1. Chronic Pain Following Breast Cancer Surgery
Eric J. Visser, Churack Chair, UNDA

2. Chronic pain following breast surgery
Pain is common, but (thankfully) usually not severe
We don’t see many cases in the pain clinic
Patients may be learning to live with it?
Grateful to have survived?
Worried about the pain (recurrence)?
Meretoja, Tuomo J., et al. "Pain at 12 months after surgery for breast cancer." JAMA (2014): 90-92; Gartner R et al. JAMA 2009.

3. Chronic pain following breast surgery
Breast cancer surgery (overall): ~50%
Mastectomy: ~50%
Breast conserving surgery: ~50%
Breast augmentation: %
Abnormal sensory (neuropathic) symptoms: ~80%
Phantom breast pain: ~5-10%
Meretoja, Tuomo J., et al. "Pain at 12 months after surgery for breast cancer." JAMA (2014): 90-92; Gartner R et al. JAMA 2009.

4. Features of chronic pain after breast surgery
Gartner R et al. JAMA 2009
Daily pain %
Moderate-mild (≤4/10) %
Severe %
Site: -Breast or chest wall %
-Axilla or arm %
-Regional (neck & shoulder) %
-Other sites (widespread) %

5. Chronic pain syndromes
Post-mastectomy syndrome (‘neuropathic pain’)
-Inter-costo-brachial neuralgia (axillary dissection)
-‘Scar pain’ (neuroma)
Reconstructive (flap/implant) surgery
-No difference in pain; mastectomy alone ± plastics
Phantom breast pain

6. Chronic pain syndromes
Secondary pain syndromes (arm, shoulder)
-‘Frozen shoulder’
-Neck & shoulder myofascial pain (trigger points)
-Lymphoedema
-Complex Regional Pain Syndrome
Cancer pain syndromes
-Local invasion, metastases
-Treatment effects (chemo-neuropathies)

7. Neuropathic pain (nerve pain)
Pain due to a lesion or
disease of the nervous system
(IASP 2015)

8. Neuropathic pain (nerve pain)
Neuropathic pain descriptors
‘Electrical’
Burning, shooting, stabbing
‘Positive’ signs & symptoms
Allodynia
(touch, pressure, cold pain)
Dysesthesiae
Phantom sensations
‘Negative’ signs & symptoms
Numbness
Anaesthesia dolorosa

9. Allodynia (touch pain) & neuropathic pain9

10. Post-mastectomy pain syndrome
Jung BF et al. Pain 2003
A neuropathic pain syndrome
Pain & altered sensation in breast, axilla, chest wall
Inter-costo-brachial neuralgia
Dissection of the axilla
Scar pain (neuroma) ~30-50%

11. Risk factors for chronic pain
High BMI
Younger age
Pre-op pain (breast, widespread pain, fibromyalgia)
Severe acute post-operative pain (>6/10)
Complex surgery: revision, reconstruction
Nerve injury: axillary dissection vs sentinel node
Radiotherapy (chemotherapy)
Limb immobilization (frozen shoulder, CRPS)
Lymphoedema
Andersen, Kenneth Geving, and Henrik Kehlet. "Persistent pain after breast cancer treatment: a critical review of risk factors and strategies for prevention." The Journal of Pain 12.7 (2011):

12. Risk factors for chronic pain: Psychosocial ‘Yellow Flags’
C.H.A.M.P.S
Catastrophic thinking (hypervigilance, ruminating)
Anxiety, depression
Medically-focused
Passive coping style
Single (poor social support)

13. Risk factors with breast pain: ‘Red Flags’
T.I.N.T
Tumour: cancer recurrence
Infection/inflammation: seroma
Neuropathic pain
Trauma: lymphoedema

14. Prevention of chronic pain
Avoid ‘unnecessary’ surgery & re-operations (cosmetic?)
Surgical technique (minimally invasive, nerve sparing)
Screen & monitor at ‘risk patients’
‘Preventive analgesia’ techniques
Multidisciplinary rehabilitation

15. Preventive analgesia techniques
Multimodal analgesia
Paracetamol (5/7)
Parecoxib or celecoxib (5/7)
Neuropathic pain drugs
Pregabalin (10/7)
Tramadol or tapentadol

16. Preventive analgesia techniques
Local anaesthetic infiltration
EMLA cream (5/7)?
Paravertebral block???
Epidural???
IV Lignocaine infusion?
IV Dexmedetomidine?

17. Breast pain management checklist
Provide education & information about breast pain
Always ask about neuropathic pain & phantom sensations
Test for allodynia, DN4Q
Check for lymphoedema
Check for shoulder pain & stiffness
Check for Complex Regional Pain Syndrome (CRPS)

18. Breast pain management checklist
Check for ‘red flags’ (TINT) (infection, cancer)
Check ‘yellow flags’ (CHAMPS)
Indentify those at risk of chronic pain & disability
Early referral to a pain management clinic
Start multimodal analgesia (paracetamol, coxibs)
Tramadol or tapentadol & pregabalin

19. Breast pain management checklist
Start Vitamin C 1000 mg/d & Vitamin E 500IU/d for 2M
Physiotherapy (TENS, trigger points)
Keep shoulder & arm moving
Scar or neuroma injections
Shoulder injections
Lignocaine patches
Behavioural pain management & social support

20. What’s new? Genetic risk Catecholamine (COMT) enzyme
Potassium channel in nerves
Cancer recurrence and analgesia technique
Opioids?

21. Chronic Pain Following Breast Cancer Surgery Thank you
Eric J. Visser, Churack Chair, UNDA