Long-term follow-up of breast cancer survivors with post-mastectomy pain syndrome

Prevention of persistent pain with lidocaine infusions in breast cancer surgery (PLAN): study protocol for a multicenter randomized controlled trial

BACKGROUND

Persistent pain is a common yet debilitating complication after breast cancer surgery. Given the pervasive effects of this pain disorder on the patient and healthcare system, post-mastectomy pain syndrome (PMPS) is becoming a larger population health problem, especially as the prognosis and survivorship of breast cancer increases. Interventions that prevent persistent pain after breast surgery are needed to improve the quality of life of breast cancer survivors. An intraoperative intravenous lidocaine infusion has emerged as a potential intervention to decrease the incidence of PMPS. We aim to determine the definitive effects of this intervention in patients undergoing breast cancer surgery.

METHODS

PLAN will be a multicenter, parallel-group, blinded, 1:1 randomized, placebo-controlled trial of 1,602 patients undergoing breast cancer surgery. Adult patients scheduled for a lumpectomy or mastectomy will be randomized to receive an intravenous 2% lidocaine bolus of 1.5 mg/kg with induction of anesthesia, followed by a 2.0 mg/kg/h infusion until the end of surgery, or placebo solution (normal saline) at the same volume. The primary outcome will be the incidence of persistent pain at 3 months. Secondary outcomes include the incidence of pain and opioid consumption at 1 h, 1-3 days, and 12 months after surgery, as well as emotional, physical, and functional parameters, and cost-effectiveness.

DISCUSSION

This trial aims to provide definitive evidence on an intervention that could potentially prevent persistent pain after breast cancer surgery. If this trial is successful, lidocaine infusion would be integrated as standard of care in breast cancer management. This inexpensive, widely available, and easily administered intervention has the potential to reduce pain and suffering in an already afflicted patient population, decrease the substantial costs of chronic pain management, potentially decrease opioid use, and improve the quality of life in patients.

TRIAL REGISTRATION

This trial has been registered on clinicaltrials.gov (NCT04874038, Dr. James Khan. Date of registration: May 5, 2021).

Metabolic Dysregulation and Its Role in Postoperative Pain among Knee Osteoarthritis Patients

Knee osteoarthritis (KOA) is characterized by low-grade inflammation, loss of articular cartilage, subchondral bone remodeling, synovitis, osteophyte formation, and pain. Strong, continuous pain may indicate the need for joint replacement in patients with end-stage OA, although postoperative pain (POP) of at least a two-month duration persists in 10-40% of patients with OA.

STUDY PURPOSE

The inflammation observed in joint tissues is linked to pain caused by the production of proinflammatory cytokines. Since the biosynthesis of cytokines requires energy, their production is supported by extensive metabolic conversions of carbohydrates and fatty acids, which could lead to a disruption in cellular homeostasis. Therefore, this study aimed to investigate the association between POP development and disturbances in energy metabolic conversions, focusing on carbohydrate and fatty acid metabolism.

METHODS

Peripheral blood samples were collected from 26 healthy subjects and 50 patients with end-stage OA before joint replacement surgery. All implants were validated by orthopedic surgeons, and patients with OA demonstrated no inherent abnormalities to cause pain from other reasons than OA disease, such as malalignment, aseptic loosening, or excessive bleeding. Pain levels were assessed before surgery using the visual analogue scale (VAS) and neuropathic pain questionnaires, DN4 and PainDETECT. Functional activity was evaluated using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Three and six months after surgery, pain indices according to a VAS of 30 mm or higher were considered. Total RNA isolated from whole blood was analyzed using quantitative real-time RT-PCR (qRT-PCR) for the expression of genes related to carbohydrate and fatty acid metabolism. Protein levels of the examined genes were measured using an ELISA in the peripheral blood mononuclear cells (PBMCs). We used qRT-PCR because it is the most sensitive and reliable method for gene expression analysis, while an ELISA was used to confirm our qRT-PCR results.

KEY FINDINGS

Among the study cohort, 17 patients who reported POP demonstrated significantly higher (p < 0.05) expressions of the genes PKM2, LDH, SDH, UCP2, CPT1A, and ACLY compared to pain-free patients with KOA. Receiver-operating characteristic (ROC) curve analyses confirmed the association between these gene expressions and pain development post-arthroplasty. A principle component analysis identified the prognostic values of ACLY, CPT1A, AMPK, SDHB, Caspase 3, and IL-1β gene expressions for POP development in the examined subjects.

CONCLUSION

These findings suggest that the disturbances in energy metabolism, as observed in the PBMCs of patients with end-stage KOA before arthroplasty, may contribute to POP development. An understanding of these metabolic processes could provide insights into the pathogenesis of KOA. Additionally, our findings can be used in a clinical setting to predict POP development in end-stage patients with KOA before arthroplasty.

Incidence and characteristics of chronic postsurgical pain at 6 months after total mastectomy under pectoserratus and interpectoral plane block combined with general anesthesia: a prospective cohort study

INTRODUCTION

Chronic postsurgical pain (CPSP) occurs in 20%-30% of patients who undergo total mastectomy (TM) performed under general anesthesia alone and significantly affects the quality of life. Pectoserratus and interpectoral plane block have been reportedly combined with general anesthesia to control immediate postoperative pain after TM. Our prospective cohort study aimed to evaluate the incidence of CPSP after TM when pectoserratus and interpectoral plane block were combined with general anesthesia.

METHODS

We recruited adult women scheduled to undergo TM for breast cancer. Patients planned for TM with flap surgery, those who underwent breast surgery in the past 5 years, or those presenting with residual chronic pain after prior breast surgery were excluded. After general anesthesia induction, an anesthesiologist performed pectoserratus and interpectoral plane block with a ropivacaine (3.75 mg/mL) and clonidine (3.75 µg/mL) in 40 mL of 0.9% sodium chloride. The primary endpoint was the occurrence of CPSP-defined as pain with a Numeric Rating Scale Score of ≥3, either at the breast surgical site and/or at axilla, without other identifiable causes-evaluated during a pain medicine consultation at 6 months post TM.

RESULTS

Overall, 43/164 study participants had CPSP (26.2%; 95% CI: 19.7 to 33.6); of these, 23 had neuropathic type of pain (53.5%), 19 had nociceptive (44.2%), and 1 had mixed (2.3%) type of pain.

CONCLUSION

Although postoperative analgesia has significantly improved in the last decade, there is still need for improvement to reduce CPSP after oncologic breast surgery.

TRIAL REGISTRATION NUMBER

NCT03023007.

Combined treatment with basalt stone and placenta extract to improve the chronic pain and scar after breast cancer surgery: a case report

BACKGROUND

The changes in body image caused by breast deformities and postoperative pain have a detrimental influence on the physical and mental health of patients with breast cancer. The postoperative quality of life (QOL) of these patients reduces significantly owing to the changes in the breast, an organ unique to women, that occur following breast cancer surgery.

CASE PRESENTATION

This case report presents the case of a Asian woman in her early 40 s with postoperative hypertrophic scarring and contraction of the scar following mastectomy; the patient presented with decreased range of motion of the upper arm, hyperpigmentation from radiation burns, changes in breast shape, and chronic pain. The patient received a combination therapy comprising Basalt Stone Treatment and the application of horse placenta extract. As a result of a total of eight sessions conducted once every two weeks, the patient's pain and scar improved. No adverse events were observed after the therapy.

