Persistent Postmastectomy Pain Research Articles

Examining Trajectories In Postoperative Anxiety Among Women Who Developed Persistent Post-Mastectomy Pain After Breast Surgery

Examining Trajectories In Postoperative Anxiety Among Women Who Developed Persistent Post-Mastectomy Pain After Breast Surgery

Applying the Rapid OPPERA Algorithm to Predict Persistent Pain Outcomes Among a Cohort of Women Undergoing Breast Cancer Surgery

Persistent postmastectomy pain after breast surgery is variable in duration and severity across patients, due in part to interindividual variability in pain processing. The Rapid OPPERA Algorithm (ROPA) empirically identified 3 clusters of patients with different risk of chronic pain based on 4 key psychophysical and psychosocial characteristics. We aimed to test this type of group-based clustering within in a perioperative cohort undergoing breast surgery to investigate differences in postsurgical pain outcomes. Women (N = 228) scheduled for breast cancer surgery were prospectively enrolled in a longitudinal observational study. Pressure pain threshold (PPT), anxiety, depression, and somatization were assessed preoperatively. At 2-weeks, 3, 6, and 12-months after surgery, patients reported surgical area pain severity, impact of pain on cognitive/emotional and physical functioning, and pain catastrophizing. The ROPA clustering, which used patients’ preoperative anxiety, depression, somatization, and PPT scores, assigned patients to 3 groups: Adaptive (low psychosocial scores, high PPT), Pain Sensitive (moderate psychosocial scores, low PPT), and Global Symptoms (high psychosocial scores, moderate PPT). The Global Symptoms cluster, compared to other clusters, reported significantly worse persistent pain outcomes following surgery. Findings suggest that patient characteristic-based clustering algorithms, like ROPA, may generalize across diverse diagnoses and clinical settings, indicating the importance of “person type” in understanding pain variability. PerspectiveThis article presents the practical translation of a previously developed patient clustering solution, based within a chronic pain cohort, to a perioperative cohort of women undergoing breast cancer surgery. Such preoperative characterization could potentially help clinicians apply personalized interventions based on predictions concerning postsurgical pain.

Efficacy and Safety of Topical Morphine: A Narrative Review.

Background. Opioids are the cornerstone of the therapy used in both acute and chronic pain syndromes to treat pain of moderate to severe intensity. The knowledge that opioid receptors also occur in other tissues outside the central nervous system has created a possibility for the topical use of opioids. Thus, local analgesia may be obtained without systemic adverse effects. Methods. A narrative review of scientific papers discussing the topical use of morphine was conducted. For this purpose, the PubMed, Google Scholar, Cochrane Library, and Mendeley databases were searched. Results. The current knowledge on topical morphine does not allow for its recommended use in everyday medical practice, but suggests it may be effective, particularly in the treatment of ulcers and erosions of inflammatory etiology and painful skin lesions including persistent post-mastectomy pain due to breast cancer. Conclusions. Topical morphine has its place beside other analgesics. An important issue is the practical possibility to meet the demand for topical formulations, which is limited by technical difficulties.

What Is My Patient's Pain Phenotype? An Exercise in Transferring Patient Clustering Solutions between Institutions and across Patient Samples

Persistent post-mastectomy pain (PPMP) is a consequence of breast surgery that is variable in duration and severity across patients. The biopsychosocial model of pain acknowledges the impact of psychosocial and biophysical factors to modulate pain outcomes. The Rapid OPPERA Algorithm (ROPA) empirically clusters patients based on their biophysical and psychosocial characteristics and identified 3 clusters of patients based on 4 phenotypic characteristics with different risk of chronic pain. We aimed to understand the translatability of this type of phenotypic-based clustering, developed in patients with TMD, to a cohort undergoing breast cancer surgery, to predict pain severity and functional pain outcomes. Women (N:228, age:55.8±12.4, 87% White) scheduled for breast cancer surgery were prospectively enrolled in a longitudinal observational study. Preoperative pressure pain threshold (PPT) was measured using brief bedside QST, and anxiety, depression, and somatization were assessed using validated questionnaires. At 2-weeks, 3, 6, and 12-months after surgery, participants reported surgical area pain severity and frequency, and the impact of pain on cognitive/emotional and physical functioning. The ROPA clustering algorithm was applied using preoperative scores for anxiety, depression, somatization, and PPT. We determined differences between the identified clusters using general estimating equations linear regressions for longitudinal pain-related outcomes during the first year after surgery. Patients fell into three identified clusters: Adaptive (low psychosocial factors, low PPT; n=61), Pain Sensitive (moderate psychosocial factors, low PPT; n=125), and Global Symptoms (high psychosocial factors, moderate PPT; n=42). The Global Symptoms cluster, compared to other clusters, reported significantly greater pain severity and worse functional pain outcomes (p's<.05). The ROPA clustering algorithm identified a group at higher risk of PPMP, based on 4 preoperative phenotypic measures. Findings suggest that pain phenotyping may extend across patients with different diagnoses and clinical settings, highlighting the importance of personalized medicine, treating the "person type" as much as the diagnosis. Grant support from NIH/NIGMS: K23 GM110540.

