John Liszka-Hackzell, MD, PhDUniversity of Arizona

Anesthesiology and Pain Medicine

1- Discuss the etiology of pain in breast cancer survivors2- Describe the multidisciplinary approach to pain management assessment and treatment3- Outline the appropriate use of pain evaluation tools

Reasons Why Breast Cancer Patients

May Have Pain

- Acute postoperative pain- Chronic pain- Neuropathic / Phantom Breast Pain- Bone pain / Metastatic Cancer

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

Surgical Procedures for Breast Cancer

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)

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

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

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

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

Regional anesthesia techniques in combination with general

anesthesia may decrease the incidence of

long-term pain

Thoracic epiduralParavertebral block

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

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)

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)

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)

Sensory abnormalities in the intercostobrachial nerve distribution in 60-80% 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)

Other Nerve Injury Pains

-Medial and Lateral Pectoral (maj/min pectoral)

-Long Thoracic (post shoulder/scapula, winged scapula)

-Thoracodorsal (latissimus)

-Usually spared

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

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

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

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

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)

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

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

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

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

Management of Chronic Pain Neuropathic Pain

- Multidisciplinary approach- Physical therapy- Occupational therapy- Behavioral / Pain management- Acupuncture / Chiropractic- Medical Management

Management of Chronic - Neuropathic Pain

Management of Chronic - Neuropathic Pain

Management of Chronic - Neuropathic Pain

Neuropathic Pain Adjuvant Medications

- Lyrica (Pregabalin)- Works on Ca channels- Approved for DPN, PHN, Fibromyalgia- Side effects: Drowsiness, Sedation,

Blurred vision- 300-600 mg/day (bid-tid)

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

Conclusion

- Chronic pain seen in many patients (Nociceptive vs. Neuropathic)

- Surgical technique- Good peri-operative pain control- Multidisciplinary management- Multiple options for medical

management