CONCLUSION

Combination therapy with Basalt Stone Treatment and horse placenta extract improved the chronic pain and scar after breast cancer surgery.

Postmastectomy Pain Syndrome: A Narrative Review

Postmastectomy pain syndrome is a very common disorder in breast cancer survivors. The impact on the quality of patients' lives is significantly adverse. The precise pathophysiology has not been determined as yet though various risk factors have been identified that make the patient vulnerable. Required preoperative work includes the identification and possible elimination of risk factors. Treatment is multidisciplinary involving surgical and non-surgical modalities. There is a great scope of research in this field.

Development and validation of a symptom illustration scale from the patient-reported outcome common terminology criteria for adverse events for patients with breast cancer

PURPOSE

Emojis are commonly used for daily communication and may be useful in assessing patient-reported outcomes (PROs) in breast cancer. The purpose of this study is to develop and validate a Symptom Illustration Scale (SIS) as a new PRO measurement.

METHODS

Eighteen original SIS items were developed from the PRO-CTCAE. In cohort one, the SIS validity and reliability were examined in patients with breast cancer, using a semi-structured five-question survey to investigate content validity. PROs with PRO-CTCAE and SIS were examined twice to determine criteria validity and test-retest reliability. In cohort two, the responsiveness of the scales were examined in patients treated with anthracycline, docetaxel, paclitaxel, and endocrine therapy. PROs with PRO-CTCAE and SIS were investigated two or three times, depending on the therapy.

RESULTS

Patients were enrolled from August 2019 to October 2020. In cohort one (n = 70), most patients had no difficulties with the SIS, but 16 patients indicated that it was difficult to understand severities in the SIS. For criterion validity, Spearman rank correlation coefficients (rs) between PRO-CTCAE and SIS items were ≥ 0.41, except for "Decreased appetite." For test-retest reliability, κ coefficients of the SIS were ≥ 0.41 for 16/18 items (88.9%). Response time was significantly shorter for the SIS than for PRO-CTCAE (p < 0.001). In cohort two (n = 106), score changes between PRO-CTCAE and SIS for relevant symptoms all had correlations with rs ≥ 0.41.

CONCLUSION

An original SIS from the PRO-CTCAE for patients with breast cancer were verified the validity, reliability, and responsiveness. Further studies to improve and validate the SIS are needed.

Successful neurolytic thoracic sympathetic ganglion block using C-arm fluoroscopic cone-beam computed tomography in patients with postmastectomy pain syndrome: a report of 3 cases

BACKGROUND

Postmastectomy pain syndrome involves persistent neuropathic and sympathetically maintained neuropathic pain that can be improved using a thoracic sympathetic ganglion block. However, conventional fluoroscopic procedures pose technical difficulties and are associated with potential severe complications. We report the use of C-arm fluoroscopic cone-beam computed tomography to enhance procedural success and treatment safety.

CASE PRESENTATION

Three women diagnosed with postmastectomy pain syndrome and experiencing persistent pain underwent C-arm fluoroscopic cone-beam computed tomography-assisted ethanol neurolytic thoracic sympathetic ganglion block. Pain severity decreased substantially after the procedure. The therapeutic effects were sustained for 12 months in cases 1 and 2 and for 5 months in case 3. All patients experienced a remarkable decrease in allodynia and hyperalgesia intensities.

CONCLUSION

C-arm fluoroscopic cone-beam computed tomography-assisted neurolytic thoracic sympathetic ganglion block offers a valuable alternative for managing otherwise intractable postmastectomy pain syndrome before considering more invasive techniques.

Predictors of postoperative pain six months after breast surgery

Breast cancer, with a high prevalence and survival rate, leads to long-term complications. A major sequel is acute or chronic postoperative pain, and we investigated the possible relationship with clinical and psychological variables. Patients undergoing breast surgery filled out the loneliness (ULS-8) and depression (HADS) questionnaires. Patients rated their pain intensity with the Numerical Rating Scale (0-10, NRS) two days, seven days, and six months after surgery. Of 124 patients, the mean age was 45.86 years old, and the pain scores on the second and seventh postoperative days were 5.33 and 3.57, respectively. Sixth-month pain was significantly correlated with the acute scores with a mean of 3.27; and in the multivariate analysis, it was significantly associated with preoperative pain (p-value = 0.007), self-reported loneliness (p-value = 0.010), and adjuvant radiotherapy (p-value = 0.004). In conclusion, loneliness may be a risk factor for postoperative pain in breast surgery.

Evaluating the effect of upper-body morbidity on quality of life following primary breast cancer treatment: a systematic review and meta-analysis

PURPOSE

Improvements in breast cancer management continue to increase survival and life expectancy after treatment. Yet the adverse effects of treatment may persist long term, threatening physical, psychological, and social wellbeing, leading to impaired quality of life (QOL). Upper-body morbidity (UBM) such as pain, lymphoedema, restricted shoulder range of motion (ROM), and impaired function are widely reported after breast cancer treatment, but evidence demonstrating its impact on QOL is inconsistent. Therefore, the aim of the study was to conduct a systematic review and meta-analysis evaluating the effect of UBM on QOL following primary breast cancer treatment.

METHODS

The study was prospectively registered on PROSPERO (CRD42020203445). CINAHL, Embase, Emcare, PsycInfo, PubMed/Medline, and SPORTDiscus databases were searched for studies reporting QOL in individuals with and without UBM following primary breast cancer treatment. Primary analysis determined the standardised mean difference (SMD) in physical, psychological, and social wellbeing scores between UBM + /UBM - groups. Secondary analyses identified differences in QOL scores between groups, according to questionnaire.

RESULTS

Fifty-eight studies were included, with 39 conducive to meta-analysis. Types of UBM included pain, lymphoedema, restricted shoulder ROM, impaired upper-body function, and upper-body symptoms. UBM + groups reported poorer physical (SMD =  - 0.99; 95%CI =  - 1.26, - 0.71; p < 0.00001), psychological (SMD =  - 0.43; 95%CI =  - 0.60, - 0.27; p < 0.00001), and social wellbeing (SMD =  - 0.62; 95%CI =  - 0.83, - 0.40; p < 0.00001) than UBM - groups. Secondary analyses according to questionnaire showed that UBM + groups rated their QOL poorer or at equal to, UBM - groups across all domains.

CONCLUSIONS

Findings demonstrate the significant, negative impact of UBM on QOL, pervading physical, psychological, and social domains.

IMPLICATIONS FOR CANCER SURVIVORS

Efforts to assess and minimise the multidimensional impact of UBM are warranted to mitigate impaired QOL after breast cancer.

Post Treatment Mastalgia is a Common Complaint but not an Indication of Recurrence or Second Primary Breast Cancer

BACKGROUND

Post-treatment mastalgia is a common complaint in up to 68% of patients after treatment. This symptom is worrisome to patients as many believe it is a sign of recurrence. The current study was performed to evaluate if post-treatment mastalgia is associated with a second breast cancer diagnosis.

MATERIALS AND METHODS

Patients included were seen from January 1, 2000 to December 31, 2020. All patients who were treated for breast cancer and then presented with breast pain during follow up were considered to have post-treatment mastalgia. All patients who were diagnosed with a second breast cancer but did not experience post-treatment mastalagia were also evaluated.

