Thursday, November 12, 2009

Prevalence of Persistent Pain Following Breast Cancer Surgery – Article Review

Rune Gärtner, MD, of the University of Copenhagen, and colleagues have done a population-based study on persistent pain following surgical treatment in breast cancer patients.  It was published in the Nov. 11 issue of the JAMA.  Their goal was to examine the prevalence, associated factors, and severity of chronic pain and sensory disturbances after surgery for breast cancer.  See the reference below.

Persistent pain following surgical treatment for breast cancer can be a significant problem for nearly half of all breast cancer survivors.  Younger women and those who have an axillary lymph node dissection are most at risk.

Persistent pain after breast cancer surgery  is often due to multiple mechanisms, including nerve damage related to surgical technique resulting in risk of intercostobrachial neuralgia, neuroma pain, or phantom breast pain.  

The researchers used a nationwide cross-sectional questionnaire study of 3754 women aged 18 to 70 years who received surgery and adjuvant therapy (if indicated) for primary breast cancer in Denmark between January 1, 2005, and December 31, 2006.  The study questionnaire was sent to the women between January and April 2008.  None reported a breast cancer recurrence or other malignancy since the initial treatment.

Findings

A total of 1543 patients (47%) reported pain in 1 or more areas, of which 201 (13%) reported severe pain (scores of 8-10 on the numeric rating scale of 0-10 scores), 595 (39%) reported moderate pain (scores of 4-7), and 733 (48%) reported light pain (scores of 1-3). Fourteen patients (1%) did not rate severity of pain. Among those patients reporting pain, the mean pain score in the 4 different areas varied between 3.5 and 4.0 (range, 0-10). Among women reporting severe pain, 77% experienced pain every day, whereas only 36% of women experiencing light pain had pain every day.

Of patients reporting pain, 306 (20%) had contacted a physician within the prior 3 months due to pain, 439 (28%) had taken analgesics due to pain in the surgical area, and 397 (26%) had received other treatments for pain (ie, physiotherapy, massage). A total of 1265 women (40%) reported pain in other parts of the body/nonsurgical areas (eg, low back pain, headache). Pain complaints in nonsurgical areas were associated with a higher incidence of chronic postoperative pain because 810 women (65%) had pain in the surgical regions, whereas 674 women (37%) without pain in the nonsurgical area had pain in the surgical area (P < .001)

The most common site of pain was the breast area (86%), followed by the axilla (63%), arm (57%), and side of the body (56%).

A total of 1265 women (40%) reported pain in other parts of the body/nonsurgical areas (eg, low back pain, headache). Pain complaints in nonsurgical areas were associated with a higher incidence of chronic postoperative pain because 810 women (65%) had pain in the surgical regions, whereas 674 women (37%) without pain in the nonsurgical area had pain in the surgical area.

Factors that predicted persistent pain were age younger than 40  (OR 3.62), axillary lymph node dissection (OR 1.77 versus sentinel lymph node dissection), and radiotherapy (OR 1.50 to 1.35).

Sensory disturbances  can include allodynia, aftersensations, burning, or sensory loss, and appear linked to chronic pain.

Conclusions

Based on the results of our study together with previously reported findings, chronic pain after breast cancer surgery and adjuvant therapy may predominantly be characterized as a neuropathic pain state and probably related to intraoperative injury of the intercostal-brachial nerve. In accordance with these findings, preliminary observations with nerve-sparing techniques may suggest such approaches to reduce the risk of developing a chronic neuropathic pain state. ………

So far, analgesic and other interventions with paravertebral blocks, topical capsaicin, gabapentin and local anesthetics, N-methyl-D-aspartate–receptor antagonists,  or glucocorticoids may suggest certain benefits, but large-scale studies including well-characterized relevant subpopulations are required before general recommendations can be made. …..

 

 

REFERENCES

Prevalence of and factors associated with persistent pain following breast cancer surgery; JAMA 2009; 302: 1985-92.; Gärtner R, et al

Evaluating patients with chronic pain after breast cancer surgery: The search for relief; JAMA 2009; 302: 2034-35.; Loftus LS, Laronga C

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