1. Approaches to Pain Management and Breast Cancer
John Liszka-Hackzell, MD, PhD
University of Arizona
Anesthesiology and Pain Medicine

2. Educational Objectives
1- Discuss the etiology of pain in
breast cancer survivors
2- Describe the multidisciplinary
approach to pain management
assessment and treatment
3- Outline the appropriate use of pain
evaluation tools

3. Reasons Why Breast Cancer Patients
May Have Pain
Acute postoperative pain
Chronic pain
Neuropathic / Phantom Breast Pain
Bone pain / Metastatic Cancer

4. Surgical Procedures for Breast Cancer
Radical Mastectomy (breast, skin, pectoralis, lymph nodes)
Modified radical Mastectomy (pectoralis left intact)
Lumpectomy with/without axillary nodes.
Lumpectomy with Sentinel node biopsy

5. Surgical Procedures for Breast Cancer

6. Choice of Surgical Procedure or Technique May Influence the Occurrence of Chronic Pain
Not shown that breast-conserving treatment vs. modified radical mastectomy decreases risk of chronic pain
Evidence of more chronic pain following breast-conserving surgery and axillary node dissection
(Wallace et al, Pain 1996)

7. Choice of Surgical Procedure or Technique May Influence the Occurrence of Chronic Pain
Increased risk of chronic pain after breast-conserving procedure may be related to increased use of chemo/radiation
Women who have breast prosthesis may have an increased incidence of chronic pain

8. Breast Cancer Surgery – Innervation
Third through sixth Intercostal nerves
Lateral cutaneous branch of T2 (ICB) – upper, medial portion of the arm
Lateral and anterior branches – anterior chest, upper back
T3 innervates the axilla, anterior and posterior torso
T4 and below innervates the torso. Nipple is primarily T4

9. Acute Post-Operative Pain Following Breast Surgery
Relationship between intensity of acute post-operative pain and Chronic post-treatment pain (Tasmuth et al, Acta Oncol, 1997).
Severity of acute postoperative pain is the best predictor of chronic pain in Breast Cancer

10. Increased Postoperative Pain
May Be Related to:
Unrecognized preoperative neuropathic pain
Poor postoperative pain management
Pre-existing depression/anxiety
Surgical technique (nerve sparing procedures)
Postoperative complications (infection / bleeding)
Pre-existing chronic pain

11. Regional anesthesia techniques in combination with general anesthesia may decrease the incidence of
long-term pain
Thoracic epidural
Paravertebral block

12. Pre-emptive Pain Management
Postoperative Pain
and
Pre-emptive Pain Management
Evidence that effective preoperative and intraoperative pain management reduces postoperative pain
Pre-emptive pain management may reduce risk of chronic pain

13. Chronic Pain Following Breast Surgery
Risk Factors
Age? <35 worse prognosis in general
Chemo, Radiation – not associated with Phantom breast pain, but other chronic pains
Chronic Pain possibly greater in patients with pre-existing anxiety/depression
(Tasmuth et al, Pain, 1996)

14. Chronic Pain Following Breast Surgery
May be seen in up to 50% of mastectomy patients
“Postmastectomy pain syndrome” has four components:
1) Phantom breast pain
2) ICB neuralgia
3) Neuroma pain (scar pain)
4) Other nerve injury pains
(Jung et al, Pain, 2003)

15. Intercostobrachial Neuralgia
- Arises from the lateral cutaneous branch of the second intercostal nerve
Occurs more frequently with axillary node dissection (Jung et al, Pain, 2003)
Technically difficult to preserve the nerve
Neuropathic pain
Involves axilla and medial upper arm
Neuroma formation (macro/micro)

16. Chronic Pain Following Breast Cancer Surgery
Sensory abnormalities in the intercostobrachial nerve distribution in % of women following breast cancer surgery (breast conserving vs. radical)
25% of these women will develop intercostobrachial neuralgia
(Maunsell et al, Can J Surg, 1993)