RESULTS

1799 patients had a mean age 52.9 years. 36% of patients experienced post-treatment mastalgia. Of patients who complained of post-treatment mastalgia, 19 were diagnosed with a chest wall recurrence (CW), ipsilateral breast tumor recurrence (IBTR), or contralateral breast cancer (CBC). 17 of the 19 patients had breast pain after the second diagnosis and treatment were completed. The average duration between their second diagnosis and initial complaint of breast pain was 6.2 years. The two patients who complained of breast pain prior to their second diagnosis did not have mastalgia at the time of their second diagnosis. Local recurrence or contralateral breast cancer were more common in patients without post treatment mastalgia (10.1% vs 0.3%, p < 0.0001) during follow up.

CONCLUSION

Post treatment mastalgia is not associated with recurrence. Interval or repeat imaging does not appear necessary and instead patient education and reassurance are important in its management.

Chronic pain and its correlates among long-term breast cancer survivors

PURPOSE

Chronic pain is a common symptom affecting quality of life for breast cancer survivors. However, its prevalence and correlate factors in long-term breast cancer survivors, particularly Asian women, are understudied. The reported study is to address these knowledge gaps.

METHODS

We evaluated pain severity and frequency, and their associations with clinical features and lifestyle factors among 3640 5-year breast cancer survivors who participated in the Shanghai Breast Cancer Survival Study. Demographic, clinical, and lifestyle information was collected at study enrollment, which occurred 6 months post-diagnosis, and pain was assessed at the 5-year post-diagnosis follow-up survey.

RESULTS

In total, 42% of participants reported experiencing pain. Pain is more prevalent among survivors with low educational attainment or low income. Multivariable polytomous regression analyses showed that pain was positively associated with metastasis or recurrence (moderate pain OR: 2.17, 95% CI: 1.45, 3.26, frequent pain OR: 1.92, 95% CI: 1.37, 2.70), triple negative status (infrequent pain OR: 1.36, 95% CI: 1.04, 1.78), obesity (frequent pain OR: 1.80, 95% CI: 1.41, 2.31), and multiple comorbidities. Exercise (OR: 0.65, 95%: 0.49, 0.88), chemotherapy (OR: 0.59, 95% CI: 0.41, 0.849), and HER2-positive and ER/PR-negative status (OR: 0.64, 95% CI: 0.43, 0.97) were inversely associated with moderate pain.

CONCLUSIONS

Chronic pain is highly prevalent among long-term breast cancer survivors in China and was associated with obesity, physical inactivity, and several clinical factors.

IMPLICATIONS FOR CANCER SURVIVORS

This study highlights the importance of promoting weight control and exercise to alleviate chronic pain.

Efficacy and safety of erector spinae plane block for postoperative analgesia in breast cancer surgery-A systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

We aim to evaluate the analgesic efficacy and safety of erector spinae plane block (ESPB) for postoperative analgesia in breast cancer surgeries.

METHODS

PubMed, Web of Science, CBM, Embase, Cochrane, Wanfang, VIPP, and CNKI were searched to identify published eligible randomized controlled trials. The primary results were the postoperative 24 h morphine consumption and pain scores, while the secondary outcomes included pain scores at other times, press times of patient-controlled intravenous analgesia (PCIA), times to request for first rescue analgesia, the incidence of request for rescue analgesia, opioid-related complications, nerve blocks related complications and patient satisfaction.

RESULTS

We included 20 studies meeting the inclusion criteria, which involved 1293 participants. The morphine consumption and the pain scores during 24 h postoperatively were significantly decreased in the ESPB group versus the control group (p < 0.00001). Furthermore, ESPB also reduced pain scores at other time points, press times of PCIA, and times to first rescue analgesia requirement. Meanwhile, there was a lower incidence of postoperative nausea and vomiting, and skin pruritus in the ESPB group than in the control group.

CONCLUSIONS

Compared to general anesthesia alone, ESPB combined with general anesthesia can effectively reduce the postoperative pain intensity within 48 h and opioid consumption within 24 h after breast cancer surgery, and reduce the incidence of opioid and nerve blocks related complications.

A comparative study between ultrasound-guided thoracic paravertebral block, pectoral nerves block, and erector spinae block for pain management in cancer breast surgeries. A randomized controlled study

OBJECTIVES

Achieving adequate perioperative analgesia can be challenging in patients undergoing breast surgeries due to the complex nerve supply of the breast and axilla. The study aims to investigate the efficacy of ESPB in comparison to conventional regional anesthesia techniques (TPVB and PECS).

METHODS

Eighty female patients who were scheduled for elective MRM, with ASA score I-II, and aged between 18 and 60 years, were included in the study. Patients were randomized into four groups, the TPVB, PECS, ESPB, and the control group. All patients in either block groups received 25 ml bupivacaine 0.25% with ultrasound guidance. The control group received only opioids for perioperative pain management. The patients were observed for 48 h after surgery for the duration of analgesia (primary outcome).

RESULTS

ESPB has a shorter duration of analgesia than PECS block with no significant statistical difference compared with group TPVB. Morphine consumption is increased in ESPB compared to the PECS group, with an insignificant difference compared to group TPVB. There was an insignificant difference between the groups concerning hemodynamics and complications, with one pneumothorax case reported in the TPVB group.

CONCLUSION

PECS and ESPB represent a good alternative to TPVB for post-mastectomy analgesia with a superior analgesic effect of PECS block regarding opioid consumption, duration of the analgesia, and VAS score.

Estimation of Neural Tissue Mobility in Breast Cancer Survivors with Lymphedema

BACKGROUND

Lymphedema in breast cancer survivors is a very common condition which progressively may lead to entrapment  neuropathy. In lymphedema there is accumulation of fluid due to removal of lymph nodes which causes stretching of nerve fibres within the skin, compression on top of the nerve bundle leading to nerve entrapment. This will increase the neural mechanosensitivity and functional impairment of shoulder as a protective neural response to movement or traction.

METHODS

This study was carried out by assessing the total 72 breast cancer survivor women, with lymphedema. Out of 72, 28 of women underwent lumpectomy, 12 underwent quadrantectomy and 32 underwent unilateral mastectomy.  These subjects were assessed for neural tissue mobility by taking pain assessment using visual analogue scale (VAS), range of motion (ROM) using goniometer, lymphedema measurement using an inch tape. The neural tissue mobility for  median nerve, ulnar nerve and radial nerve was measured using limb tension test.

RESULT

The result obtained from this study showed that neural tissue mobility was significantly impaired in breast cancer survivors with lymphedema. The result of the upper limb tension tests showed 32 women with mild lymphedema had median nerve affected on the involved side 54.1%, about  21 women had moderate lymphedema with 75% of women had median and 25% ulnar nerve affected with median nerve affected in majority of women. Only 19 women with severe lymphedema had all the three nerves affected.

CONCLUSION

This study of women who have undergone surgical intervention for breast cancer concludes that there was significant amount of neural tissue impairment noted to mechanical provocation test post operatively after 6 months of surgery. The study suggests that severity of lymphedema was directly related to the nerves affected due to neural tissue impairment.

Risk factors associated with chronic pain after mastectomy: a prospective study with a 5-year follow-up in Japan

BACKGROUND

Chronic pain is a major complication following breast surgery including breast reconstruction. We previously examined prospective patient-specific and medical/surgical factors that predict chronic pain a year after breast surgery in the Japanese population. Five-year survivorship is essential for breast cancer patients. This report is a 4-year follow-up study following the previous research.

METHODS

A follow-up observation study was performed 5 years after breast operations. The subjects were patients who underwent breast surgery, including tissue expander/implant (TE/implant), DIEP procedures and mastectomy only. Pain at 5 years was assessed using the Japanese Version of the Short-Form McGill Pain Questionnaire (SF-MPQ-JV). A multiple linear regression model was used to examine the relationships of clinical factors with chronic pain.

