Advances in the management and prevention of chronic pain following breast cancer surgery

Background: Post-mastectomy pain syndrome (PMPS) has been reported to occur in 25–60% of patients following surgeries for breast cancer, the highest occurring cancer in women worldwide. There has been much research interest due to this high prevalence. However, there is still a lack of incorporation of PMPS prevention strategies in standard perioperative plans, and our understanding of this condition is still incomplete. Objectives: This narrative review discusses recent literature on modifiable risk factors, current approaches to prevention and treatment and potential directions for future treatment and research. Methods: A PubMed search with the relevant keywords was done for articles published in the last 10 years. Results: The incidence of PMPS can be reduced by early recognition and management of modifiable risk factors as well as the perioperative use of analgesics and regional nerve blocks. These also have a significant role in the management of established PMPS together with surgical interventions and physical therapy. Conclusions: PMPS is still poorly defined and hence underdiagnosed and undertreated at this point. Perioperative peripheral nerve blocks have a very promising role as preventive analgesia to reduce the risk of developing PMPS, but large-scale randomised controlled studies will need to be done to evaluate their comparative efficacy. There is a need to prioritise PMPS prevention as a standard inclusion into the perioperative plans of mastectomy patients.

Chronic Pain Syndrome After Breast Cancer Surgery, defined as Postmastectomy Pain Syndrome (PMPS), is a condition in which, according to statistics, about 60% of patients experience low-intensity pain for three to six months after surgery in the intervention area, while 15-25% of patients suffer from moderate or high-intensity pain. The objective of this review is to analyze literature sources containing relevant data on anesthesia and analgesia methods used to prevent PMPS, as well as studies on new perioperative and postoperative PMPS prevention techniques. The authors conducted a search and review of literature in the PubMed, Ovid MEDLINE, Google Scholar, and ScienceDirect databases. The review included studies published between 2014 and 2024, where the study population consisted of adult female patients who underwent mastectomy for breast cancer treatment or prophylactic risk reduction, as well as data on pharmacological and regional anesthesia methods for PMPS prevention over 3 months or more after surgery. Regional nerve blocks as a method of intraoperative anesthesia demonstrated high efficacy and good analgesic effects during mastectomy, reducing the need for opioid analgesics. However, data on their effectiveness in preventing PMPS remain inconclusive. Studies on the efficacy of Pectoral Nerve Block (PECSII) in reducing post-breast cancer surgery pain found no statistically significant differences in PMPS incidence at 3 and 6 months post-surgery between patient groups. Compared to ketamine and lidocaine, pregabalin showed greater efficacy in preventing chronic pain syndrome, though its benefits were primarily short-term, and long-term effects require further research. Physiotherapy methods did not lead to significant improvements compared to traditional approaches, which may be due to small sample sizes in the studies. Psychotherapeutic interventions, such as cognitive-behavioral therapy (CBT) and hypnosis, proved effective in reducing pain perception and stress levels during the perioperative period.

Background:Postmastectomy pain syndrome (PMPS) is defined as a chronic (continuing for 3 or more months) neuropathic pain affecting the axilla, medial arm, breast, and chest wall after breast cancer surgery. The prevalence of PMPS has been reported to range from 20% to 68%. In this study, we aimed to determine the prevalence of PMPS among mastectomy patients, the severity of neuropathic pain in these patients, risk factors that contribute to pain becoming chronic, and the effect of PMPS on life quality.Methods:This cross-sectional study was approved by the Sakarya University, Medical Faculty Ethical Council and included 146 patients ranging in age from 18 to 85 years who visited the pain clinic, general surgery clinic, and oncology clinic and had breast surgery between 2012 and 2014. Patients were divided into two groups according to whether they met PMPS criteria: pain at axilla, arm, shoulder, chest wall, scar tissue, or breast at least 3 months after breast surgery. All patients gave informed consent prior to entry into the study. Patient medical records were collected, and pain and quality of life were evaluated by the visual analog scale (VAS) for pain, a short form of the McGill Pain Questionnaire (SF-MPQ), douleur neuropathique-4 (DN-4), and SF-36.Results:Patient mean age was 55.2 ± 11.8 years (33.0–83.0 years). PMPS prevalence was 36%. Mean scores on the VAS, SF-MPQ, and DN-4 in PMPS patients were 1.76 ± 2.38 (0–10), 1.73 ± 1.54 (0–5), and 1.64 ± 2.31 (0–8), respectively. Of these patients, 31 (23.7%) had neuropathic pain characteristics, and 12 (9.2%) had phantom pain according to the DN-4 survey. Patients who had modified radical mastectomy were significantly more likely to develop PMPS than patients who had breast-protective surgery (P = 0.028). Only 2 (2.4%) of PMPS patients had received proper treatment (anticonvulsants or opioids).Conclusions:PMPS seriously impacts patients’ emotional situation, daily activities, and social relationships and is a major economic burden for health systems. We conclude that the rate of PMPS among patients receiving breast cancer surgery in Turkey is 64.1% and that challenges to the proper treatment of these patients deserve further investigation.

