Why Breast Cancer Surgery Pain Can Linger

Breast cancer survivors may have postsurgical pain years later

(RxWiki News) Most women with breast cancer undergo some form of surgery ranging from a lumpectomy to remove the tumor and surrounding tissue to a mastectomy that removes the entire breast. Pain after mastectomies may be the most troubling long-term symptom among breast cancer survivors, according to a recent study.

The new research showed that the type of surgery performed did not impact persistent post-mastectomy pain (PPMP). Psychological factors, on the other hand, did affect pain.

The study found that women who reported high levels of anxiety, depression, troubled sleep, unexplained physical symptoms and/or excessive negative thinking were likely to experience persistent post-mastectomy pain.

"Talk to your doctor about any pain you experience after cancer treatment."

Inna Belfer, MD, PhD, of the Departments of Anesthesiology and Human Genetics at the University of Pittsburgh School of Medicine, headed this study to determine which factors contributed to PPMP.

The researchers used a number of different survey instruments to phone interview 611 breast cancer survivors about pain. The responses of 582 of these survivors were included in the analysis.

The participants had undergone either a total mastectomy or a segmental mastectomy in which part of the breast was removed. They were interviewed just over three years after their surgery.

Three different types of surveys were used to assess pain location, severity and burden: the Breast Cancer Pain Questionnaire (BCPQ), the Brief Pain Inventory (BPI) and the Short form McGill Pain Questionnaire (MPQ).

The BCPQ uses a 0-10 scale, and women reporting the severity of their pain as 3 or above were placed in what the researchers called the “clinically significant” PPMP group.

Several survey instruments were used to assess psychosocial functioning. The Pain Catastrophizing Scale was used to measure catastrophic (jumping to the worst conclusions) thinking about pain.

Other questionnaires were used to evaluate depression, anxiety, stress levels, somatization (pain with no physical cause) and emotional stability.

Patient records were used to detail cancer type, tumor size, surgery and other treatments given.

About a third of the women reported clinically significant (score of 3 out of 10) pain in the breast, armpit, side or arm closest to the surgery site.

The researchers analyzed the responses of these participants to drill down on factors associated with PPMP.

“Specifically, anxiety, depressive symptoms, sleep disturbance somatization, catastrophizing, and perceived stress were all significantly associated with PPMP,” the researchers wrote.

Pain catastrophizing was the most significant psychosocial factor seen among women reporting significant PPMP, the authors noted.

“Conversely, treatment-related factors including surgical type, axillary node dissection, surgical complication, recurrence, tumor size, radiation, and chemotherapy were not significantly associated with PPMP,” according to the researchers.

Cary Kaufman, MD, a breast surgeon and specialist at Bellingham Regional Breast Center in Bellingham, WA, told dailyRx News he saw flaws in the way this study was conducted. "This study did not find medical factors associated with pain, yet they did not utilize the type of research protocols that were used to find these factors in other reports," Dr. Kaufman said.

"My personal experience is that certain factors increase the likelihood of post-surgical pain, similar to other reports. These include young age, the use of radiation treatment and use of axillary dissection [removal of lymph nodes in the armpit] rather than sentinel node biopsy [removal of lymph nodes closest to tumor]," Dr. Kaufman said.

"Specifically, this study appears to focus on the psychological status of the patients they interviewed rather than a detailed medical chart review. The article mentioned that the pre-existing psychological status of each patient may be important in the development of persistent pain, but they were unable to assess pre-surgical state since they only had a single phone call from 6 months to 18 years after the surgery," he said.

"Finally, patients who are very anxious or depressed are more likely to be dissatisfied with the spectrum of post treatment side effects from each treatment modality. This and other articles have found that post-surgical pain is a difficult disorder and it takes efforts from many viewpoints to identify both causative and beneficial factors.  Continued research is necessary," Dr. Kaufman said.

Results from this study were published in the November issue of The Journal of Pain.

Support for this work came from the National Institutes of Health and the Department of Anesthesiology at the University of Pittsburgh.

Review Date: 
November 8, 2013