RESULTS

Questionnaires were completed by 132 subjects. No factor related to chronic pain was significantly related to the MPQ pain ratings. Among patient characteristics, a psychotic or neurological medical history was related to significantly lower visual analog scale (p = 0.02) and present pain index (p = 0.04) scores. A history of chemotherapy and/or hormone therapy was significantly associated with the frequency of use of pain medication postoperatively (p = 0.05) and effect on the social life of the patients (p = 0.02).

CONCLUSIONS

A psychotic or neurological history and a history of chemotherapy and/or hormone therapy were identified as risk factors for chronic pain after breast surgery, but the type of operation was not associated with chronic pain.

Efficacy of PECS block in addition to multimodal analgesia for postoperative pain management in patients undergoing outpatient elective breast surgery: A retrospective study

Background

Pectoralis nerve blocks (PECS) have been shown in numerous studies to be a safe and effective method to treat postoperative pain and reduce postoperative opioid consumption after breast surgery. However, there are few publications evaluating the PECS block effectiveness in conjunction with multimodal analgesia (MMA) in outpatient breast surgery. This retrospective study aims to evaluate the efficacy of PECS's blocks on perioperative pain management and opioid consumption.

Methods

We conducted a retrospective study to assess the efficacy of preoperative PECS block in addition to preoperative MMA (oral acetaminophen and/or gabapentin) in reducing opioid consumption in adult female subjects undergoing outpatient elective breast surgery between 2015 and 2020. A total of 228 subjects were included in the study and divided in two groups: PECS block group (received PECS block + MMA) and control Group (received only MMA). The primary outcome was to compare postoperative opioid consumption between both groups. The secondary outcome was intergroup comparisons of the following: postoperative nausea and vomiting (PONV), incidence of rescue antiemetic medication, PACU non-opioid analgesic medication required, length of PACU stay and the incidence of 30-day postoperative complications between both groups.

Results

Two hundred and twenty-eight subjects (n = 228) were included in the study. A total of 174 subjects were allocated in the control group and 54 subjects were allocated in the PECS block group. Breast reduction and mastectomy/lumpectomy surgeries were the most commonly performed procedures (48% and 28%, respectively). The total amount of perioperative (intraoperative and PACU) MME was 27 [19, 38] in the control group and 28.5 [22, 38] in the PECS groups (p = 0.21). PACU opioid consumption was 14.3 [7, 24.5] MME for the control group and 17 [8, 23] MME (p = 0.732) for the PECS group. Lastly, the mean overall incidence of postsurgical complications at 30 days was 3% (N = 5), being wound infection, the only complication observed in the PECS groups (N = 2), and hematoma (N = 2) and wound dehiscence (N = 1) in the control group.

Conclusion

PECS block combined with MMA may not reduce intraoperative and/or PACU opioid consumption in patients undergoing outpatient elective breast surgery.

Clinical and sociodemographic determinants of disease-specific health-related quality of life in long-term breast cancer survivors

PURPOSE

It is important to monitor disease-specific health-related quality of life (HRQoL) in breast cancer (BC) survivors to identify potential unmet supportive care needs. However, previous studies were characterized by small samples of mostly short-term survivors and were limited to certain age ranges, stages and/or treatments.

METHODS

We used data from 3045 long-term BC survivors (5-15 years post-diagnosis) recruited in a German multi-regional population-based study. We assessed disease-specific HRQoL with the EORTC QLQ-BR23, scoring from 0 to 100. Differences in functioning and symptoms according to age at survey, self-reported treatments, stage, and disease status (disease-free vs. active disease) were assessed with multiple regression. Active disease was defined as any self-report of recurrence, metastasis or second primary cancer after the index cancer.

RESULTS

Older BC survivors reported a higher body image and a better future perspective, but lower sexual functioning. Survivors aged 30-49 years who had breast-conserving therapy or mastectomy with breast reconstruction reported a better body image compared to those who had mastectomy only. We also found differences in symptoms according to treatments in some age groups. Stage at diagnosis was not associated with HRQoL overall and in most age subgroups. Disease-free BC survivors aged 30-79 years reported a better future perspective and less systemic therapy side effects than those with active disease.

CONCLUSION

Several treatment-associated symptoms and functioning detriments were found 5-15 years after diagnosis. The results emphasize the need of a comprehensive, individualized survivorship care, recognizing differential needs of long-term BC survivors according to age, treatment modalities, and disease status.

Pre- and post-operative psychological interventions to prevent pain and fatigue after breast cancer surgery (PREVENT): Protocol for a randomized controlled trial

Background

Breast cancer is the most common cancer type among women worldwide with over a million new cases each year. More than 40% of these women will struggle with chronic pain and fatigue after surgery, regardless of surgical procedure. These consequences are detrimental and result in distress and disability, including work disability. Few attempts have been made to prevent chronic pain and fatigue after surgery by applying a psychological approach, despite psychological risk factors being crucial in the development of both chronic pain and fatigue. In this study, we aim to develop and test an easily implementable strategy of preventing chronic pain and fatigue after breast cancer surgery. The intervention strategy involves a pre-operative hypnosis session and a web-based post-operative Acceptance and Commitment Therapy (ACT). The hypnosis has previously been found effective in alleviating acute post-operative pain and fatigue in breast cancer patients, while ACT is well suited to cancer populations as it offers a model of healthy adaptation to difficult circumstances. Together they form an intervention strategy with both a preventive and a rehabilitative focus.

Methods/Design

This randomized controlled trial aims to estimate the effects of the pre- and post- operative interventions compared to attentional control and treatment as usual (TAU) and will also include a qualitative process evaluation. Participants will be randomized to receive either a pre-operative brief hypnosis session and a post-operative web-based psychological intervention (iACT) or a pre-operative one-session mindfulness through an audio file and post-operative TAU. Self-reported questionnaire data and biomarker data will be assessed pre-surgery, post-surgery and 3 and 12 months after surgery. In addition, we will assess registry data on sick leave and prescriptions until 2-year follow-up. In the qualitative process evaluation, data will be collected from participants from both study arms (through interviews and a diary) and two different analyses performed (socio-narrative and Grounded Theory) with the objective to describe the development of chronic post-surgical pain and fatigue and the potential influence of the interventions on these processes. The study is set-up to demonstrate a minimum difference in pain of 1 point on NRS (0–10) and 3 points on FACIT-F (0–52) between the groups at 3-months follow-up by including 200 breast cancer patients in total.

Discussion

This trial will be the first study to estimate the effect of a combined pre-operative hypnosis with a post-operative iACT to prevent pain and fatigue after breast cancer surgery. The results from our study might i) help the large group of women affected by chronic pain and fatigue after breast cancer surgery, ii) shed light on the mechanisms involved in chronic pain and fatigue development, and iii) serve as a model for other surgical procedures.

Trial registration

Clinicaltrials.gov, registration number NCT04518085. Registered on January 29th, 2020. https://clinicaltrials.gov/ct2/show/NCT04518085.

Effects of delayed breast reconstruction on the thoracolumbar vertebrae in patients undergoing unilateral mastectomy: A retrospective cohort study

BACKGROUND

Post-mastectomy changes vertebral column alignment. There is limited data assessing spine curvature after breast reconstruction. In this study, the effects of delayed breast reconstruction on the Cobb angle and quality of life indicator (Oswestry disability index [ODI]) were evaluated in patients undergoing unilateral mastectomy.

