged suppression of the hyperactivity of neurons in the anterior cingulate cortex (ACC), a brain region well known to regulate pain affect. Therefore, our results indicate that it is feasible to dissociate the affective from the sensory component of pain, and demonstrate the potential for low-dose ketamine to be an important therapy for chronic pain syndromes.

Ketamine is a short-acting analgesic that also has anti-depressant effects. Here the authors show in rat models of chronic pain that low-dose ketamine can induce an anti-aversive state that persists after the initial short term analgesia has ended.

Assessment of biomechanical parameters of the shoulder joint at the operated side versus non-operated side in patients treated surgically for breast cancer

Aim

Isokinetic assessment of biomechanical parameters of the shoulder joint at the operated side versus non-operated side in patients treated surgically for breast cancer according to the type of surgery performed.

Background

Despite significant progress in medicine, comprehensive cancer therapy may still cause a number of undesired structural and functional effects. The most frequent complications include long-term weakening of muscles within the shoulder and upper extremity at the operated side.

Materials and methods

The study enrolled 57 patient, divided into two groups: mastectomy and BCT. Diagnostic tests were carried out on the groups to assess biomechanical parameters (peak torque, power, total work) of the shoulder joint in internal and external rotation.

Results

The results of the isokinetic test revealed a considerable reduction of dynamic properties of the muscle groups responsible for the function of the shoulder joint at the operated side. The deficits observed, depending on the angular speed and plane of rotation, were from 22.3% to 32.7% and from 23.1% to 29.4% for muscle power and total work, respectively. The least noticeable loss was that of muscular torque, ranging from 6.5% to 18.3%.

Conclusion

None of the treatment methods applied ensured a full release of the restriction within the shoulder and upper limb. The deficits observed may constitute a serious disorder of the musculoskeletal system; therefore, a clinical study of biomechanical parameters of the shoulder joint may be an important control of patients' functional status after breast cancer treatment.

Inhibition of the Prefrontal Projection to the Nucleus Accumbens Enhances Pain Sensitivity and Affect

Cortical mechanisms that regulate acute or chronic pain remain poorly understood. The prefrontal cortex (PFC) exerts crucial control of sensory and affective behaviors. Recent studies show that activation of the projections from the PFC to the nucleus accumbens (NAc), an important pathway in the brain's reward circuitry, can produce inhibition of both sensory and affective components of pain. However, it is unclear whether this circuit is endogenously engaged in pain regulation. To answer this question, we disrupted this circuit using an optogenetic strategy. We expressed halorhodopsin in pyramidal neurons from the PFC, and then selectively inhibited the axonal projection from these neurons to neurons in the NAc core. Our results reveal that inhibition of the PFC or its projection to the NAc, heightens both sensory and affective symptoms of acute pain in naïve rats. Inhibition of this corticostriatal pathway also increased nociceptive sensitivity and the aversive response in a chronic neuropathic pain model. Finally, corticostriatal inhibition resulted in a similar aversive phenotype as chronic pain. These results strongly suggest that the projection from the PFC to the NAc plays an important role in endogenous pain regulation, and its impairment contributes to the pathology of chronic pain.

Local field potential decoding of the onset and intensity of acute pain in rats

Pain is a complex sensory and affective experience. The current definition for pain relies on verbal reports in clinical settings and behavioral assays in animal models. These definitions can be subjective and do not take into consideration signals in the neural system. Local field potentials (LFPs) represent summed electrical currents from multiple neurons in a defined brain area. Although single neuronal spike activity has been shown to modulate the acute pain, it is not yet clear how ensemble activities in the form of LFPs can be used to decode the precise timing and intensity of pain. The anterior cingulate cortex (ACC) is known to play a role in the affective-aversive component of pain in human and animal studies. Few studies, however, have examined how neural activities in the ACC can be used to interpret or predict acute noxious inputs. Here, we recorded in vivo extracellular activity in the ACC from freely behaving rats after stimulus with non-noxious, low-intensity noxious, and high-intensity noxious stimuli, both in the absence and chronic pain. Using a supervised machine learning classifier with selected LFP features, we predicted the intensity and the onset of acute nociceptive signals with high degree of precision. These results suggest the potential to use LFPs to decode acute pain.

