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Hello Heather,
Thank you so much for raising such an important topic. I have met many women who are suffering from Post Mastectomy Pain Syndrome (PMPS).
PMPS is a type of neuropathic pain, a complex chronic pain state that is typically caused by direct nerve injury during the breast cancer operation. The pain is typically localized to the anterior chest wall, axilla, and/or upper arm and the classic features of such pain are burning, tingling, shooting, stinging, or stabbing pains.
The overall incidence of nerve injury following a breast cancer operation ranges from 20 to 72 percent- unfortunately we don’t have the exact statistics partly explained by discrepancies in terms of definitions of PMPS. Risk factors include younger age, higher BMI, the type of operation and other post-operative complications (hematoma, infection, lymphedema) and psychological factors (depression, anxiety). As you mentioned, pain can be severe enough to cause long-term disabilities and impact quality of life. It can interfere with sleep and performance of daily activities including use of the affected arm, leading to Frozen shoulder). Unfortunately, the pain can also seriously affect the patient's mood, everyday activities, and social function.
I agree with you, the development of PMPS is complex and the treatment options are limited. So, the focus should on perioperative measures that can mitigate the modifiable risk factors for PMPS and thereby prevent patients from developing PMPS in the first place. This includes preventive analgesia, regional nerve blocks, preservation of axillary nerves when performing an axillary lymph node dissection (ALND) as well as being proactive in addressing psychological issues. You are totally right, counselling patients about potential side effects of surgery is crucial and women should receive the right support pre/post operation.
In terms of treatment, pharmacologic therapy remains the initial treatment for PMPS. Although patients with neuopathic pain may respond poorly to commonly used analgesic like NSAID and opioids, using antiepileptic medications (gabapentin) SNRI (venlafaxine, duloxetine) can provide pain relief). Surgical intervention includes autologous fat grafting, nerve blocks. Physiotherapy also can help with restoring joint mobility, reducing pain and addressing tight muscles with manual stretching and transverse strain, and strengthening shoulder. A recent systematic review showed that physiotherapy was useful for the treatment of breast cancer pain(1).
Complementary and alternative medicine CAM such as guided imagery, acupuncture, and biofeedback, has also been used in managing chronic neuropathic pain. Approximately 25 to 60 percent of breast cancer patients have used at least one form of CAM to treat cancer pain and the side effects of chemotherapy and radiation and to improve quality of life. One study showed that Acupuncture is an effective treatment strategy to manage some of the symptoms associated with breast cancer surgery and is a safe alternative with minimal complications or side effects (2). I personally have met a few women who had some benefits from Acupuncture.
Thanks once again for your question. I knew that I might not answer all your questions here but I agree with you that more attention is needed on this topic. It’s complex and research still ongoing to look for new surgical modalities to manage this condition. I am currently looking forward to invite an expert to our monthly zoom meeting to speak about this topic.
Take care
Muna
De Groef A, Van Kampen M, Dieltjens E, et al. Effectiveness of postoperative physical therapy for upper-limb impairments after breast cancer treatment: a systematic review. Arch Phys Med Rehabil 2015; 96:1140.
Dos Santos S, Hill N, Morgan A. Acupuncture for treating common side effects associated with breast cancer treatment: a systematic review. Medical Acupuncture 2010; 22:81.