METHODS

This study was performed as a retrospective review of 40 patients who had delayed reconstruction for breast cancer at a single center between 2015 and 2018. Patients completed a standardized questionnaire, the ODI, at the beginning and 12 months after the operation. The Cobb angles of the vertebral columns and spinal curve directions were determined using posteroanterior chest radiographs obtained pre- and postoperatively.

RESULTS

Mean age and body mass index (BMI) were 49.9 ± 9 years and 30.1 kg/m², respectively. The Cobb angles were found to differ before and after the reconstruction; the difference was statistically significant, and the average change in Cobb angle was 4.3° (p = 0.03). The Cobb angles were also found to be significantly different between patients with implants and those who underwent autologous tissue reconstruction (p = 0.026). Although delayed reconstruction performed with autologous tissue or implant improves post-mastectomy scoliosis, autologous tissue reconstruction yields better outcomes. The mean preoperative ODI score was 21.6%, and 8.8% patients presented no back pain. The mean score was 3.2% at 12 months postoperation. These results are statistically significant (p<0.001).

CONCLUSIONS

Breast reconstruction positively affects vertebral alignment and leads to better posture, physical function and decreased back pain in breast cancer survivors, significantly improving their quality of life.

Adhesion Molecules ICAM-1 and PECAM-1 as Potential Biomarkers of Central Nervous System Damage in Women Breast Cancer Survivors

Breast cancer (BC) is the most common tumor in women worldwide with high mortality rates. Surgical methods followed by radio–chemotherapy are used to treat these tumors. Such treatment can lead to various side effects, including neurological complications. The development of a reliable biomarker to predict the onset of CNS complications could improve clinical outcomes. In the current study, ICAM-1 and PECAM-1 serum levels were measured as potential biomarkers in 45 female patients in a long-term follow-up period after breast cancer treatment, and compared to 25 age-matched female healthy volunteers. Serum levels of both biomarkers, ICAM-1 and PECAM-1 were significantly higher in patients after breast cancer treatment and could be associated with cognitive dysfunction, depression, and vestibulocerebellar ataxia. In conclusion, our results provide a first hint that elevated serum levels of ICAM-1 and PECAM-1 could serve as early predictive biomarkers in breast cancer survivors that might help to improve the management of these patients.

Comparison of Postoperative Pain in 70 Women with Breast Cancer Following General Anesthesia for Mastectomy with and without Serratus Anterior Plane Nerve Block

Background

This study was conducted at a single center and aimed to compare postoperative pain in 70 women with breast cancer following general anesthesia for mastectomy with and without serratus anterior plane (SAP) block.

Material/Methods

A total of 70 breast cancer patients who met the criteria were randomly divided into the general anesthesia combined with SAP block group (group S) and the general anesthesia only group (group G). Perioperative anesthetic drug dosage, the visual analog scale (VAS) score at different time points, and the patient’s satisfaction with analgesia 24 h after surgery, and incidence of postmastectomy pain syndrome (PMPS) were statistically analyzed in the 2 groups.

Results

Compared with group G, group S had lower intraoperative remifentanil dosages (P=0.003), a lower total amount of sufentanil via analgesia pump during the 24-h postoperative period (P<0.001), and lower VAS scores at 2 h, 4 h, and 8 h after surgery, and the differences were significant (P<0.05). Compared with group G, group S had a shorter first flatus time, got out of bed sooner, had a lower incidence of nausea and vomiting (P<0.05), and lower incidence of PMPS at 3 and 6 months after the operation (P<0.05).

Conclusions

At a single center, preoperative SAP block can significantly reduce postoperative pain after modified radical mastectomy for breast cancer.

Exercise to prevent shoulder problems after breast cancer surgery: the PROSPER RCT

BACKGROUND

Upper limb problems are common after breast cancer treatment.

OBJECTIVES

To investigate the clinical effectiveness and cost-effectiveness of a structured exercise programme compared with usual care on upper limb function, health-related outcomes and costs in women undergoing breast cancer surgery.

DESIGN

This was a two-arm, pragmatic, randomised controlled trial with embedded qualitative research, process evaluation and parallel economic analysis; the unit of randomisation was the individual (allocated ratio 1 : 1).

SETTING

Breast cancer centres, secondary care.

PARTICIPANTS

Women aged ≥ 18 years who had been diagnosed with breast cancer and were at higher risk of developing shoulder problems. Women were screened to identify their risk status.

INTERVENTIONS

All participants received usual-care information leaflets. Those randomised to exercise were referred to physiotherapy for an early, structured exercise programme (three to six face-to-face appointments that included strengthening, physical activity and behavioural change strategies).

MAIN OUTCOME MEASURES

The primary outcome was upper limb function at 12 months as assessed using the Disabilities of Arm, Hand and Shoulder questionnaire. Secondary outcomes were function (Disabilities of Arm, Hand and Shoulder questionnaire subscales), pain, complications (e.g. wound-related complications, lymphoedema), health-related quality of life (e.g. EuroQol-5 Dimensions, five-level version; Short Form questionnaire-12 items), physical activity and health service resource use. The economic evaluation was expressed in terms of incremental cost per quality-adjusted life-year and incremental net monetary benefit gained from an NHS and Personal Social Services perspective. Participants and physiotherapists were not blinded to group assignment, but data collectors were blinded.

RESULTS

Between 2016 and 2017, we randomised 392 participants from 17 breast cancer centres across England: 196 (50%) to the usual-care group and 196 (50%) to the exercise group. Ten participants (10/392; 3%) were withdrawn at randomisation and 32 (8%) did not provide complete baseline data. A total of 175 participants (89%) from each treatment group provided baseline data. Participants' mean age was 58.1 years (standard deviation 12.1 years; range 28-88 years). Most participants had undergone axillary node clearance surgery (327/392; 83%) and 317 (81%) had received radiotherapy. Uptake of the exercise treatment was high, with 181 out of 196 (92%) participants attending at least one physiotherapy appointment. Compliance with exercise was good: 143 out of 196 (73%) participants completed three or more physiotherapy sessions. At 12 months, 274 out of 392 (70%) participants returned questionnaires. Improvement in arm function was greater in the exercise group [mean Disabilities of Arm, Hand and Shoulder questionnaire score of 16.3 (standard deviation 17.6)] than in the usual-care group [mean Disabilities of Arm, Hand and Shoulder questionnaire score of 23.7 (standard deviation 22.9)] at 12 months for intention-to-treat (adjusted mean difference Disabilities of Arm, Hand and Shoulder questionnaire score of -7.81, 95% confidence interval -12.44 to -3.17; p = 0.001) and complier-average causal effect analyses (adjusted mean difference -8.74, 95% confidence interval -13.71 to -3.77; p ≤ 0.001). At 12 months, pain scores were lower and physical health-related quality of life was higher in the exercise group than in the usual-care group (Short Form questionnaire-12 items, mean difference 4.39, 95% confidence interval 1.74 to 7.04; p = 0.001). We found no differences in the rate of adverse events or lymphoedema over 12 months. The qualitative findings suggested that women found the exercise programme beneficial and enjoyable. Exercise accrued lower costs (-£387, 95% CI -£2491 to £1718) and generated more quality-adjusted life years (0.029, 95% CI 0.001 to 0.056) than usual care over 12 months. The cost-effectiveness analysis indicated that exercise was more cost-effective and that the results were robust to sensitivity analyses. Exercise was relatively cheap to implement (£129 per participant) and associated with lower health-care costs than usual care and improved health-related quality of life. Benefits may accrue beyond the end of the trial.

