Breast Reconstruction Does Not Increase the Incidence of Postmastectomy Pain Syndrome: Results of a Meta-Analysis

Prevalence and Severity of Chronic Pain in Patients Receiving Mastectomy with Alloplastic Immediate Breast Reconstruction: A Survey Study

Introduction: Breast cancer is the most frequently diagnosed cancer worldwide. For those undergoing mastectomy, the choice of alloplastic immediate breast reconstruction (IBR) is increasingly favored. Post-operative chronic pain is an important consideration in this decision, but there is a paucity of data for those undergoing alloplastic IBR. We sought to examine the prevalence, severity, and risk factors for the development of chronic pain in this cohort using validated patient-reported outcome measures. Methods: A cross-sectional survey study was conducted among patients receiving mastectomy with alloplastic IBR. Participants completed 3 surveys querying chronic pain, specifically the Breast Cancer Pain Questionnaire (BCPQ), Brief Pain Inventory (BPI), and BREAST-Q. Participant medical records were reviewed for demographic and surgical variables. Results: A total of 118 patients participated in the study-a response rate of 33.6%. Chronic pain prevalence was high (52.5%), and only 29.0% of these patients had consulted a physician regarding their pain. Among those reporting chronic pain (n = 62), the median severity of pain was 3.1 on an 11-point scale. Chronic pain was associated with radiation (p = .018), bilateral reconstruction (p = .05), worse emotional health (p = .0003), less self (p = .022), and sexual confidence (p = .044). Inter-tool reliability was high, with no significant difference in responses between the 3 surveys. Conclusion: In this cohort, chronic pain is supported as a significant concern among patients who have undergone mastectomy with alloplastic IBR. Given the burden of chronic pain, there is an opportunity to intervene with preventative measures and support for its management.

Chronic pain in breast cancer patients post mastectomy with alloplastic reconstruction: A scoping review

INTRODUCTION

Women diagnosed with breast cancer are receiving mastectomy with implant-based reconstruction at an increasing rate. Chronic post-surgical pain can be a major concern for these patients. This review sought to address the knowledge gap on the prevalence, severity and characteristics of chronic pain in this population.

METHODS

A scoping review was conducted using the Arksey and O'Malley framework. Five databases were searched using keywords. Two independent reviewers performed selection and data extraction of studies that met inclusion criteria.

RESULTS

Seventeen studies were included in this review. Ten studies reported prevalence of chronic pain which ranged from 7.3%-90.9% with pooled prevalence of 26.3%. Nine studies reported severity of chronic pain using various scales and methodology; most patients' pain was not severe. Risk factors for chronic pain included axillary dissection, lack of perioperative local anaesthetic, younger age and use of a tissue expander. No studies reported on possible correlation between ethnicity and pain. Eleven different assessment tools were used to measure pain.

CONCLUSION

Chronic pain following post-mastectomy implant-based breast reconstruction is prevalent, associated with specific risk factors and poorly characterised. There is a need to investigate and evaluate chronic pain in this population using validated breast cancer specific pain assessment tools.

Explore the Application Value of Prospective Monitoring Model in the Nursing Management of Breast Cancer Patients During Perioperative Period

Purpose

To explore the application value of prospective monitoring model in the nursing management of breast cancer patients during perioperative period.

Methods

300 perioperative breast cancer patients admitted to our hospital from January to August 2021 were randomly divided into the control group (n = 150) and the model group (n = 150). Both groups used routine nursing management, and the model group added nursing management based on a prospective monitoring model. The quality of surgical nursing, circumference of the upper limbs, and the scores of disability of arm-shoulder-hand (DASH), exerciseofself-care agencyscale (ESCA), social self-esteem scale (SSES), multidimensional fatigue symptom inventory-short form (MFSI-SF) and functional assessment of cancer therapy-breast cancer (FACT-B) were compared of the two groups.

