medical update

Post Breast Therapy Pain
Dr. Pippa Hawley FRCPC, Pain & Symptom Management Specialist
BC Cancer Agency, Vancouver

The treatment of breast cancer almost always involves surgery to remove the cancer, and often radiation treatment to try to kill any remaining cancer cells. These treatments can cause pain which can sometimes persist and occasionally become severe. In the past this has been referred to as "Post Mastectomy Pain." In recent years there have been important improvements in breast cancer surgery and complete mastectomies are done less often. It is now recognised that ongoing pain can occur even when a mastectomy has not been performed, hence the change in name for the condition to "Post Breast Therapy Pain" (PBTP).

Most PBTP is due to direct nerve damage from surgery and is not usually a sign of recurrent or ongoing cancer. Nerve damage is less often caused by the cancer itself or radiation treatments. Women are often worried that persistent pain might mean that there is still some cancer left behind. Women with larger tumours tend to have more extensive surgery, which carries a higher risk of nerve damage (as well as risk of recurrence of cancer), but PBTP can occur in people who are cured of their cancer and who never have a recurrence.

Women experiencing PBTP often experience numb or tight sensations, along with local tenderness and sometimes shooting pains or tingling sensations. PBTP is usually felt in the armpit and the chest wall, sometimes extending into the breast or chest wall where the breast tissue was removed. Pain can sometimes radiate down the arm or around to the back or shoulder. These abnormal sensations result from the nerves in the area trying to repair themselves and in the process undergo electrical firing. When a nerve fires, signals are transmitted resulting in the person sensing pain as if there might be some injury happening, when there is none.

The actual numbers of women suffering from PBTP are hard to assess as surgical techniques have changed over time to reduce this complication. A 1996 survey1 reported PBTP occurring in 43% of 408 Scottish women who had had a mastectomy. In 2002, about 9 years after surgery, about half of the women followed were pain free, but half still had some pain, though the pain intensity and its impact on quality of life had improved over time.
A more recent American study2 comparing two kinds of surgery looked at 187 women who had their surgery 5 years previously. The study found that 40% of those who had axillary node dissection and 33% of those who had more limited surgery (sentinel node biopsy) had PBTP. The level of discomfort dropped quite markedly after 3 months, and less quickly thereafter. Reconstructive surgery did not have any association with pain after 5 years.

Treatment of PBTP is often very effective. In the immediate post-operative period and for a few weeks afterwards, standard pain killers such as acetaminophen (Tylenol®) and anti-inflammatories (Advil® or Motrin®) can be very helpful. It is however, not recommended to use anti-inflammatory medications long-term. If pain persists or is very bothersome, other pain medications may be appropriate, Check with your doctor as to which may be best for you.

PBTP can be made worse by activities involving stretch of that area, but it is important to keep the shoulder joint moving so as not to develop a "frozen" shoulder, which can occur if a woman holds her arm too still after surgery. A physiotherapist may be helpful in suggesting a safe and effective exercise plan.

Wearing close-fitting clothing can sometimes be helpful if the skin is hypersensitive. Alternatively some prefer loose-fitting clothing if the area feels very tight. While there are no non-drug treatments which have been shown to speed recovery of PBTP, some therapies such as massage and acupuncture can be helpful to some women. Also, ensuring adequate sleep and avoiding stress are sound recommendations for any type of chronic pain.

In summary, a woman having breast surgery is at risk of from suffering from post-breast therapy pain, with the more extensive operations carrying the highest risk. In the majority of patients, pain will resolve within the first 3 months, and in the rest the severity of the pain usually improves over the next few years. A few patients however will still have some residual discomfort many years after the surgery.

1 Long-term follow-up of breast cancer survivors with post-mastectomy pain syndrome. British Journal of Cancer. 92(2):225-30, 2005.

2 Eighteen sensations after breast cancer surgery: a 5-year comparison of sentinel lymph node biopsy and axillary node dissection. Annals of Surgical Oncology. 14(5):1653-1661, 2007.

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