Chronic Pain Following Breast Reconstruction: A Scoping Review

BACKGROUND

Breast cancer survival rates have increased significantly, underscoring the importance of enhancing long-term health-related quality of life. Breast reconstruction following mastectomy has emerged as a common approach that contributes to improved health-related quality of life. Nonetheless, chronic pain following breast reconstruction is a prevalent issue that has a negative impact on overall well-being.

METHODS

To examine recent findings on chronic pain after breast reconstruction and progress in pain management, we performed a review of the literature through independent searches using the MEDLINE database within NIH National Library of Medicine PubMed.

RESULTS

The review suggested that autologous reconstruction causes chronic postsurgical pain, especially at specific donor sites, whereas implant-based reconstruction does not seem to increase the risk of chronic pain. Moreover, certain operational and patient factors are also associated with chronic pain. Appropriate pain management can reduce chronic pain and prevent the transition from acute to chronic pain.

CONCLUSION

This scoping review evaluated the characteristics of long-term chronic pain after breast reconstruction. The findings provide patients with important treatment information and will assist with their decision on their preferred treatment.

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.

Factors affecting upper limb functional recovery after mastectomy with immediate breast reconstruction: a prospective study

BACKGROUND

Little is known about the differences in postoperative shoulder function following two common approaches for immediate breast reconstruction (IBR): abdominal-based breast reconstruction and implant-based breast reconstruction (ABR and IMBR). It was hypothesized that postoperative upper limb function would differ between the ABR and IMBR due to incomplete detachment of the pectoral muscles.

PURPOSE

This study aimed to investigate the factors for shoulder function recovery post-IBR and compare recovery outcomes between ABR and IMBR.

METHODS

This single-center prospective follow-up study included 60 patients who underwent IBR for 4 months postoperatively. Patients were invited to complete functional measurements 1 and 4 months postoperatively. The primary outcome was improvement in upper limb disability based on the Q-DASH score. Secondary outcomes were functional shoulder recovery markers: shoulder flexibility, strength, movement accuracy, scapular alignment, body schema accuracy, and neuropathic pain. Repeated-measures analyzes of variance and linear regression were performed.

RESULTS

Within-group differences were found for most variables (p < .05) except for neuropathic pain (p = .929). However, there was no overall main group effect (p > .05). Multivariate regression analysis established significant models for ABR and IMBR (R2 = 0.430, p = .002 and R2 = 0.442, p < .001, respectively). However, the variables included in the model showed between-group differences.

CONCLUSION

Postoperative shoulder function was comparable between the two IBR approaches. However, different factors were associated with improved upper limb disability between ABR and IMBR. Acute rehabilitation focused on resolving muscle tightness and pain may help mitigate upper limb disabilities following IBR.Trial registration number: KCT 0006501.

An update on rehabilitative treatment of shoulder disease after breast cancer care

According to the latest statistics of the American Cancer Society 2022, breast cancer is a leading cause of morbidity and death among women worldwide. As a result of oncological procedures, breast cancer survivors often complain of pain and disability to the ipsilateral arm and shoulder. Objective: we aimed to analyze the latest literature regarding the efficacy of different rehabilitation treatments in patients affected by shoulder impairment secondary to breast cancer care. A comprehensive literature search was conducted on PubMed, PEDRO and Scopus databases. All English studies, published in the last decade up to March 2023, reporting shoulder problems in adult women treated for breast cancer with partial or total mastectomy ± breast reconstruction, lymphadenectomy, radio-, chemo-, hormonal or biologic therapy were assessed for eligibility. The methodological quality of the included trials was evaluated using the Cochrane bias tool. Of 159 articles identified, 26 were included in qualitative synthesis. Data from 1974 participants with a wide heterogeneity of breast cancer treatments were analyzed in this review. The methodological quality for most included studies was moderate. Several physiotherapy and interventional protocols showed some evidence of efficacy in shoulder range of motion (ROM), upper limb function, strength, pain and quality of life recovery after breast cancer treatment. Both physiotherapy alone or in combination with other techniques significantly improves shoulder disability, pain, and quality of life of patients undergoing breast cancer treatment regardless of their baseline characteristics or the time passed from surgery. The optimal treatment protocol and dosage remain unclear, and more homogeneous studies are needed in order to perform a meta-analysis of the literature.

Perioperative care of nipple-areola complex-sparing mastectomy and one-stage breast reconstruction via endoscopic axillary approach for ductal carcinoma in situ: A case report

RATIONALE

Breast cancer represents a prevalent malignancy that primarily impacts women, with pronounced consequences on their overarching health. The major therapeutic approach, encompassing surgical procedures, can often culminate in mastectomy, potentially inciting psychological turmoil and disorders.

PATIENT CONCERNS

A patient was admitted to our facility on May 5, 2023, precipitated by the discovery of bilateral breast masses during a routine physical examination conducted 3 days before admission.