Neuropathic Pain Causes Pyramidal Neuronal Hyperactivity in the Anterior Cingulate Cortex

The anterior cingulate cortex (ACC) is thought to be important for acute pain perception as well as the development of chronic pain after peripheral nerve injury. Nevertheless, how ACC neurons respond to sensory stimulation under chronic pain states is not well understood. Here, we used an in vivo two-photon imaging technique to monitor the activity of individual neurons in the ACC of awake, head restrained mice. Calcium imaging in the dorsal ACC revealed robust somatic activity in layer 5 (L5) pyramidal neurons in response to peripheral noxious stimuli, and the degree of evoked activity was correlated with the intensity of noxious stimulation. Furthermore, the activation of ACC neurons occurred bilaterally upon noxious stimulation to either contralateral or ipsilateral hind paws. Notably, with nerve injury-induced neuropathic pain in one limb, L5 pyramidal neurons in both sides of the ACC showed enhanced activity in the absence or presence of pain stimuli. These results reveal hyperactivity of L5 pyramidal neurons in the bilateral ACC during the development of neuropathic pain.

Exploring the Lived Experience of Women Immediately Following Mastectomy: A Phenomenological Study

BACKGROUND

In 2014, it is estimated that 232,670 new cases of breast cancer occurred in the United States. Unilateral or bilateral mastectomy is a frequently chosen option for treating this disease.

OBJECTIVE

The purpose of this study was to explore, through an in-depth interview process, the lived experience of women immediately following mastectomy when they see their scars for the first time.

METHODS

Purposeful sampling was used until saturation was reached. In-depth interviews were conducted with 10 women related to their mastectomy experience. The data were analyzed using a phenomenological approach.

RESULTS

The following 8 themes emerged from the data; lasting impact, personal impact, relational impact, gratitude, support system, coping strategies, timing, and discomfort.

CONCLUSIONS

The results of the study provide evidence that women face ongoing challenges following seeing their mastectomy scars for the first time that is not adequately addressed by healthcare professionals.

IMPLICATIONS FOR PRACTICE

Nurses and other healthcare professionals need to gain a better understanding of the difficulties perceived by women following seeing the scars from mastectomy and implement strategies to assist in successful adaptation to the experience.

Chronic pain induces generalized enhancement of aversion

A hallmark feature of chronic pain is its ability to impact other sensory and affective experiences. It is notably associated with hypersensitivity at the site of tissue injury. It is less clear, however, if chronic pain can also induce a generalized site-nonspecific enhancement in the aversive response to nociceptive inputs. Here, we showed that chronic pain in one limb in rats increased the aversive response to acute pain stimuli in the opposite limb, as assessed by conditioned place aversion. Interestingly, neural activities in the anterior cingulate cortex (ACC) correlated with noxious intensities, and optogenetic modulation of ACC neurons showed bidirectional control of the aversive response to acute pain. Chronic pain, however, altered acute pain intensity representation in the ACC to increase the aversive response to noxious stimuli at anatomically unrelated sites. Thus, chronic pain can disrupt cortical circuitry to enhance the aversive experience in a generalized anatomically nonspecific manner.

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.

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.

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

CONTEXT

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Repetitive transcranial magnetic stimulation in neuropathic pain secondary to malignancy: a randomized clinical trial

BACKGROUND

Significant analgesic effects of repetitive transcranial magnetic stimulation (rTMS) have been found in several studies of patients with chronic pain of various origins, but never for malignancy. The objective of this study was to assess the efficacy of 10 sessions of rTMS over the primary motor cortex (M1) in patients suffering from malignant neuropathic pain.

METHODS

Thirty-four patients were randomly allocated into one of two groups to receive real (20 Hz, 10 s, 10 trains with 80% intensity) or sham rTMS daily for 10 consecutive days. Patients were evaluated using a verbal descriptor scale (VDS), a visual analogue scale (VAS), Leeds assessment of neuropathic symptoms and signs (LANSS) and Hamilton rating scale for depression (HAM-D) at baseline, after the first, fifth and 10th treatment sessions, and then 15 days and 1 month after treatment.