Background: Post mastectomy pain syndrome (PMPS) is a type of neurogenic pain that persists for a long period after surgery for breast cancer. The present study aims to find out the prevalence of this syndrome and investigate its contributing risk factors. Methods: A descriptive cross-sectional study was carried out among 167womenoperated for breast cancer. Patients with either modified radical mastectomy(MRM) or breast conserving therapy (BTC) were enrolled in the study. Detailed medical history with special emphasis on the presence of pain and its characteristics, duration and location were performed to all patients. Full clinical examination was also performed to exclude other possible causes of pain. All expected risk factors were traced and correlated to the patient condition. Reviewing of medical records of all patients was performed to find out operation details, tumor stage and way of management of axillary lymph nodes. Results: Eighty seven (52%) out of the 167 studied women reported PMPS. The mean age was 54 ± 18.3 years. The incidence of PMPS was more evident in younger age group and in women with advanced tumor stage. There is significant decrease in the incidence of PMPS in patients underwent sentinel lymph node biopsy (SLNB) (Chi-2=4.10 & P-value=0.043).Moderate and severe pain were most commonly reported among patients underwent MRM while mild pain was most commonly reported among patients underwent BCT (Chi-2=17.51 & P-value=0.001). Intercostobrachial neuralgia was the most commonly reported type of pain among patients underwent MRM and patients underwent BCT (Chi-2=10.47 & P-value=0.015). Pain occurred more frequently at the shoulder, axilla and arm complex (48.3%). Conclusion: PMPS is an evident problem. Cancer surgeons should clearly identify patients who are at risk aiming to minimize or even eliminate the chance of developing this syndrome.

Postmastectomy pain syndrome is a common and disabling side effect of breast cancer treatment. Medical treatment seems to be insufficient for a considerable proportion of patients. Fat grafting has shown promise in relieving pain from postmastectomy pain syndrome, but no randomized clinical trial comparing fat grafting to a sham operation has been performed to date. The authors' objective was to compare the effect of fat grafting compared to a sham operation for treating postmastectomy pain syndrome. The authors conducted a single-center, double-blind, randomized clinical trial with two arms between October of 2017 and September of 2020. The authors assessed four patients suffering from postmastectomy pain syndrome for inclusion. The intervention group received scar-releasing rigottomy and fat grafting to the area of pain. The control group received scar-releasing rigottomy and a placebo of saline solution. The primary outcome was the degree of pain measured using the Numerical Rating Scale. The secondary outcomes were the degree and quality of neuropathic pain (Neuropathic Pain Symptom Inventory) and quality of life (36-Item Short-Form Health Survey). Follow-up was 6 months. Thirty-five participants completed follow-up: 18 participants in the intervention group and 17 in the control group. The authors detected no statistically significant changes in average and maximum pain or neuropathic pain. Regarding quality of life, the control group reported a statistically significant improvement in emotional problem parameters, whereas the intervention group reported a deterioration. The authors observed no serious adverse effects. The authors did not find evidence to support that fat grafting is superior to a placebo when treating postmastectomy pain syndrome. Therapeutic, I.

