Postmastectomy pain syndrome: Risk reduction and management
- Jeannie Shen, MD
Jeannie Shen, MD
- Clinical Assistant Professor
- Division of Surgical Oncology
- UCLA Medical Center
- Section Editor
- Anees B Chagpar, MD, MSc, MA, MPH, MBA, FACS, FRCS(C)
Anees B Chagpar, MD, MSc, MA, MPH, MBA, FACS, FRCS(C)
- Section Editor — Breast Surgery
- Associate Professor, Department of Surgery
- Yale University School of Medicine
Postmastectomy pain syndrome (PMPS) is a chronic neuropathic pain disorder that can occur following breast cancer-related operative procedures [1-5]. The optimal approaches to reducing the risk of and managing PMPS are presented here. The clinical manifestations and diagnosis of PMPS are reviewed separately. (See "Clinical manifestations and diagnosis of postmastectomy pain syndrome".)
One caveat for determining the effectiveness of preventive strategies in reducing the incidence of postmastectomy pain syndrome (PMPS) is the lack of an established definition. For example, some studies define PMPS as pain persisting for more than three months, and others define it as pain persisting for more than 18 months. (See "Clinical manifestations and diagnosis of postmastectomy pain syndrome", section on 'Definition'.)
Preemptive analgesia — Preemptive analgesia is the administration of local or regional (eg, wound infiltration, paravertebral block , anesthetic creams ) or systemic (eg, ibuprofen, ketorolac, gabapentin) analgesics prior to the onset of noxious stimuli (eg, surgical incision). Preemptive analgesia as a component of postoperative pain management, including a review of local anesthetics and systemic medications, is reviewed separately. (See "Management of acute perioperative pain", section on 'Preventive analgesia'.)
Most prospective studies identified a perioperative benefit (eg, fewer postoperative analgesic requirements) for administration of preemptive analgesia for patients undergoing breast cancer procedures [8-12]. However, long-term pain control and reduced risk of PMPS with preemptive analgesia have not been clearly established. Variations in study design, including application and duration of administration of preemptive analgesics and duration of observation, limit direct comparisons.
The following studies identified short-term pain control benefit from various preemptive analgesics (ie, local, regional, and systemic) for women undergoing breast cancer operations:
- Gärtner R, Jensen MB, Nielsen J, et al. Prevalence of and factors associated with persistent pain following breast cancer surgery. JAMA 2009; 302:1985.
- Caviggioli F, Maione L, Forcellini D, et al. Autologous fat graft in postmastectomy pain syndrome. Plast Reconstr Surg 2011; 128:349.
- Stubblefield MD, Custodio CM. Upper-extremity pain disorders in breast cancer. Arch Phys Med Rehabil 2006; 87:S96.
- Smith WC, Bourne D, Squair J, et al. A retrospective cohort study of post mastectomy pain syndrome. Pain 1999; 83:91.
- Miguel R, Kuhn AM, Shons AR, et al. The effect of sentinel node selective axillary lymphadenectomy on the incidence of postmastectomy pain syndrome. Cancer Control 2001; 8:427.
- Kairaluoma PM, Bachmann MS, Rosenberg PH, Pere PJ. Preincisional paravertebral block reduces the prevalence of chronic pain after breast surgery. Anesth Analg 2006; 103:703.
- Fassoulaki A, Sarantopoulos C, Melemeni A, Hogan Q. EMLA reduces acute and chronic pain after breast surgery for cancer. Reg Anesth Pain Med 2000; 25:350.
- Vigneau A, Salengro A, Berger J, et al. A double blind randomized trial of wound infiltration with ropivacaine after breast cancer surgery with axillary nodes dissection. BMC Anesthesiol 2011; 11:23.
- Fassoulaki A. Brachial plexus block for pain relief after modified radical mastectomy. Anesth Analg 1982; 61:986.
- Adam F, Libier M, Oszustowicz T, et al. Preoperative small-dose ketamine has no preemptive analgesic effect in patients undergoing total mastectomy. Anesth Analg 1999; 89:444.
- Fassoulaki A, Patris K, Sarantopoulos C, Hogan Q. The analgesic effect of gabapentin and mexiletine after breast surgery for cancer. Anesth Analg 2002; 95:985.
- Grover VK, Mathew PJ, Yaddanapudi S, Sehgal S. A single dose of preoperative gabapentin for pain reduction and requirement of morphine after total mastectomy and axillary dissection: randomized placebo-controlled double-blind trial. J Postgrad Med 2009; 55:257.
- Zielinski J, Jaworski R, Smietanska I, et al. A randomized, double-blind, placebo-controlled trial of preemptive analgesia with bupivacaine in patients undergoing mastectomy for carcinoma of the breast. Med Sci Monit 2011; 17:CR589.
- Rodriguez Viales R, Diotel N, Ferg M, et al. The helix-loop-helix protein id1 controls stem cell proliferation during regenerative neurogenesis in the adult zebrafish telencephalon. Stem Cells 2015; 33:892.
- Amr YM, Yousef AA. Evaluation of efficacy of the perioperative administration of Venlafaxine or gabapentin on acute and chronic postmastectomy pain. Clin J Pain 2010; 26:381.
- Reuben SS, Makari-Judson G, Lurie SD. Evaluation of efficacy of the perioperative administration of venlafaxine XR in the prevention of postmastectomy pain syndrome. J Pain Symptom Manage 2004; 27:133.
- Caffo O, Amichetti M, Ferro A, et al. Pain and quality of life after surgery for breast cancer. Breast Cancer Res Treat 2003; 80:39.
