Neuropathic pain associated with non-surgical treatment of breast cancer

Management of treatment-related symptoms in patients with breast cancer

Although the benefits of current treatment strategies are well established, many cancer survivors are at risk for developing physiologic and psychological late effects of cancer treatment that might lead to premature mortality and morbidity and compromise their quality of life. Psychological symptoms include anxiety, depression, fatigue, difficulty sleeping, and loss of self-esteem. Physiologic symptoms include pain, numbness, cognitive impairment, weight gain, loss of sexual interest, spontaneous menopause, and peripheral neuropathy. Both length and quality of survival are important end points. The goal of this review is to summarize the psychological and physiologic symptoms related to breast cancer treatment; the prevalence, contributing therapies, and inter-relatedness of these symptoms; current interventions to prevent, ameliorate, or treat these symptoms; and effectiveness and safety of these interventions. The results of this review will identify the gaps in knowledge and assist in the design of assessments and approaches to improve mortality and quality of life and provide the foundation for the development of evidence-based guidelines to standardize palliative care in cancer survivors.

Neuropathic pain in breast cancer survivors: using the ID pain as a screening tool

Neuropathic pain (NP) is a debilitating symptom experienced by a number of patients with cancer. We evaluated the validity of ID Pain as a screening tool for NP in breast cancer survivors using the Self-Report Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) and a reported diagnosis of NP as criterion measures. Two hundred forty breast cancer survivors with a mean age of 58 years (standard deviation=16) participated in this survey. Forty-five percent of the sample reported having pain in the past week. Of those reporting pain, 33% reported that they had been diagnosed by their health care provider with NP, 39% had a positive ID Pain (> or = 2) score, and 19% had a positive S-LANSS score. The most commonly endorsed ID Pain item was "hot/burning" (n=48) followed by feeling "numb" (n=47) and "pins and needles" (n=45). Total ID Pain score was significantly associated with a clinical diagnosis of NP (r=0.41; P<0.001) and the S-LANSS total score (r=0.54; P<0.001). Receiver operating curve analysis demonstrated that ID Pain has a predictive validity of 0.72 and 0.70 for diagnosis of NP as made by clinicians and the S-LANSS, respectively. We also found that an ID Pain score greater than or equal to 2 corresponded with the likelihood of NP in this sample, consistent with the original ID Pain development study. This study provides evidence for ID Pain as a valid screening measure for NP in breast cancer survivors.

Chronic pain and other sequelae in long-term breast cancer survivors: nationwide survey in Denmark

OBJECTIVES

To investigate self-reported chronic pain and other sequelae in a nationally representative sample of long-term breast cancer survivors (BCS).

DESIGN

Age-stratified random sample of 2,000 female BCS 5 years after primary surgery without recurrence drawn from the Danish Breast Cancer Cooperative Group register, which is representative regarding long-term BCS in Denmark.

ASSESSMENT

Self-administered questionnaire including questions on sociodemography, chronic pain (6 months), health-related quality of life (HRQOL) and other sequelae related to breast cancer. Associations with treatment were investigated. Report of chronic pain was compared to normative data.

RESULTS

The response rate was 79%. Chronic pain prevalence of 42% was significantly higher in BCS compared to general population women (SRR: 1.32; 95% CI: 1.23-1.42). Sequelae related to breast cancer were paraesthesia 47%, chronic pain 29%, arm/shoulder swelling 25%, phantom sensations 19%, and allodynia 15%. Chronic pain related to breast cancer was significantly associated with poorer HRQOL and higher medicine consumption, and, in multiple logistic regression analysis, with age (<70 years), short education, being single (divorced, widowed, separated), radiotherapy, and time since operation <10 years. Radiotherapy and younger age were significantly associated with most sequelae.

CONCLUSION

Chronic pain was more prevalent in BCS compared to the general population. Significant predictors for sequelae related to breast cancer were radiotherapy and younger age. Future research should therefore prioritize sequelae prevention.