Background: Breast cancer is the second most common cancer world-wide following lung cancer. Post-mastectomy pain syndrome (PMPS) is one of the chronic post-surgical pain disorders (CPSP) of neuropathic character; nearly 20–50% of patients may develop PMPS. Stellate ganglion blockade has been performed as a diagnostic, prognostic, or therapeutic intervention for different pain syndromes. Objective: The aim of this study is to evaluate and compare the efficacy and safety of thermal versus super voltage pulsed radiofrequency (RF) application of stellate ganglion in neuropathic PMPS in cancer patients. Study Design: A prospective, double-blind, randomized, and controlled trial. Methods: Eighty patients with PMPS after surgery for breast cancer were recruited from the pain clinic of the National Cancer Institute with pain duration of more than 6 months and less than 2 years, visual analog scale (VAS) ≥ 40 mm, and not responding to oxycodone and pregabalin for at least 4 weeks. The pain had to be of positive neuropathic character, as detected by the grading system for neuropathic pain (GSNP; score of 3 or 4). The patients were allocated into 2 equally sized groups: Group A: Pulsed RF; super voltage pulsed RF was applied with a time of 360 seconds at 42º C, with a pulse width of 20 m/sec and voltage of 60–70 v. Group B: Thermal RF; thermal RF neurolysis was applied with a time of 60 seconds at 80º C, and was then was repeated twice after needle-tip rotation. Stellate ganglion RF therapy was done under fluoroscopy, integrated by ultrasound guidance. The patients were assessed for pain relief by change in VAS score, functional improvement, and the analgesic concomitant medication (oxycodone and pregabalin) consumption prior to block and at 1, 4, 12, and 24 weeks thereafter. The impact of treatment on quality of life (assessed by short-form health survey questionnaire [SF36]) and patient function capacity (assessed by the Eastern Cooperative Oncology Group [ECOG]) were also recorded. Results: The percentage of patients who had successful response was significantly higher in the thermal RF group compared to the pulsed RF group at the first week and first, third, and sixth months, with significant difference in post-mastectomy pain intensity, functional improvement, and less rescue analgesia. There was no significant difference in quality of life or patient functional capacity. Limitations: A longer follow-up period may be needed for the evaluation of RF effect on PMPS. Conclusions: Thermal RF of the stellate ganglion is a safe and successful treatment for PMPS. It appears to be more effective than pulsed RF of the stellate ganglion in this pain syndrome. Key words: Cancer breast, post mastectomy pain syndrome, stellate ganglion block, radiofrequency therapy

Background. The postmastectomy pain syndrome (PMPS) is chronic pain after breast cancer surgery and is reported to influence quality of life. The aim of this study was to provide long term reduction of PMPS, improve range of motion of the shoulder, and decrease the need for postoperative analgesia using ultrasound guided stellate ganglion block. Method. Sixty patients with PMPS were randomly allocated into 1 of 3 groups: bupivacaine group (group 1), bupivacaine plus ketamine group (group 2), and bupivacaine plus morphine group (group 3). Each patient received 3 blocks with an interval of one week in between. Patients were assessed for: pain visual analogue score (VAS), movement of the shoulder, skin temperature, and the need for analgesic drugs. Results. The pain VAS was significantly decreased in group 2 as compared to the other two groups. Shoulder movement improved significantly in the three studied groups with the best results observed after the third block. The need for the analgesic drugs in the form of gabapentin was more in the bupivacaine and bupivacaine plus morphine groups than in bupivacaine plus ketamine group. Conclusion. Treatment of PMPS with ultrasound guided stellate ganglion block using ketamine (0.5 mg/kg) as adjuvant to bupivacaine (0.25%) successfully decreased pain VAS and the need for analgesic drugs.

Post-mastectomy pain syndrome (PMPS) is chronic pain after breast cancer surgery and is reported to influence quality of life (QOL). Although the results of a survey in Japan showed high incidence, at 21-65 %, many of the patients had never been treated for PMPS. One reason for this low treatment rate may be poor understanding of PMPS by medical personnel. In this study, we conducted the survey by using questionnaire to assess current treatment and the recognitions of the medical personnel. We mailed a questionnaire to 647 specialist members of the Breast Cancer Society. Of those, 34.7 % responsed. While PMPS was recognized by as much as 70.5 % of responding physicians, it was treated by as little as 47.7 % of the responders. In addition, while non-steroidal anti-inflammatory drugs (NSAIDs), which were ineffective in relieving PMPS, were used by 78.4 % of the responders, effective drugs were rarely used; therefore, treatment was considered ineffective by 69.5 %. This indicates that appropriate therapies are not widely used, and none of the current therapies are very effective. The results showed high recognition of PMPS pathology among physicians, but the treatment rate was as low as 47.7 %. NSAIDs were the main treatment, and the treatment effects were not satisfactory. It was revealed that currently appropriate treatment modalities have not been widely used. Education of physicians, distribution of treatment information and further studies are considered necessary for the spread of appropriate treatment modality.