DIAGNOSIS

The breasts were symmetric, with the right nipple inverted and a palpable mass in the upper outer quadrant of the right breast, measuring approximately 5 cm × 4 cm. The mass was firm with indistinct borders, relatively regular morphology, poor mobility, and no tenderness. Outpatient color Doppler ultrasound revealed heterogeneous echogenicity in the right breast, classified as Breast Imaging Reporting and Data System (BI-RADS) category 0, along with multiple ductal dilatations. The left breast exhibited a hypoechoic area (BI-RADS 3), indicative of proliferative changes. Radiographic mammography confirmed diffuse changes in the right breast (BI-RADS 0) and proliferative signs in the left breast (BI-RADS 2). Biopsy results reveal significant atypical ductal hyperplasia consistent with intermediate-grade ductal carcinoma in situ. This patient was diagnosed as ductal carcinoma in situ of the right breast (cTisN0M0 and Stage 0), accompanied by a left breast mass.

INTERVENTIONS

On May 15, 2023, the patient was readmitted for further surgical intervention. Following relevant auxiliary examinations, the patient underwent nipple-areola complex-sparing radical mastectomy for the right breast, sentinel lymph node biopsy in the right axillary area, prosthesis-based breast reconstruction for the right breast, and microrotatotomy of the left breast mass on the left side on May 17.

OUTCOMES

The patient made a successful recovery under scrupulous perioperative supervision and was discharged 7 days post-surgery.

LESSONS

The axillary approach for endoscopic mammary gland excision and immediate implant reconstruction permits patients to preserve the esthetics of the female form while undergoing conventional medical treatment. This methodology considerably enhances the psychophysical health of the patients, thereby marking it as an advantageous practice worthy of broad dissemination in the medical community.

Distorted body schema after mastectomy with immediate breast reconstruction: a 4-month follow up study

Background

After breast cancer, some patients report residual pain-related upper limb disability without physical impairment. Although pain and altered proprioception are known to affect the working body schema (WBS), there is little available evidence investigating the WBS of breast cancer survivors (BrCS). WBS-body representations in the brain-affect the "neuromatrix" that modulates pain sensitivity and the threshold for threatening stimuli. The aim of this study was to investigate whether WBS was disrupted after mastectomy with immediate breast reconstruction (IBR) for breast cancer and whether pain and proprioceptive changes affected WBS.

Methods

Thirty-five BrCS participated in the 4-month follow-up study. They were observed at 1 and 4 months postoperatively. The main outcome measures were the left right judgement test (LRJT) results, absolute angle error, pectoralis minor length index (PMI), pain, and Quick-Disabilities of the Arm, Shoulder, and Hand (Q-DASH) score. They were measured at each observation, and parametric tests were performed to identify the nature of WBS.

Results

Both the reaction time and accuracy of the hand LRJT were poorer than those of the foot and back LRJT (p < 0.001). The hand LRJT reaction time and accuracy were unchanged over the total follow-up period (p = 0.77 and p = 0.47, respectively). There was a weak correlation between the LRJT reaction time and PMI (r = -0.26, p = 0.07), pain severity (r = 0.37, p = 0.02), and Q-DASH score (r = 0.37, p = 0.02). There was also a weak correlation between LRJT accuracy and Q-DASH score (r = -0.31, p = 0.04). The LRJT accuracy of BrCS who underwent surgery on their dominant side was higher than that of BrCS who underwent surgery on their non-dominant side (p = 0.002). Regression analysis found a weak but significant relationship between the early hand LRJT results and late pain severity (adjusted R² = 0.179, p = 0.007). A similar relationship was found between early hand LRJT results and Q-DASH score (adjusted R² = 0.099, p = 0.039).

Conclusion

To the best of our knowledge, this is the first study providing the nature of WBS after mastectomy with IBR. In this population, it is necessary to postoperatively preserve WBS integrity for pain and upper limb disability.

Conservative interventions and clinical outcome measures used in the perioperative rehabilitation of breast cancer patients undergoing mastectomy: a scoping review

BACKGROUND

Mastectomy is the first-line treatment approach for more than 90% of breast cancer patients. The numerous physical impairments associated with this surgical procedure negatively impact the patient's quality of life. To date, rehabilitation resources available for breast cancer patients undergoing mastectomy within the institutions affiliated to the Centre intégré universitaire de soins de santé et de services sociaux de la Mauricie-et-du-Centre-du-Québec (CIUSSS-MCQ) are lacking and do not always seem to reflect the particularities of breast cancer care pathways. The purpose of this review was to identify and describe the conservative interventions and the clinical outcome measures used in the perioperative physical rehabilitation of women with breast cancer who are awaiting or have undergone mastectomy. We also aimed to report on the barriers and facilitators to study participation and completion.

METHODS

MEDLINE, CINAHL, and the Cochrane Library were searched from inception to January 2021, and we updated the search on July 11, 2022. We included peer-reviewed English and French literature with quantitative designs, describing conservative interventions and clinical outcome measures used within rehabilitation programs designed for women who were awaiting or had undergone mastectomy. Paired reviewers independently reviewed all citations and articles using a two-phase screening process and independently extracted the data.

RESULTS

Of the 6080 articles identified, 57 met the inclusion criteria. Most interventions were multimodal, which combined exercise with patient education, manual therapy, and/or lymphatic drainage. The most frequently used objective measures of physical function were shoulder range of motion, muscle strength, and signs of lymphedema. In contrast, the primary patient-reported outcome measures were quality of life, shoulder function, and pain. Undergoing another breast surgery, death, and cancer recurrence were the most reported barriers to study completion.