RESULTS

There were no significant differences between real and sham groups in the duration of illness or pain rating scores at the baseline. A significant 'Time × Group' interaction was recorded indicating that real and sham rTMS had different effects on the VDS, VAS, LANSS and HAM-D scales. Post-hoc testing showed that the group of patients treated with real rTMS had greater improvement in all scales that persisted up to 15 days, but were not present 1 month later. Significant positive correlations between the percentage of pain reduction and HAM-D after the 10th session and 15 days later were recorded.

CONCLUSION

The results demonstrate that 10 rTMS sessions over the M1 can induce short-term pain relief in malignant neuropathic pain.

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

PURPOSE

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

METHODS AND SAMPLE

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

RESULTS

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

CONCLUSIONS

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

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

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

PERSPECTIVE

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

Breast care in the transgender individual

INTRODUCTION

Transgender individuals undergo hormone therapy and/or alter their breasts or genitals to facilitate a transition from male to female or female to male. Changes in the breast tissue from hormone therapy, breast binding, mastectomy, or breast augmentation are of specific interest to women's health care providers. To provide competent care, providers must be knowledgeable about unique aspects of breast health in this vulnerable population, including screening guidelines and client education. The purpose of this integrative literature review is to compile the current research on breast health for transgender individuals and to serve as a resource for providers.

METHODS

A search of the literature was performed using CINAHL, Ovid, and PubMed. Results were reviewed for relevant articles, and the reference lists of these were reviewed for additional resources. When available, studies specific to the transgender population are presented; studies of other populations are also included when relevant. Theories of human endocrinology, physiology, and anatomy will provide the foundation for the review and discussion.

RESULTS

Research into breast care for transgender individuals is limited. Often, practitioners must draw conclusions for practice from scattered case studies or research with nontransgender populations. Many of the procedures and practices transgender individuals choose to undergo, such as implantation, injection, binding, and mastectomy, carry serious risks.

DISCUSSION

Transgender individuals should be counseled on all the possible outcomes of their decisions, so they are capable of making informed choices. They must also be followed with careful consideration of these choices. More research in many areas of transgender breast care is necessary.

An overview of predictors for persistent neuropathic pain

Neuropathic pain (NP) is a pain arising as a direct consequence of a lesion or disease affecting the somatosensory system. A variety of factors associated with the development of persistent NP have been suggested. The goal of the present article is to provide an overview of current knowledge about prognostic factors for persistent NP. The International Classification of Functioning, Disability and Health model is used as a framework to categorize these predictors. Most reported predictors in the literature were found in the International Classification of Functioning, Disability and Health-category of personal factors, especially age and psychological factors, functions and structure, including sensory signs and symptoms. Predictors in the category of environmental factors, activities and participation were less frequently described.

The information needs and media preferences of Canadian cancer specialists regarding breast cancer treatment related arm morbidity

The information needs and media preferences of Canadian cancer specialists regarding breast cancer treatment related arm morbidity. Breast cancer treatment related arm morbidity is a common but pernicious condition that is under-recognised, under-diagnosed, and can result in long-term impairment and disability. Despite the prevalence of this condition, little is known about breast cancer specialists' information needs and media preferences around this issue. In-depth telephone interviews with 14 Canadian cancer specialists were conducted, and were coded and analysed using a grounded theory approach. Findings revealed that cancer specialists were open to receiving all types of information about treatment related arm morbidity, and have preferences for particular types of media formats. However, barriers that could problematise the uptake of research findings into clinical practice were also noted and included gaps in specialists' knowledge of the complex nature of treatment related lymphoedema. Hence providing specialists with summary information about arm morbidity will not suffice, and an educational campaign around this condition, including the importance of physician vigilance in regularly monitoring patients for early and latent indications of this morbidity may be necessary.