- Wallace MS, Wallace AM, Lee J, Dobke MK. Pain after breast surgery: a survey of 282 women. Pain 1996; 66:195.
- Steegers MA, Wolters B, Evers AW, et al. Effect of axillary lymph node dissection on prevalence and intensity of chronic and phantom pain after breast cancer surgery. J Pain 2008; 9:813.
- Ververs JM, Roumen RM, Vingerhoets AJ, et al. Risk, severity and predictors of physical and psychological morbidity after axillary lymph node dissection for breast cancer. Eur J Cancer 2001; 37:991.
- Paredes JP, Puente JL, Potel J. Variations in sensitivity after sectioning the intercostobrachial nerve. Am J Surg 1990; 160:525.
- Temple WJ, Ketcham AS. Preservation of the intercostobrachial nerve during axillary dissection for breast cancer. Am J Surg 1985; 150:585.
- Freeman SR, Washington SJ, Pritchard T, et al. Long term results of a randomised prospective study of preservation of the intercostobrachial nerve. Eur J Surg Oncol 2003; 29:213.
- Salmon RJ, Ansquer Y, Asselain B. Preservation versus section of intercostal-brachial nerve (IBN) in axillary dissection for breast cancer--a prospective randomized trial. Eur J Surg Oncol 1998; 24:158.
- Taira N, Shimozuma K, Ohsumi S, et al. Impact of preservation of the intercostobrachial nerve during axillary dissection on sensory change and health-related quality of life 2 years after breast cancer surgery. Breast Cancer 2014; 21:183.
- Bokhari F, Sawatzky JA. Chronic neuropathic pain in women after breast cancer treatment. Pain Manag Nurs 2009; 10:197.
- Derogatis LR, Morrow GR, Fetting J, et al. The prevalence of psychiatric disorders among cancer patients. JAMA 1983; 249:751.
- Burgess C, Cornelius V, Love S, et al. Depression and anxiety in women with early breast cancer: five year observational cohort study. BMJ 2005; 330:702.
- Vecht CJ, Van de Brand HJ, Wajer OJ. Post-axillary dissection pain in breast cancer due to a lesion of the intercostobrachial nerve. Pain 1989; 38:171.
- Kwekkeboom K. Postmastectomy pain syndromes. Cancer Nurs 1996; 19:37.
- Stillman M. Clinical approach to patients with neuropathic pain. Cleve Clin J Med 2006; 73:726.
- Tasmuth T, Härtel B, Kalso E. Venlafaxine in neuropathic pain following treatment of breast cancer. Eur J Pain 2002; 6:17.
- Kalso E, Tasmuth T, Neuvonen PJ. Amitriptyline effectively relieves neuropathic pain following treatment of breast cancer. Pain 1996; 64:293.
- Wong L. Intercostal neuromas: a treatable cause of postoperative breast surgery pain. Ann Plast Surg 2001; 46:481.
- Tinel J. The "tingling sign" in peripheral nerve lesions (Translated by EB Kaplan). In: Injuries to the Major Branches of Peripheral Nerves of the Forearm, Spinner M (Ed), WD Saunders Co, Philadelphia 1978. p.8.
- Wisotzky EM, Saini V, Kao C. Ultrasound-Guided Intercostobrachial Nerve Block for Intercostobrachial Neuralgia in Breast Cancer Patients: A Case Series. PM R 2016; 8:273.
- Zocca JA, Chen GH, Puttanniah VG, et al. Ultrasound-Guided Serratus Plane Block for Treatment of Postmastectomy Pain Syndromes in Breast Cancer Patients: A Case Series. Pain Pract 2017; 17:141.
- Piracha MM, Thorp SL, Puttanniah V, Gulati A. "A Tale of Two Planes": Deep Versus Superficial Serratus Plane Block for Postmastectomy Pain Syndrome. Reg Anesth Pain Med 2017; 42:259.
- Wisotzky E, Hanrahan N, Lione TP, Maltser S. Deconstructing Postmastectomy Syndrome: Implications for Physiatric Management. Phys Med Rehabil Clin N Am 2017; 28:153.
- Harris SR, Schmitz KH, Campbell KL, McNeely ML. Clinical practice guidelines for breast cancer rehabilitation: syntheses of guideline recommendations and qualitative appraisals. Cancer 2012; 118:2312.
- De Groef A, Van Kampen M, Dieltjens E, et al. Effectiveness of postoperative physical therapy for upper-limb impairments after breast cancer treatment: a systematic review. Arch Phys Med Rehabil 2015; 96:1140.
- Richardson MA, Sanders T, Palmer JL, et al. Complementary/alternative medicine use in a comprehensive cancer center and the implications for oncology. J Clin Oncol 2000; 18:2505.
- Eisenberg DM, Kessler RC, Foster C, et al. Unconventional medicine in the United States. Prevalence, costs, and patterns of use. N Engl J Med 1993; 328:246.
- Burstein HJ, Gelber S, Guadagnoli E, Weeks JC. Use of alternative medicine by women with early-stage breast cancer. N Engl J Med 1999; 340:1733.
- Dos Santos S, Hill N, Morgan A. Acupuncture for treating common side effects associated with breast cancer treatment: a systematic review. Medical Acupuncture 2010; 22:81.
- He JP, Friedrich M, Ertan AK, et al. Pain-relief and movement improvement by acupuncture after ablation and axillary lymphadenectomy in patients with mammary cancer. Clin Exp Obstet Gynecol 1999; 26:81.