Predictors and consequences of multiple persistent postmastectomy pains

Persistent postmastectomy pain is quite common and has been classified into several distinct types. Few studies, however, have investigated either the predictors or functional impact of multiple types of post mastectomy pain. In this investigation, 278 women, who were, on average, several years post mastectomy, completed questionnaires assessing pain, pain-related physical function, and psychosocial distress. We assessed three distinct categories of postmastectomy pain: phantom breast pain, scar pain, and other mastectomy-related pain. Each of the three types of postmastectomy pain was strongly related to one another (i.e., women reporting one type of pain were more likely to report the other types as well). In general, the more types of postmastectomy pain a woman reported, the greater the degree of disability and distress. Collectively, the presence of "other mastectomy-related pain" was a stronger unique predictor of disability and distress than were the other two categories of pain. Interestingly, demographic and surgical factors, including time since surgery, were not consistent predictors of pain or function. The findings suggest that the assessment of postmastectomy pain should include formal evaluation of multiple types of pain, with additional attention paid to the category of "other mastectomy-related pains," and that the number of types of pain reported by women after surgery may be important in predicting functional outcomes.

Management strategies for pain in breast carcinoma patients: current opinions and future perspectives

Breast cancer is the most frequently encountered carcinoma in women worldwide. Pain is the most distressing symptom in patients with breast carcinoma and can occur at all stages of the disease due to the cancer per se as well as due to various diagnostic and treatment modalities. A proper pain assessment helps in identification of pain syndromes and guides in formulating analgesic strategies. Primary therapies of breast carcinoma like surgery, chemotherapy, and radiotherapy for bony metastases can cause substantial pain relief. However, multimodal analgesic approaches incorporating pharmacological, interventional as well as non-conventional techniques should be employed prior to, in conjunction with, and after primary therapies of breast cancer. The prevalence of chronic neuropathic pain following breast cancer surgery may exceed 50% by current estimates, and with the increase in life expectancy of these patients, providing adequate pain relief is of paramount importance to improve their quality of life. In this review, we discuss prevailing methods of evaluation and management of pain in patients of breast carcinoma and the new techniques that may become the mainstay of pain management protocols in future.

Changes in shoulder muscle size and activity following treatment for breast cancer

BACKGROUND

Morbidity of the shoulder after breast cancer is a well-known phenomenon. MRI studies have shown muscle morbidity in cervical cancer and prostate cancer. In breast cancer clinical observations and patient reports include muscle morbidity in a number of muscles acting at the shoulder. Several of these muscles lie in the field of surgery and radiotherapy. Timed interaction between muscles that stabilise the shoulder and those acting as prime movers is essential to achieve a smooth scapulohumeral rthythm during functional elevation of the arm.

METHOD

CROSS-SECTIONAL STUDY: Seventy-four women treated for unilateral carcinoma of the breast were included in the study. All patients filled out the Shoulder Pain and Disability Index (SPADI). EMG activity of four muscles was recorded during scaption on the affected and unaffected side. Muscle cross sectional area and signal intensity was determined from MRI scans. The association between EMG and covariates was determined using multiple linear regression techniques.

RESULTS

Three of the 4 muscles on the affected side demonstrated significantly less EMG activity, particularly when lowering the arm. Upper trapezius demonstrated the greatest loss in activity. Decreased activity in both upper trapezius and rhomboid were significantly associated with an increase in SPADI score and increased time since surgery. Pectoralis major and minor were significantly smaller on the affected side.

CONCLUSION

Muscles affected in the long term are the muscles associated with pain and disability yet are not in the direct field of surgery or radiotherapy. Primary muscle shortening and secondary loss of muscle activity may be producing a movement disorder similar to the 'Dropped Shoulder Syndrome'. Exercise programmes should aim not only for range of movement but also for posture correction and education of potential long-term effects.