17. Other Nerve Injury Pains
Medial and Lateral Pectoral (maj/min pectoral)
Long Thoracic (post shoulder/scapula, winged scapula)
Thoracodorsal (latissimus)
Usually spared

18. Distribution / Description
Chronic Pain
Distribution / Description
Nociceptive – injury to ligament, muscle etc.
Neuropathic. Originates in the nervous system
Arm, neck, shoulder, axilla, chest wall or breast “continuation of acute pain”
Paresthesia, Dysesthesia,
Allodynia, Hyperalgesia

19. Chronic Pain Neuropathic Pain
Paresthesia: a sensation of tingling, pricking or numbness
Dysesthesia: a spontaneous or evoked unpleasant abnormal sensation
Allodynia: a painful response to a usually non-painful stimulus
Hyperalgesia: an increased sensititivity to pain

20. Chronic Pain Phantom Breast Pain and Neuropathic Pain
Neuropathic pain. Damage to peripheral nerve
“Regeneration” Neuroma formation
Spontaneous firing
Often pain is sharp, shooting and burning

21. Chronic Pain Phantom Breast Pain and Neuropathic Pain
- Phantom pain. Not referred, but perceived
- Different from Phantom sensation
- Sharp, often stabbing pain
- Similar to neuropathic pain
- Develops weeks to months after procedure
May be associated with
neuroma formation

22. Phantom Pain - Mechanisms
Not well understood
Peripheral changes. Ectopic discharges from peripheral and central neuron, sympatheric activation and loss of noiception
Cortical re-mapping: pre-existing pain creates a cortical pain memory Re- organization in somatosensory cortex following amputation
(Flor et at, Pain Clin Update, 2000)

23. Chronic Pain and Breast Cancer
Postoperative radiation is a risk factor for chronic arm and breast pain
Correlation between axillary radiation and arm pain (Keramopoulos et al, Oncology, 1993)
Plexus injuries

24. Chronic Pain – Prognosis
Typically decreasing over the first year
31% at 1-2 years to 20% at 4 years (Ivens et al Br J Cancer, 1992)
Chronic nociceptive pain better prognosis than neuropathic
Neuropathic pain / Phantom breast pain are more chronic and problematic
Association with depression/anxiety

25. Bone Pain / Metastatic Disease
Results in anemia, risk of infection, pain, fractures decreased mobility
Difficult to fully control (Mercadante, Pain, 1997)
May be osteolytic or osteoblastic
Osteoblastic tumors may provide more mechanical stability

26. Acute Post-operative Pain
Management of
Acute Post-operative Pain
Pre-emptive analgesia (block, adjuvants) may decrease risk of chronic pain
Standard opioids
Postoperative PCA
Consider appropriate regional anesthesia for postoperative pain

27. Management of Chronic Pain Neuropathic Pain
Multidisciplinary approach
Physical therapy
Occupational therapy
Behavioral / Pain management
Acupuncture / Chiropractic
Medical Management

28. Management of Chronic - Neuropathic Pain

29. Management of Chronic - Neuropathic Pain

30. Management of Chronic - Neuropathic Pain

31. Neuropathic Pain Adjuvant Medications
Lyrica (Pregabalin)
Works on Ca channels
Approved for DPN, PHN, Fibromyalgia
Side effects: Drowsiness, Sedation, Blurred vision
mg/day (bid-tid)

32. Management of Chronic Pain/ Neuropathic Pain

33. Management of Bone Pain
Opiods may attenuate bone pain
Biphosphonates may be helpful, however no data suggests effect on long-term survival (Fulfaro et al, Pain, 2001)
COX-2 inhibitors prevents inflammatory response, bone resorption and may reduce tumor burden

34. Conclusion
Chronic pain seen in many patients (Nociceptive vs. Neuropathic)
Surgical technique
Good peri-operative pain control
Multidisciplinary management
Multiple options for medical management