LIMITATIONS

Postal follow-up was lower than estimated; however, the study was adequately powered. No serious adverse events directly related to the intervention were reported.

CONCLUSIONS

This trial provided robust evidence that referral for early, supported exercise after breast cancer surgery improved shoulder function in those at risk of shoulder problems and was associated with lower health-care costs than usual care and improved health-related quality of life.

FUTURE WORK

Future work should focus on the implementation of exercise programmes in clinical practice for those at highest risk of shoulder problems.

TRIAL REGISTRATION

This trial is registered as ISRCTN35358984.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 15. See the NIHR Journals Library website for further project information.

Racial Differences in Pain, Nutrition, and Oxidative Stress

Investigating the disproportionate rates of chronic pain and their related comorbidities between Black and non-Hispanic White (White) individuals is a growing area of interest, both in the healthcare community and in general society. Researchers have identified racial differences in chronic pain prevalence and severity, but still very little is known about the mechanisms underlying them. Current explanations for these differences have primarily focused on socioeconomic status and unequal healthcare between races as causal factors. Whereas these factors are informative, a racial gap still exists between Black and White individuals when these factors are controlled for. One potential cause of this racial gap in chronic pain is the differences in nutrition and dietary intake between groups. Certain foods play a key role in the inflammatory and oxidative stress pathways in the human body and could potentially influence the severity of the pain experience. Here, we review the previous literature on the surrounding topics and propose a potential mechanism to explain racial differences in the chronic pain population, based on established racial differences in diet and oxidative stress.

Pain in the Cancer Survivor

Recent decades have demonstrated significant strides in cancer screening, diagnostics and therapeutics. As such there have been dramatic changes in survival following a diagnosis of cancer.

Post-Breast Surgery Pain Syndrome: Shifting a Surgical Paradigm

Post-mastectomy pain syndrome and the less well-described post-breast surgery pain syndrome are long-term neuropathic pain conditions that may affect more than 50% of patients after mastectomy and breast surgery. While the etiology, risk factors, and management have been reviewed in our literature, we offer here a focused outline that will gear the plastic surgeon with tools to lead a multidisciplinary, algorithmic approach to the care of patients with post-mastectomy pain syndrome/post-breast surgery pain syndrome. After reading this article, we hope the reader will have improved awareness of post-mastectomy pain syndrome/post-breast surgery pain syndrome, and thus be able to incorporate appropriate treatments and preventative steps into their primary surgical routine.

Serratus anterior plane versus paravertebral nerve blocks for postoperative analgesia after non-mastectomy breast surgery: a randomized controlled non-inferiority trial

Background

Paravertebral and serratus plane blocks are both used to treat pain following breast surgery. However, it remains unknown if the newer serratus block provides comparable analgesia to the decades-old paravertebral technique.

Methods

Subjects undergoing unilateral or bilateral non-mastectomy breast surgery were randomized to a single-injection serratus or paravertebral block in a subject-masked fashion (ropivacaine 0.5%; 20 mL unilateral; 16 mL/side bilateral). We hypothesized that (1) analgesia would be non-inferior in the recovery room with serratus blocks (measurement: Numeric Rating Scale), and (2) opioid consumption would be non-inferior with serratus blocks in the operating and recovery rooms. In order to claim that serratus blocks are non-inferior to paravertebral blocks, both hypotheses must be at least non-inferior.

Results

Within the recovery room, pain scores for participants with serratus blocks (n=49) had a median (IQR) of 4.0 (0–5.5) vs 0 (0–3.0) for those with paravertebral blocks (n=51): 0.95% CI −3.00 to −0.00; p=0.001. However, the difference in morphine equivalents did not reach statistical significance for superiority with the serratus group consuming 14 mg (10–19) vs 10 mg (10–16) for the paravertebral group: 95% CI −4.50 to 0.00, p=0.123. Since the 95% CI lower limit of −4.5 was less than our prespecified margin of −2.0, we failed to conclude non-inferiority of the serratus block with regard to opioid consumption.

Conclusions

Serratus blocks provided inferior analgesia compared with paravertebral blocks. Without a dramatic improvement in safety profile for serratus blocks, it appears that paravertebral blocks are superior to serratus blocks for postoperative analgesia after non-mastectomy breast surgery.

Trial registration number

NCT03860974.

Perioperative factors associated with persistent post-surgical pain after hysterectomy, cesarean section, prostatectomy, and donor nephrectomy: a systematic review and meta-analysis

ABSTRACT

Persistent postsurgical pain (PPSP) is a common, and often disabling postoperative morbidity, but many questions remain about factors associated with PPSP. This systematic review and meta-analysis aimed to identify preoperative, intraoperative and postoperative factors associated with PPSP after gynecological surgeries, namely hysterectomy and cesarean section (C-section), and urological surgeries, namely prostatectomy and donor nephrectomy. Overall, 18 gynecological surgery studies, 4 prostatectomy studies, and 2 donor nephrectomy studies met the review criteria providing data that could be meta-analyzed. Average (±SD) PPSP occurrence after gynecological surgery was 20±11%; factors associated with increased risk of PPSP included smoking, preoperative abdominal or pelvic pain, preoperative pain elsewhere in the body, longer duration of surgery, more intense acute postoperative pain, and surgical wound infection. The use of neuraxial anesthesia was associated with decreased PPSP risk. Average PPSP occurrence was 20±9% after prostatectomy and 15±2% after donor nephrectomy. For urological procedures, the existing data did not allow for identification of significant factors associated with PPSP, except for laparoscopic and hand assisted laparoscopic approaches that were associated with lower incidence of PPSP for donor nephrectomy, and the use of neuraxial anesthesia which was associated with lower incidence of PPSP after prostatectomy. PPSP after gynecological and urological surgeries is common. This systematic review identified important factors associated with C-section and hysterectomy that can help identify women who are at high risk of PPSP. More high-quality studies with consistent methodology are needed to understand the factors associated with PPSP risk, particularly for surgeries such as prostatectomy and nephrectomy.

Postmastectomy Pain Syndrome: A Primer for Plastic Surgeons

Postmastectomy pain syndrome (PMPS) is defined as chronic pain after breast cancer surgery lasting greater than 3 months and has been shown to affect up to 60% of breast cancer patients. Substantial research has been performed to identify risk factors and potential treatment options, although the exact cause of PMPS remains elusive. As breast reconstruction becomes increasingly popular, plastic surgeons are likely to encounter more patients presenting with PMPS. This article summarizes current evidence on risk factors and treatment options for PMPS and highlights further areas of study.

Post-mastectomy pain syndrome: A timely review of its predisposing factors and current approaches to treatment

Background:

Post-mastectomy pain syndrome (PMPS) has been reported to occur in 25–60% of patients following surgeries for breast cancer, the highest occurring cancer in women worldwide. There has been much research interest due to this high prevalence. However, there is still a lack of incorporation of PMPS prevention strategies in standard perioperative plans, and our understanding of this condition is still incomplete.

Objectives:

This narrative review discusses recent literature on modifiable risk factors, current approaches to prevention and treatment and potential directions for future treatment and research.

Methods:

A PubMed search with the relevant keywords was done for articles published in the last 10 years.

Results:

The incidence of PMPS can be reduced by early recognition and management of modifiable risk factors as well as the perioperative use of analgesics and regional nerve blocks. These also have a significant role in the management of established PMPS together with surgical interventions and physical therapy.