Results

Postoperatively, the quality of surgical nursing was better in the model group than in the control group (P < 0.05). At 3 months postoperatively, the number of cases of upper limb lymphedema was higher in both groups than before (P < 0.05), but there was no statistical difference between the two groups in the preoperative and 3 months postoperative comparisons (P > 0.05). At 3 months postoperatively, the total DASH score was higher than preoperatively in both groups, but lower in the model group than in the control group (P < 0.05). After nursing, the ESCA and SSES scores of each dimension were higher in both groups than before, and the model group was higher than the control group (P < 0.05). At 3 months postoperatively, the total MFSI-SF score was lower than preoperatively in both groups, and lower in the model group than in the control group (P < 0.05). At 3 months postoperatively, the FACT-B scores of each dimensions were higher in the model group than in the control group (P < 0.05).

Conclusion

The implementation of nursing management based on a prospective monitoring model for breast cancer patients during the perioperative period has important clinical value in improving the quality of surgical nursing and improving postoperative upper limb lymphedema, upper limb function, self-care ability, social self-esteem, cancer-related fatigue symptoms, quality of life, etc.

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.

The Impact of implant-based reconstruction on persistent pain after breast cancer surgery: A systematic review

INTRODUCTION

With the increasing number of breast cancer survivors and reconstruction operations, persistent pain following breast cancer surgery (PPBCT) and its management is becoming a challenge for plastic surgeons. To date, most studies compared the difference in the level of PPBCT in reconstruction versus nonreconstruction groups. We systematically reviewed the literature to assess the impact of implant-based reconstruction on PPBCT levels.

MATERIALS AND METHODS

PubMed, Embase, CINAHL, and Scopus databases were searched for relevant articles. We used five search strategies: (persistent pain after breast cancer surgery AND reconstruction), (chronic postsurgical pain AND breast reconstruction), (Breast Implantation [MeSH Terms] AND "Chronic Pain" [MeSH Terms]), (breast reconstruction AND chronic pain), and (postmastectomy pain syndrome AND breast reconstruction).

RESULTS

A total of 2281 articles were detected. After scanning for the title and abstract, full-text articles were reviewed to identify the eligible articles. Eleven articles were included in the final review, with seven of these reporting no increased chance of PPBCT following reconstruction with implants, whereas two articles described lower chances of PPBCT following implant-based reconstruction.

CONCLUSION

We discovered that implant-based reconstruction does not increase the risk of PPBCT in comparison to other surgical techniques or mastectomy alone. This relationship may facilitate doctors and their patients in the decision-making of the appropriate reconstruction technique to use. In addition, our results should prompt plastic surgeons to prescribe the same dosage and frequency of analgesics to patients undergoing implant reconstruction as they would to their patients not undergoing reconstruction.

Post-Breast Surgery Pain Syndrome: Shifting a Surgical Paradigm

Post-mastectomy pain syndrome and the less well-described post-breast surgery pain syndrome are long-term neuropathic pain conditions that may affect more than 50% of patients after mastectomy and breast surgery. While the etiology, risk factors, and management have been reviewed in our literature, we offer here a focused outline that will gear the plastic surgeon with tools to lead a multidisciplinary, algorithmic approach to the care of patients with post-mastectomy pain syndrome/post-breast surgery pain syndrome. After reading this article, we hope the reader will have improved awareness of post-mastectomy pain syndrome/post-breast surgery pain syndrome, and thus be able to incorporate appropriate treatments and preventative steps into their primary surgical routine.

Prediction of Persistent Pain Severity and Impact 12 Months After Breast Surgery Using Comprehensive Preoperative Assessment of Biopsychosocial Pain Modulators

BACKGROUND

Persistent post-mastectomy pain (PPMP) is a significant negative outcome occurring after breast surgery, and understanding which individual women are most at risk is essential to targeting of preventive efforts. The biopsychosocial model of pain suggests that factors from many domains may importantly modulate pain processing and predict the progression to pain persistence.

METHODS

This prospective longitudinal observational cohort study used detailed and comprehensive psychosocial and psychophysical assessment to characterize individual pain-processing phenotypes in 259 women preoperatively. Pain severity and functional impact then were longitudinally assessed using both validated surgery-specific and general pain questionnaires to survey patients who underwent lumpectomy, mastectomy, or mastectomy with reconstruction in the first postsurgical year. An agnostic, multivariable modeling strategy identified consistent predictors of several pain outcomes at 12 months.