Ultrasound-guided superficial serratus plane block for persistent post-mastectomy pain: four case reports

Persistent post-mastectomy pain (PPMP) is common after surgery. Although multiple modalities have been used to treat this type of pain, including medications, physical therapy, exercise interventions, cognitive-behavioral psychology, psychosocial interventions, and interventional approaches, managing PPMP may be still a challenge for breast cancer survivors. Currently, serratus plane block (SPB) as a novel regional anesthetic technique shows promising results for controlling chronic pain.We report four cases of patients with PPMP that were treated using superficial serratus plane block (SSPB) at our clinic. A retrospective review of effect of pain relief was collected through postprocedure interviews.We found that two of our patients were successfully treated with SSPB for pain after treatment for breast cancer. The third patient had an intercostobrachial nerve block that produced incomplete pain relief but had adequate pain relief with a SSPB. However, the fourth patient reported no pain relief after SSPB.These cases illustrate that the patients with PPMP could benefit from SSPB. Particularly, we find patients with a subjective sense of "tightness" relating to reconstructive surgeries may be a good candidate for SSPB. Further studies are warranted to evaluate this block for PPMP, as it is low risk and relatively simple to perform.

Effect of perioperative pain neuroscience education in patients with post-mastectomy persistent pain: a retrospective, propensity score-matched study.

Central sensitization (CS)-related symptoms and pain catastrophizing contribute to persistent post-mastectomy pain (PPMP). Pain neuroscience education (PNE) is effective in reducing CS-related symptoms and pain catastrophizing in patients with chronic pain. However, to date, no intervention study of PNE has been conducted to patients with PPMP. This study was aimed to examine whether PNE is more effective than biomedical education (BME) for PPMP. In this retrospective case-control study, 118 patients were included. We intervened different patients at different times as follows: (1) a BME group (n = 58) of patients who received BME combined with physiotherapy and (2) a PNE group (n = 60) of patients who received PNE combined with physiotherapy. One year after surgery, we assessed pain intensity and interference (brief pain inventory [BPI]), CS-related symptoms (central sensitization inventory [CSI]), and pain catastrophizing (pain catastrophizing scale [PCS]). Propensity score matching was used to reduce or minimize selection bias and confounding biases and to make the number of cases in both groups match 1:1. Propensity score matching generated the BME group (n = 51) and the PNE group (n = 51). The BPI score, CSI score, and PCS score were statistically significantly lower in the PNE group than in the BME group (all, p < 0.05). The effect sizes for the BPI intensity (r = 0.31) were moderate. PNE resulted in a better outcome of pain management with less functional disability and CS-related symptoms compared to BME after breast surgery.

Persistent Post-Mastectomy Pain: The Impact of Regional Anesthesia Among Patients with High vs Low Baseline Catastrophizing