Persistent postmastectomy pain in breast cancer survivors: analysis of clinical, demographic, and psychosocial factors

Persistent postmastectomy pain (PPMP) is increasingly recognized as a major individual and public health problem. Although previous studies have investigated surgical, medical, and demographic risk factors, in this study we aimed to more clearly elucidate the relationship of psychosocial factors to PPMP. Postmastectomy patients (611) were queried about pain location, severity, and burden 38.3 ± 35.4 months postoperatively. Validated questionnaires for depressive symptoms, anxiety, sleep, perceived stress, emotional stability, somatization, and catastrophizing were administered. Detailed surgical, medical, and treatment information was abstracted from patients' medical records. One third (32.5%) of patients reported PPMP, defined as ≥3/10 pain severity in the breast, axilla, side, or arm, which did not vary according to time since surgery. Multiple regression analysis revealed significant and independent associations between PPMP and psychosocial factors, including catastrophizing, somatization, anxiety, and sleep disturbance. Conversely, treatment-related factors including surgical type, axillary node dissection, surgical complication, recurrence, tumor size, radiation, and chemotherapy were not significantly associated with PPMP. These data confirm previous studies suggesting that PPMP is relatively common and provide new evidence of significant associations between psychosocial characteristics such as catastrophizing with PPMP, regardless of the surgical and medical treatment that patients receive, which may lead to novel strategies in PPMP prevention and treatment.

PERSPECTIVE

This cross-sectional cohort study of 611 postmastectomy patients investigated severity, location, and frequency of pain a mean of 3.2 years after surgery. Significant associations between pain severity and individual psychosocial attributes such as catastrophizing were found, whereas demographic, surgical, medical, and treatment-related factors were not associated with persistent pain.

Alteration in pain modulation in women with persistent pain after lumpectomy: influence of catastrophizing

CONTEXT

Persistent pain is common after surgical treatment of breast cancer, but fairly little is known about the changes in sensory processing that accompany such pain syndromes.

OBJECTIVES

This study used quantitative sensory testing to compare psychophysical responses to standardized noxious stimulation in two groups of women who had previously undergone breast cancer surgery: women with (n=37) and without (n=34) persistent postoperative pain.

METHODS

Participants underwent a single testing session in which responses to a variety of noxious stimuli were assessed.

RESULTS

Findings suggested that women with chronic pain after breast cancer surgery display enhanced temporal summation of mechanical pain, deficits in endogenous pain inhibition, and more intense painful aftersensations compared with those without long-term pain. Some of these group differences were mediated by higher levels of pain catastrophizing in the group of women with persistent pain.

CONCLUSION

These findings suggest that persistent postoperative pain is associated with alterations in central nervous system pain-modulatory processes. Future treatment studies might benefit from targeting these pain-modulatory systems, and additional studies using functional neuroimaging methods might provide further valuable information about the pathophysiology of long-term postsurgical pain in women treated for breast cancer.

Profile and predictors of long-term morbidity in breast cancer survivors

BACKGROUND

A sound understanding of the benefits of different treatment options and their health-related quality of life (HRQoL) impacts is required for optimal breast cancer care.

METHODS

A cross-sectional cohort study was conducted to determine the prevalence and severity of persistent functional decrements and symptoms and identify demographic, clinical and treatment variables associated with poorer outcomes. Four hundred English-speaking women treated for ductal carcinoma-in-situ or stage I to III breast cancer between 1999 and 2009, at least 12 months after surgery and currently disease free, were randomly selected and invited to complete (1) the Breast Cancer Treatment Outcome Scale and (2) the EORTC core Quality of Life Questionnaire, version 3.

RESULTS

The response rate was 85.60 %. Many participants reported moderate to severe decrements in a number of HRQoL domains, including functional well-being (15 %), cosmetic status (32 %) and overall quality of life (21 %). There were significant associations (p < .05) between younger age and poorer HRQoL but none between time since surgery and morbidity (p > .05). Different treatments were associated with different HRQoL impacts. Poorer functional status was predicted by axillary dissection (p = .011), and adjuvant radiotherapy was a significant predictor of breast-specific pain (p < .05).

CONCLUSIONS

Many breast cancer survivors report long-term morbidity that is unaffected by time since surgery. The significant associations between the extent of locoregional therapies and poorer HRQoL outcomes emphasize the importance of the safe tailoring of these treatments.