Postmastectomy pain syndrome (PMPS) represents a common complication following breast surgery defined as a chronic neuropathic pain located in the front of the chest, in the axilla and in the upper arm that for more than 3months after surgery. Several medications prove to be ineffective while autologous fat grafting revealed to be an innovative solution in the treatment of neuropathic pain syndromes based on retrospective studies. For this reason, we performed a prospective multicenter trial to reduce the memory bias and further increase the evidence of the results. From February 2018 to March 2019, 37 female patients aged between 18 and 80years, underwent mastectomy or quadrantectomy with pathologic scarring and chronic persistent neuropathic pain, compatible with PMPS, are been included in the study and treated with autologous fat grafting. During the enrollment phase, patients were asked to estimate pain using the Visual Analogue Scale (VAS) and POSAS questionnaire in order to evaluate scar outcomes. The VAS scale, starting from 6.9 (1.3), decreased in the first month by 3.10 (1.59), continuing to fall by 0.83 (1.60) to 3months and by 0.39 (2.09) at 6months. Statistical analysis showed a significant reduction after 1month (P<.0001) and 3months (P<.005). All POSAS grades documented a statistically significant reduction (P<.0001) of the scores by both observers and patients. We observed that no significant association was found between age, BMI, menopausal status of patients, days from oncologic surgery to autologous fat grafting and reduction of VAS values over time while both smoking and axillary dissection were observed as the main factor significantly associated with a reduced clinical efficacy (respectively, P=.0227 and P=.0066). Our prospective multicenter trial confirms the efficacy of fat grafting in the treatment of PMPS based on the principle of regenerative medicine with a satisfactory response in terms of pain reduction and improvement of the quality of the treated tissues. Clinical questionnaires show that the cicatricial areas improve in terms of color, thickness, skin pliability, and surface irregularities. Regenerative effect is based also on the adoption of needles. The combined effect of fat grafting and needles determines a clinical full response.

The prevalence of the postmastectomy pain syndrome (PMPS) and its clinical characteristics was assessed in a group of patients who had undergone surgery for breast cancer at the Department of Surgery, Odense University Hospital, within the period of 1 May 2003 to 30 April 2004. The study included 258 patients and a reference group of 774 women. A questionnaire was mailed to the patients 1½ year after surgery and to the women in the reference group. The PMPS was defined as pain located in the area of the surgery or ipsilateral arm, present at least 4 days per week and with an average intensity of at least 3 on a numeric rating scale from 0 to 10. The prevalence of PMPS was found to be 23.9%. The odds ratio of developing PMPS was 2.88 (95% confidence interval 1.84–4.51). Significant risk factors were as follows: having undergone breast surgery earlier (OR 8.12), tumour located in the upper lateral quarter (OR 6.48) and young age (OR 1.04). This study shows that, although recent advances in the diagnostic and surgical procedures have reduced the frequency of the more invasive surgical procedures, there still is a considerable risk of developing PMPS after treatment of breast cancer.