Persistent Post-Mastectomy Pain (PPMP) varies both in its severity and impact, with psychosocial factors such as catastrophizing conferring greater risk. Preoperative regional anesthesia (RA) is an important non-opioid therapy, but with variable success at preventing PPMP in previous reports. We previously reported that RA was associated with lower acute post-mastectomy pain and opioid use, but more prominently among patients with higher baseline catastrophizing. The current longitudinal investigation at 3, 6, and 12 months postop aimed to detect differential long-term impact of RA on PPMP among patients with high vs low catastrophizing. In this prospective observational study, patients (n=123) completed preoperative psychosocial assessment and underwent mastectomy either with (n=56) or without (n=67) preoperative RA. Generalized estimating equation (GEE) regression analysis assessed impact of baseline catastrophizing, RA, and their interaction, on the primary outcome of pain severity index, as well as secondary outcomes including cognitive and emotional impact of pain, and persistent opioid use. We observed a significant interaction between the effect of catastrophizing and RA on PPMP. Specifically, RA was associated with reduced pain severity and pain impact 3, 6, and 12 months postoperatively, but only among those with high baseline catastrophizing scores. In addition, both RA and lower catastrophizing scores were associated with lower incidence of persistent opioid use. The efficacy of therapies to prevent PPMP may be importantly influenced by pain-modulatory psychosocial characteristics. These findings underscore the importance of considering individual patient factors when applying preventive treatments, and of including their assessment in future trials.

Persistent Post-Mastectomy Pain: Randomized Clinical Trial of Targeted Pain Coping Skills Training

Persistent Post-Mastectomy Pain: Randomized Clinical Trial of Targeted Pain Coping Skills Training

Persistent Postmastectomy Pain in Breast Cancer Patients: Incidence, Pain Characteristics and Effects on Quality of Life

Persistent Postmastectomy Pain in Breast Cancer Patients: Incidence, Pain Characteristics and Effects on Quality of Life

Two cases of persistent postmastectomy pain with different outcomes resulting from immobilization

Two cases of persistent postmastectomy pain with different outcomes resulting from immobilization

Fat grafting is found to halve post-mastectomy pain

Persistent post-mastectomy neuropathic pain is a serious problem for many patients undergoing the procedure for breast cancer, with almost half of patients in some studies reporting the symptom.

Persistent postmastectomy pain syndrome and posttraumatic stress disorder among breast cancer survivors (ORTHUS study): A study of the palliative care working committee of the Turkish Oncology Group (TOG).

e21702Background: Persistent postmastectomy pain syndrome (PMPS) is one of the most important disturbing symptoms. Posttraumatic stress disorder (PTSD) is an anxiety disorder which is characterized...

Clinical and neurophysiological evaluation of persistent sensory disturbances in breast cancer women after mastectomy with or without radiotherapy.

Breast cancer surgery or radiotherapy (RT) are potential causes of persistent pain syndrome. It remains to be clarified whether numbness or pain reported by patients after mastectomy and RT are conditioned by changes in nerve transmission. The aim of this study was to examine the potential relationship between subjective sensory complications and neurophysiological examinations in breast cancer survivors with post-mastectomy pain syndrome. Sixty breast cancer survivors (30 patients only after mastectomy - group A; and 30 after mastectomy with RT - group B) complaining of pain and sensory disturbances in the brachial plexus area and 20 healthy women (group C) were studied with regard to sensory perception and pain intensity using the Visual Analogue Scale and electroneurography (ENG). There was a statistically significant decrease in the amplitudes in SCV recordings following stimulation of the ulnar (p=0.04) and lateral cutaneous antebrachii nerves (p=0.02) in group B in comparison to group C. Additionally, a significant decrease in the amplitude and conduction velocity parameters was detected in the sensory fibers of the median and medial cutaneous antebrachii nerves in group A (p=0.00 and p=0.02, respectively) in comparison to group C. The results of this pilot study suggest persistent post-mastectomy pain syndrome sometimes appears as a result of nerve injury in course of breast cancer surgery and RT. Therefore studies in nerve conduction may be added to the comprehensive patient assessment used in planning breast cancer patients' rehabilitation after oncological treatment has finished.

Breast cancer survivors suffer from persistent postmastectomy pain syndrome and posttraumatic stress disorder (ORTHUS study): a study of the palliative care working committee of the Turkish Oncology Group (TOG).