CONCLUSION

This scoping review reports on the heterogeneity and wide range of conservative interventions and clinical outcome measures used in the physical rehabilitation of breast cancer patients who had undergone or were scheduled to undergo mastectomy. Tailoring interventions to breast cancer patients' needs and promoting outpatient rehabilitation interventions appear to be better suited to the particularities of breast cancer care pathways. Further research is needed to better identify barriers and facilitators to study participation and completion.

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.

Physical therapy after breast cancer surgery improves range of motion and pain over time

ABSTRACT Treatment of breast cancer can impair range of motion (ROM) and cause homolateral upper limb pain (UL). This study aimed to compare the ROM, intensity and characterization of UL homolateral pain between the 1st, 10th and 20th sessions of physiotherapy, besides correlating these variables. A clinical trial self-controlled study involving 49 women after mastectomy or quadrantectomy with pain complaint on UL was conducted. ROM was evaluated by goniometry and contralateral UL was adopted as control. The intensity of pain was evaluated by the visual analogue scale (VAS) and characterized by the McGill questionnaire, obtaining the number of words chosen (NWC) and the pain evaluation index (PRI). The ROM of the homolateral UL increased significantly over the 20 sessions. Comparing the homolateral UL with the control, only the abduction did not improve significantly after the 20th session. Pain intensity, PRI and NWC reduced significantly between 1st and 10th and between 1st and 20th sessions. The sensory and evaluative categories also decreased significantly. We observed a significant correlation between VAS, PRI and NWC in the 10th and 20th sessions. Physiotherapy increased ROM, reduced pain in the homolateral UL, and fewer words were chosen to characterize the pain. Significant improvements were observed at the beginning of treatment, but with additional gains over time. Exercises for bilateral flexion, abduction, and external rotation should be emphasized.

Fisioterapia após cirurgia de câncer de mama melhora a amplitude de movimento e a dor ao longo do tempo

RESUMO O tratamento do câncer de mama pode prejudicar a amplitude de movimento (ADM) e causar dor no membro superior (MS) homolateral. O objetivo deste estudo foi comparar a ADM, a intensidade e a caracterização da dor no MS homolateral à cirurgia entre as 1ª, 10ª e 20ª sessões de fisioterapia, além de correlacionar estas variáveis. Foi conduzido um ensaio clínico autocontrolado com a participação de 49 mulheres após cirurgia de câncer de mama que se queixavam de dor no MS. A ADM foi avaliada por meio de goniometria e o MS contralateral foi adotado como controle. A intensidade de dor foi avaliada pela escala visual analógica (EVA) e caracterizada pelo Questionário de McGill, obtendo-se o número de palavras escolhidas (NWC) e o índice de avaliação da dor (PRI). Verificou-se aumento significativo da ADM do MS homolateral ao longo das 20 sessões. Comparando o MS homolateral ao contralateral, somente a abdução não melhorou significativamente após a 20ª sessão. Observou-se uma redução significativa da intensidade de dor, do PRI e do NWC entre a 1ª e 10ª e entre a 1ª e 20ª sessão. As categorias sensorial e avaliativa também diminuíram significativamente. Foi encontrada uma correlação significativa entre EVA, PRI e NWC entre a 10ª e a 20ª sessão. A fisioterapia aumentou a ADM, reduziu a dor no MS homolateral e o número de palavras escolhidas para caracterizar a dor. Foram observadas melhoras expressivas no início do tratamento e ganhos adicionais ao longo do tempo. Exercícios para flexão, abdução e rotação externa bilaterais devem ser enfatizados no tratamento.

Exercise Protocol With Limited Shoulder Range of Motion for 15 or 30 Days After Conservative Surgery for Breast Cancer With Oncoplastic Technique: A Randomized Clinical Trial

OBJECTIVE

The objective is to evaluate the effect of limiting shoulder range of motion (ROM) for 15 or 30 days on surgical complications and on shoulder ROM, pain, and upper limb function of breast cancer patients following conservative oncoplastic surgery.

MATERIALS AND METHODS

A randomized clinical trial was conducted with 60 women with breast cancer who underwent conservative oncoplastic surgery. The day after surgery, all patients started an exercise protocol with shoulder exercises limited to 90 degrees. Two weeks after surgery they were randomized into Free ROM Group (n=30) or Limited ROM Group (n=30). The Free ROM Group was allowed to perform shoulder exercises with unlimited ROM; the Limited ROM Group continued with shoulder movement restricted at 90 degrees until 30 days after surgery, at which time they were also allowed free ROM. The primary outcome was the incidence of postoperative complications (dehiscence, seroma, infection, and necrosis) and secondary outcomes were shoulder ROM, pain, and upper limb function.

RESULTS

No difference in the incidence of postoperative scar complications between groups was noted. There was no difference between the groups in shoulder joint amplitude, pain, or upper limb function.

CONCLUSIONS

The free ROM exercise protocol 15 days post surgery was safe concerning cicatricial complications.