RESULTS

The preoperative characteristics most consistently associated with PPMP outcomes were preexisting surgical area pain, less education, increased somatization, and baseline sleep disturbance, with axillary dissection emerging as the only consistent surgical variable to predict worse pain. Greater pain catastrophizing, negative affect, younger age, higher body mass index (BMI), and chemotherapy also were independently predictive of pain impact, but not severity. Sensory disturbance in the surgical area was predicted by a slightly different subset of factors, including higher preoperative temporal summation of pain.

CONCLUSIONS

This comprehensive approach assessing consistent predictors of pain severity, functional impact, and sensory disturbance may inform personalized prevention of PPMP and also may allow stratification and enrichment in future preventive studies of women at higher risk of this outcome, including pharmacologic and behavioral interventions and regional anesthesia.

Prepectoral implant pocket conversion in breast reconstruction

Introduction

While many authors have reported their experience in immediate prepectoral breast reconstruction (BR), implant pocket conversion from a submuscular to a prepectoral plane is less well described. The aim of this study is to provide a comprehensive review on plane conversion in implant-based BR, including the indications, surgical techniques, functional, and esthetic results.

Materials and Methods

A literature search via PubMed, Medline, Google Scholar, and Cochrane databases was performed using the following MeSH terms: “prepectoral pocket conversion”, “subcutaneous pocket conversion”, “prepectoral plane conversion”, “subcutaneous plane conversion”, and “prepectoral breast reconstruction”.

Results

Ten articles in which 504 breasts were studied were deemed eligible for inclusion. The indications to perform plane conversion were animation deformity (AD), chronic pain, and implant malposition. Seven studies described complete or partial capsulectomy. The use of acellular dermal matrices (ADM) was reported in all cases except for three studies. The mean follow-up was 10.64 months. There was resolution of AD in 100% of cases. Three studies reported complete resolution of chronic pain. The overall complication rate was 12.102% and capsular contracture (CC) was the most frequent complication. Cosmetic revisions were reported in six studies (9.52%). The use of ADMs and fat grafting appeared to decrease the rate of subsequent CC formation and cosmetic revisions.

Conclusions

The current article represents the first review about implant pocket conversion from a submuscular to a prepectoral plane, delineating its indications, surgical technique, postoperative complications, and functional and esthetic outcomes.

Factors associated with chronic pain following breast reconstruction in Japanese women

Chronic pain after breast surgery including breast reconstruction is a major concern for patients. However, the factors associated with chronic pain after breast surgery are uncertain in Japanese population. The aim of this study was to identify patient-specific and medical/surgical factors that predict chronic pain after breast surgery in Japanese patients. The subjects were 189 Japanese women undergoing breast surgery including tissue expander/implant (TE/implant), deep inferior epigastric perforator (DIEP) procedures and mastectomy only. Pain was assessed at one year postoperatively using a validated survey instrument: the Japanese version of the Short-Form McGill Pain Questionnaire (SF-MPQ-JV). A multiple linear regression model was used to examine the relationships of clinical factors with postoperative pain. Surveys were completed by 141 subjects. A younger age (p = .04) and bilateral procedures (p < .05) were both closely associated with the extent of increased postoperative pain at 1 year using the MPQ-Total pain rating. Compared to total mastectomy only, TE/implant procedures showed a significantly lower visual analog scale (VAS) (p = .04) and present pain index (PPI) (p = .03) scores. No factor related to chronic pain was also significantly related to the frequency of pain medication use postoperatively or the effect of social life of the patients. This study identified patients at risk for greater chronic pain after breast surgery. These findings will allow surgeons to improve patient comfort, reduce clinical morbidity and enhance patient satisfaction with their surgical outcome. Abbreviations: BMI: body mass index; CI: confidence interval; DIEP: deep inferior epigastric perforator flap; MPQ: McGill pain questionnaire; PPI: present pain index; SD: standard deviation; SF-MPQ-JV: Japanese version of the short-form McGill pain questionnaire; TE: tissue expander; VAS: visual analog scale.