Conclusions:

PMPS is still poorly defined and hence underdiagnosed and undertreated at this point. Perioperative peripheral nerve blocks have a very promising role as preventive analgesia to reduce the risk of developing PMPS, but large-scale randomised controlled studies will need to be done to evaluate their comparative efficacy. There is a need to prioritise PMPS prevention as a standard inclusion into the perioperative plans of mastectomy patients.

Comparison of PECS II and erector spinae plane block for postoperative analgesia following modified radical mastectomy: Bayesian network meta-analysis using a control group

The present study compared the effects of pectoral nerve block II (PECS II) and erector spinae plane (ESP) block for postoperative analgesia in patients who underwent modified radical mastectomy by performing a network meta-analysis (NMA) using indirect comparison with systemic analgesia. Studies comparing the analgesic effects of PECS II and ESP block were searched on MEDLINE, PubMed, EMBASE and the Cochrane Library. The primary outcome of this study was cumulative opioid consumption for 24 h postoperatively. Pain score during this period was also assessed. NMA was performed to compare the postoperative analgesic effects of plane blocks and systemic analgesia. A search of databases identified 17 studies, with a total of 1069 patients, comparing the analgesic efficacies of PECS II block, ESP block, and systemic analgesia. Compared with systemic analgesia, mean difference of opioid consumption was - 10 mg (95% credible interval [CrI] - 15.0 to - 5.6 mg) with PECS II block and - 5.7 mg (95% CrI - 11.0 to - 0.7 mg) with ESP block. Relative to systemic analgesia, PECS II block showed lower pain scores over the first postoperative 24 h, whereas ESP block did not. PECS II block showed the highest surface under the cumulative ranking curves for both opioid consumption and pain score. Both PECS II and ESP blocks were shown to be more effective than systemic analgesia regarding postoperative analgesia following modified radical mastectomy, and between the two blocks, PECS II appeared to have favorable analgesic effects compared to ESP block.

"Making Peace with Our Bodies": A Qualitative Analysis of Breast Cancer Survivors' Experiences with Qigong Mind-Body Exercise

Objectives: Breast cancer treatment leaves breast cancer survivors (BCS) with an array of lasting side effects, including persistent postsurgical pain (PPSP). In this study, we explored the perceptions of BCS with PPSP as they learned Qigong mind-body exercise (QMBE), a multimodal practice rooted in Traditional Chinese Medicine. Methods: Participants included 18 female BCS treated for stage 0-III breast cancer and experiencing PPSP. Participants were taught QMBE over 12 weeks. Semi-structured interviews were conducted before and after the intervention. Results: BCS disclosed a disconnect between mind and body that emerged during treatment. They perceived QMBE as moving meditation, which enabled them to reconnect mind and body, lessen their pain, and make peace with their bodies. Conclusion: These women's experiences both inform the promise of integrating QMBE and related mind-body exercise into PPSP clinical practice guidelines and suggest new areas of research regarding the role of multimodal interventions for holistic healing in BCS.

The Effect of Ultrasound-Guided Erector Spinae Plane Block Combined with Dexmedetomidine on Postoperative Analgesia in Patients Undergoing Modified Radical Mastectomy: A Randomized Controlled Trial

Introduction

One of the most common malignancies in women worldwide is breast cancer. Erector spinae plane block (ESPB) can reduce pain after modified radical mastectomy for breast cancer. The duration of nerve block analgesia is limited if local anesthetic agents are used alone. The purpose of this study was to evaluate the effect of dexmedetomidine on postoperative analgesia during a single injection of local anesthetics.

Methods

In this double-blind, randomized study, 60 female American Society of Anesthesiologists (ASA) I–II patients undergoing modified radical mastectomy were randomized into two groups: ultrasound (US)-guided ESPB with 30 mL of 0.33% ropivacaine (group R) and US-guided ESPB with 30 mL of dexmedetomidine plus 0.33% ropivacaine (group DR). US-guided ESPB at the T3 vertebral level was performed preoperatively in all patients. The indicators were 1-, 6-, 12-, 24-, and 48-h visual analog scale (VAS) pain scores after surgery in the resting state and at 90-degree shoulder abduction. Other measures were a comparison of intraoperative sufentanil and remifentanil, postoperative nausea and vomiting (PONV), flurbiprofen consumption, the lengths of post-anesthesia care unit (PACU) stay and hospital stay, postoperative bradycardia, and hypotension.

Results

The VAS pain score was lower in group DR than group R at any time in the resting state, except at 1 h after surgery. The VAS pain score was lower in group DR than group R at 12 and 24 h in an active state after surgery (P < 0.05 for each time interval). The intraoperative dosages of remifentanil and sufentanil in group DR were lower than that in group R. The postoperative dosage of flurbiprofen in group DR was lower than that in group R (P = 0.038). The lengths of PACU stay were longer in group DR than in group R. No significant difference was found in PONV and hospital stay between the two groups. No sinus bradycardia or hypotension after surgery occurred in the two groups.

Conclusions

Dexmedetomidine as an adjunctive to ESPB can effectively relieve pain and significantly reduce the need for opioids during modified radical mastectomy for breast cancer.

Trial Registration

The study was registered in the Chinese Clinical Trial Registry (ChiCTR2000031134, principal investigator: Yao Lu, date of registration: 2020-3-22).

Prediction of Persistent Pain Severity and Impact 12 Months After Breast Surgery Using Comprehensive Preoperative Assessment of Biopsychosocial Pain Modulators

BACKGROUND

Persistent post-mastectomy pain (PPMP) is a significant negative outcome occurring after breast surgery, and understanding which individual women are most at risk is essential to targeting of preventive efforts. The biopsychosocial model of pain suggests that factors from many domains may importantly modulate pain processing and predict the progression to pain persistence.

METHODS

This prospective longitudinal observational cohort study used detailed and comprehensive psychosocial and psychophysical assessment to characterize individual pain-processing phenotypes in 259 women preoperatively. Pain severity and functional impact then were longitudinally assessed using both validated surgery-specific and general pain questionnaires to survey patients who underwent lumpectomy, mastectomy, or mastectomy with reconstruction in the first postsurgical year. An agnostic, multivariable modeling strategy identified consistent predictors of several pain outcomes at 12 months.

RESULTS

The preoperative characteristics most consistently associated with PPMP outcomes were preexisting surgical area pain, less education, increased somatization, and baseline sleep disturbance, with axillary dissection emerging as the only consistent surgical variable to predict worse pain. Greater pain catastrophizing, negative affect, younger age, higher body mass index (BMI), and chemotherapy also were independently predictive of pain impact, but not severity. Sensory disturbance in the surgical area was predicted by a slightly different subset of factors, including higher preoperative temporal summation of pain.

CONCLUSIONS

This comprehensive approach assessing consistent predictors of pain severity, functional impact, and sensory disturbance may inform personalized prevention of PPMP and also may allow stratification and enrichment in future preventive studies of women at higher risk of this outcome, including pharmacologic and behavioral interventions and regional anesthesia.