Persistent postmastectomy pain syndrome (PMPS) is one of the most important disturbing symptoms. Posttraumatic stress disorder (PTSD) is an anxiety disorder which is characterized by reactions to reminders of the trauma that has been experienced. The purpose of this study is to evaluate the predictors of PMPS and PTSD in Turkish breast cancer survivors and the correlation between PMPS and PTSD. The study is designed as a multicenter survey study. Breast cancer patients in remission were evaluated. Patients were evaluated with structured questionnaires to assess the PMPS and clinical parameters associated with it. The Turkish version of the posttraumatic stress disorder checklist-civilian version (PCL-C) was used. Between February 2015 and October 2015, 614 breast cancer survivors in outpatient clinics were evaluated. The incidence of PMPS documented is 45.1%. In the multivariate analysis low income, presence of PTSD and <46months after surgery were associated with increased risk of PMPS. PTSD was documented in 75%, and the mean PCL-C score was 32.4 ± 11.1. PMPS and being married at the time of the evaluation were linked with PTSD. It is the first data about the association between PMPS and PTSD. The clinicians should be aware of PMPS and PTSD in breast cancer survivors.

(248) Acute and subacute postoperative pain after partial and total mastectomy: association with prospectively assessed psychosocial and psychophysical variables

Breast cancer is the most common form of female cancer, the treatment of which often involves surgery. Previous reports cite persistent post mastectomy pain (PPMP) incidence around 30%, and putative risk factors include younger age, type of surgery, axillary dissection, anesthetic technique, genetics, negative affect (psychosocial factors) and increased pain sensitivity (psychophysical factors). However, most previous studies of PPMP have been retrospective and cross sectional in design. In the current study, a broad array of potential risk factors were assessed in women prospectively before surgery. Patients undergoing partial or total mastectomy were recruited and underwent preoperative assessment including psychosocial (anxiety, depression, catastrophizing, sleep disturbance etc) and psychophysical (quantitative sensory testing; pressure tolerance, pressure threshold, pinprick temporal summation). Their degree of surgically related pain was then assessed using the Breast Cancer Pain Questionnaire, including frequency, severity and number of body areas assessments to determine a pain burden index (PBI) at several points up to 1 year after surgery. Patients undergoing more extensive surgery reported higher acute pain (postoperative day 0 and 1), with severity correlating with surgical extent (bilateral mastectomy> unilateral mastectomy> lumpectomy), as well as younger age, and higher preoperative psychosocial dysfunction (high catastrophizing, anxiety, depression). Subacute postoperative pain (postoperative day 14) also correlated with younger age and preoperative psychosocial dysfunction, but not surgical extent and duration. By 90 days after surgery, PBI was no longer associated with age or surgical factors, but remained correlated with preoperative psychosocial factors, as well as heightened baseline sensory processing (higher temporal summation of pain and painful aftersensations). These findings suggest that the factors influencing acute pain after surgery may differ somewhat from those that predict more persistent pain. By more extensively phenotyping individual differences in pain processing in the preoperative period, we may identify those at greater risk of chronic postsurgical pain.

The Effect of Ketamine Infusion on Post Mastectomy Pain Syndrome: A Randomized Controlled Study

Background: Acute postoperative pain after breast surgery is one of the major factors contributing to prolonged hospital stay. In addition persistent post mastectomy pain (PPMP) is rated as the most important cause of suffering in those patients. Objectives: The objectives of this study are to investigate the efficacy and safety of ketamine infusion on the incidence of acute postoperative and chronic post-mastectomy pain in female patients undergoing modified radical mastectomy.

Anesthesia Literature Review

Anesthesia Literature Review

Persistent Postmastectomy Pain in Breast Cancer Survivors: Analysis of Clinical, Demographic, and Psychosocial Factors

Persistent postmastectomy pain (PPMP) is increasingly recognized as a major individual and public health problem. Although previous studies have investigated surgical, medical, and demographic risk factors, in this study we aimed to more clearly elucidate the relationship of psychosocial factors to PPMP. Postmastectomy patients (611) were queried about pain location, severity, and burden 38.3 ± 35.4 months postoperatively. Validated questionnaires for depressive symptoms, anxiety, sleep, perceived stress, emotional stability, somatization, and catastrophizing were administered. Detailed surgical, medical, and treatment information was abstracted from patients' medical records. One third (32.5%) of patients reported PPMP, defined as ≥3/10 pain severity in the breast, axilla, side, or arm, which did not vary according to time since surgery. Multiple regression analysis revealed significant and independent associations between PPMP and psychosocial factors, including catastrophizing, somatization, anxiety, and sleep disturbance. Conversely, treatment-related factors including surgical type, axillary node dissection, surgical complication, recurrence, tumor size, radiation, and chemotherapy were not significantly associated with PPMP. These data confirm previous studies suggesting that PPMP is relatively common and provide new evidence of significant associations between psychosocial characteristics such as catastrophizing with PPMP, regardless of the surgical and medical treatment that patients receive, which may lead to novel strategies in PPMP prevention and treatment. PerspectiveThis cross-sectional cohort study of 611 postmastectomy patients investigated severity, location, and frequency of pain a mean of 3.2 years after surgery. Significant associations between pain severity and individual psychosocial attributes such as catastrophizing were found, whereas demographic, surgical, medical, and treatment-related factors were not associated with persistent pain.