Breast cancer is the most common cancer in women worldwide, affecting one in eight women. Breast-conserving surgery (BCS) has become a well-established alternative to mastectomy in the treatment of breast cancer, providing a less invasive treatment. Just as life expectancy after breast cancer has improved, so has morbidity increased. One of the most relevant and debilitating consequences of oncological breast surgery is postmastectomy pain syndrome (PMPS). Our results published in 2011 on the treatment of PMPS in patients who had undergone mastectomy and radiotherapy and our experience in scar treatment with fat grafts were the theoretical bases for this prospective study. From April 2011 to April 2012 a total of 96 patients, who had undergone lumpectomy and radiation therapy, with the diagnosis of PMPS were considered for fat grafts. We performed autologous fat grafting in 59 patients (study group), whereas 37 patients did not receive any further surgical procedure (control group). Pain assessment was performed using the visual analog scale (VAS) before and after treatment in the treated group and in the control group at the first visit and the control visit, with a mean follow-up of 10 months. Results were analyzed using the Wilcoxon rank sum test. Four patients were lost to follow-up (two patients in the control group and two patients in the treated group). A significant VAS pain decrease was detected in patients treated with autologous fat grafting (3.1 point reduction, p ≤ 0.005). Because of the safety, efficacy, and optimal tolerability of the procedure, we believe that fat grafting can be considered useful in treating PMPS in patients who have undergone BCS and radiotherapy. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Mastectomy with axillary dissection is still one of the most common procedures in oncologic surgery. Unfortunately, a condition of neuropathic pain, termed postmastectomy pain syndrome, can appear after mastectomy. Although evidence regarding the epidemiology of postmastectomy pain syndrome is well researched, an effective therapy is still unknown. The aim of this study was to assess the clinical effectiveness of lipoaspirate graft in the treatment of postmastectomy pain syndrome. From February of 2006 to August of 2008, a total of 113 patients affected by postmastectomy pain syndrome and severe scar retractions were enrolled for this clinical study. Seventy-two patients were treated with autologous fat grafted in painful scars, and 41 patients did not undergo any further surgical procedure. Pain assessment was performed using a visual analogue scale before and after treatment, with a mean follow-up of 13 months. In addition, antalgic drug intake was recorded in the 34 patients who received a surgical treatment. Results were analyzed using the Wilcoxon rank sum test. A significant decrease in pain according to the visual analogue scale was detected in patients treated with autologous fat graft (3.23-point reduction, p = 0.0005). Twenty-eight of 34 patients stopped their analgesic therapy with a significant follow-up (13 months). Autologous fat grafting is a safe, relatively noninvasive, and rapid surgical procedure. The authors' results suggest its effectiveness for treatment of postmastectomy pain syndrome. Therapeutic, II.

Breast cancer is the most common female malignancy worldwide. Breast surgery and adjuvant oncological therapies are often required to increase survival. Treatment-related pain may persist and evolve into postmastectomy pain syndrome (PMPS) in a significant subset of breast cancer survivors. In this retrospective investigation, we will present our experience in applying an interventional algorithmic approach to treat PMPS. A retrospective study. An academic cancer hospital. Adult females with PMPS diagnosis. We reviewed 169 records with the diagnosis of PMPS from 2015 to 2019 within our health system. Pre- and post-injection pain scores, relief duration, and medication usage changes were collected. The decision to perform each procedure was based on the anatomic location of the painful area with the corresponding peripheral sensory innervation. Decision-making flow diagrams were created to present our experience in managing PMPS beyond peripheral nerve blocks. Ultrasound-guided peripheral nerve block results (n=350) were analyzed. The mean baseline pain score was 7, compared with the post-treatment mean score of 3 (95% confidence interval: 3.58 to 3.98, P = 0.0001). Among the responders, the mean pain relief duration was 45 days, with a median of 84 days. Opioid medication consumption was reduced by 11% (t = 0.72, P = 0.47). Ultrasound-guided nerve blocks of this area could be performed safely and effectively after breast surgeries. We also present our proposed algorithm to provide a stepwise application for selecting the appropriate therapies in the management of more complex PMPS.

Postmastectomy pain syndrome (PMPS) is defined as chronic pain after breast cancer surgery lasting greater than 3 months and has been shown to affect up to 60% of breast cancer patients. Substantial research has been performed to identify risk factors and potential treatment options, although the exact cause of PMPS remains elusive. As breast reconstruction becomes increasingly popular, plastic surgeons are likely to encounter more patients presenting with PMPS. This article summarizes current evidence on risk factors and treatment options for PMPS and highlights further areas of study.

Post-mastectomy pain syndrome (PMPS) is a chronic neuropathic pain condition, affecting many women who have undergone breast cancer surgery. The development of PMPS is complex and the treatment options are limited. In this systematic review, we have analyzed the existing treatment modalities of PMPS. Six studies on five treatments were carefully selected, critically evaluated, and presented. The treatments were: antidepressants, anti-epileptics, topical capsaicin, and autologous fat grafting. Four of these treatments had a significant effect on PMPS. However, most of the studies had several flaws and therefore larger studies of high quality should be performed in the future.