Persistent pain in postmastectomy patients: Comparison of psychophysical, medical, surgical, and psychosocial characteristics between patients with and without pain

Persistent postmastectomy pain (PPMP) is a major individual and public health problem. Increasingly, psychosocial factors such as anxiety and catastrophizing are being revealed as crucial contributors to individual differences in pain processing and outcomes. Furthermore, differences in patients’ responses to standardized quantitative sensory testing (QST) may aid in the discernment of who is at risk for acute and chronic pain after surgery. However, characterization of the variables that differentiate those with PPMP from those whose acute postoperative pain resolves is currently incomplete. The purpose of this study was to investigate important surgical, treatment-related, demographic, psychophysical, and psychosocial factors associated with PPMP by comparing PPMP cases with PPMP-free controls. Pain was assessed using the breast cancer pain questionnaire to determine the presence and extent of PPMP. Psychosocial and demographic information were gathered via phone interview, and women underwent a QST session. Consistent with most prior research, surgical and disease-related variables did not differ significantly between cases and controls. Furthermore, treatment with radiation, chemotherapy, or hormone therapy was also not more common among those with PPMP. In contrast, women with PPMP did show elevated levels of distress-related psychosocial factors such as anxiety, depression, catastrophizing, and somatization. Finally, QST in nonsurgical body areas revealed increased sensitivity to mechanical stimulation among PPMP cases, while thermal pain responses were not different between the groups. These findings suggest that an individual’s psychophysical and psychosocial profile may be more strongly related to PPMP than their surgical treatment.

Pain phenotypes in American breast cancer survivors: analysis of clinical, demographic and psychosocial factors

Persistent Post-Mastectomy Pain (PPMP), the incidence of which international reports estimate at 15-58%, is increasingly recognized as a major individual and public health problem. The etiology of PPMP is likely multifactorial, may be partially neuropathic in nature, and results in considerable disability and psychological distress. Previous reports, though somewhat discrepant, indicate risk factors for PPMP may include younger age, surgical extent, axillary dissection, reconstruction, previous pain, radiation and chemotherapy. In the current study, we investigated the incidence, character, and psychosocial correlates of PPMP in 611 women receiving mastectomy and adjuvant treatment (chemotherapy, radiation, hormone therapy). Pain location, intensity, magnitude and burden were assessed using a breast cancer pain questionaire1 and other established pain assessment tools 3.20+/-2.95 years postoperatively. Nearly half (47.4%) reported pain associated with previous mastectomy, with 32.5% reporting clinically significant (>3/10) pain, and 2.9% rating pain severe (>8/10). Of those with clinically significant pain, 29% reported daily occurrence. Pain locations included breast(74%), axilla(45%), side(20%), or arm(20%). Incidence of pain did not vary according to time since surgery after 6 months. Higher pain scores correlated significantly with neuropathic quality of pain(R=0.62,p<0.05). Multifactorial analysis of psychosocial correlates showed a strong association between clinically significant pain and Pain Catastrophizing Scale(R=0.43,p<0.05) and somatization(R=0.21,p<0.05), as assessed by the Brief Symptoms Inventory-18. Anxiety(R=0.19,p<0.05), depression(R=0.18 ,p<0.05) and sleep disturbance(R=0.18 ,p<0.05) scores were also positively correlated with pain. Improved characterization of PPMP and the psychosocial landscape in which it occurs may allow prospective identification of patients at risk, and allow targeting of preventive measures in the perioperative period. (1. Gartner, JAMA, 2009.)