Paravertebral block for the prevention of chronic postsurgical pain after breast cancer surgery

Patients frequently report chronic postsurgical pain (CPSP) after breast cancer surgery (BCS). The paravertebral block (PVB) is an effective technique to reduce acute postoperative pain after BCS, but its efficacy in preventing CPSP is unclear. This meta-analysis evaluates the efficacy of PVB in preventing CPSP after BCS. We searched Medline, Embase, CENTRAL, Database of Abstracts of Reviews of Effects, ClinicalTrials.gov, and WHO International Clinical Trials Registry Platform for studies comparing PVB with control for CPSP prevention after BCS, from inception to April 2020. The primary outcome was CPSP at 6 months, and the secondary outcomes were CPSP at 3 and 12 months, chronic postsurgical neuropathic pain (CPSNP) at 6 months, and PVB-related complications. Data were pooled and analyzed with a random-effects model, and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to evaluate the certainty of evidence. A total of 12 studies were included in the study; data for the 6-month time point from 7 studies (2161 patients) were analyzed, and no difference was found between PVB and control in terms of efficacy in preventing CPSP after BCS (risk ratio (RR) 0.82 (95% CI 0.62 to 1.08)), with a moderate quality of evidence according to the GRADE system. Similar results were obtained at 3 and 12 months (RR 0.78 (95% CI 0.57 to 1.06), RR 0.45 (95% CI 0.14 to 1.41), respectively). Data for the 12-month time point from seven studies (2087 patients) were analyzed and showed that PVB protected against CPSNP, with low quality of evidence (RR 0.51 (95% CI 0.31 to 0.85)). In conclusion, CPSP was not found significantly prevented by PVB after BCS despite the limits in the included studies; nevertheless, PVB could prevent CPSNP by impacting the transition from acute to chronic pain.

Preoperative quantitative sensory testing and robot-assisted laparoscopic hysterectomy for endometrial cancer: can chronic postoperative pain be predicted?

Objectives Chronic postoperative pain is prevalent after robot-assisted laparoscopic hysterectomy for endometrial cancer. Preoperative Quantitative Sensory Testing (QST) has been utilized to identify patients at risk of developing chronic postoperative pain after a range of surgical procedures. The aim of this prospective, observational study was to (1) determine the prevalence of chronic postoperative pain, (2) assess selected preoperative risk factors for chronic postoperative pain, and (3) evaluate if preoperative QST profiling could predict the development of chronic postoperative pain following robot-assisted laparoscopic hysterectomy for endometrial cancer. Methods One-hundred and sixty consecutive patients were included and handheld pressure algometry, cuff pressure algometry, temporal summation of pain, conditioned pain modulation, and heat pain thresholds were assessed prior to surgery. Patients were asked to fill out a questionnaire concerning pain in the pre- and post-operative time period six months after surgery. Chronic postoperative pain was defined as persistent, moderate to severe pain (mean visual analogue scale (VAS)≥3) on a daily basis six months after surgery. Results The prevalence of chronic postoperative pain after robot-assisted laparoscopic hysterectomy for endometrial cancer was of 13.6% (95% CI 8.4-20.4%). Patients that would develop chronic postoperative pain had a lower BMI (p=0.032), a higher prevalence of preoperative pelvic pain (p<0.001), preoperative heat pain hyperalgesia (p=0.043) and a higher level of acute postoperative pain (p<0.001) when compared to patients that would not develop chronic postoperative pain. A logistic regression model demonstrated that the presence of preoperative pelvic pain was a significant, independent predictive risk factor for development of chronic postoperative pain (OR=6.62, 95% CI 2.26-19.44), whereas none of the QST parameters could predict postoperative pain. Conclusions Preoperative QST assessment could not predict the development of chronic postoperative pain despite preoperative heat pain hyperalgesia in patients that would develop chronic postoperative pain.

Effects of a Single Myofascial Induction Session on Neural Mechanosensitivity in Breast Cancer Survivors: A Secondary Analysis of a Crossover Study

OBJECTIVES

The purpose of this study was to investigate the short-term effects of myofascial induction on mechanosensitivity of upper limb nerves.

METHODS

In this secondary analysis of a randomized, single-blind, placebo-controlled crossover study, 21 breast cancer survivors with stage I-IIIA cancer were randomly allocated to an experimental group (30 minutes of myofascial induction session) or placebo control group (unplugged pulsed 30 minutes of shortwave therapy), with a 4-week washout period between sessions that occurred in a physical therapy laboratory in the Health Science Faculty (University of Granada, Spain). Range of motion (universal goniometry), structural differentiation, symptoms (yes/no), and pressure pain thresholds (electronic algometry) were assessed during neurodynamic tests and attitude toward massage scale as covariate.

RESULTS

An analysis of covariance revealed significant time × group interactions for range of motion in affected upper limb nerves (median, P < .001; radial, P = .036; ulnar, P = .002), but not for nonaffected upper limb nerves (median, P = .083; radial, P = .072; ulnar, P = .796). A χ² or Fisher exact test, as appropriate, also revealed a significant difference (P = .044) in sensitivity for the affected upper limb ulnar nerve in the experimental group, whereas the rest of the assessed nerves (affected and nonaffected upper limb nerves) showed no significant changes in either the experimental or control groups (P > .05). An analysis of covariance revealed no significant interactions on pressure pain thresholds over the nerves for affected (all P > .05) and nonaffected (all P > .05) upper limb nerves.

CONCLUSION

A single myofascial induction session may partially improve mechanosensitivity of median, radial, and ulnar nerves and yield positive effects on symptom mechanosensitivity, especially regarding the ulnar nerve in breast cancer survivors.

A critical overview of the current myofascial pain literature - July 2020

We are sad to report that following this issue, Dr. Li-Wei Chou will no longer be able to contribute to this quarterly literature overview. Unfortunately, his work responsibilities have increased to such an extent that they need to take priority. On behalf of the team, we would like to thank Dr. Chou for his thoughtful and balanced reviews during the past few years. Not only were we able to include an occasional Chinese-language study, he also was able to assist us in interpreting more complex medical studies. Li-Wei, we wish you all the best professionally and personally, and of course, we cannot wait until our paths will cross again sometime in the future! You may have noted that this overview article was missing from the January 2020 issue of the journal due to an administrative mix up. With the current issue we aimed to catch up and therefore, you will find a greater number of reviewed articles than usual. It becomes increasingly challenging to cover the wide range of the published myofascial pain and trigger point (TrP) literature just due to its volume. In this edition, we included 10 basic research articles, 4 reviews, 14 articles on dry needling (DN), acupuncture, and injections, 3 on manual therapies, and 4 on other clinical approaches.

Prevalence of postmastectomy pain syndrome and associated risk factors: A large single-institution cohort study

Postmastectomy pain syndrome (PMPS) is a frequent complication of breast surgery, and is considered a chronic neuropathic pain in the side of surgery which persists more than 3 months. We conducted a retrospective analysis of the largest reported cohort to investigate the prevalence of PMPS and to analyze its associated risk factors as well as the influence on quality of life (QoL). Two thousand thirty-three surgically-treated female patients diagnosed between 2012 and 2017 with early-stage breast cancer were asked to complete a questionnaire survey about their current chronic neuropathic pain problems and quality of life. Multivariate logistic regression analyses were applied to determine the associated risk factors of PMPS. Results have shown that 1983 (97.5%) patients responded and completed a questionnaire survey. Among them, PMPS was found in 28.2% of patients. In univariate analysis, age≤35 years, tumor staging, history of chronic pain, total mastectomy, and axillary lymph node dissection (ALND) were significantly correlated with PMPS (P < .05). Multivariate analysis showed that age≤35 years, history of chronic pain, total mastectomy, and ALND were the independent risk factors of PMPS. QoL outcomes have shown that the global QoL score, physical function score, role function score, and social function score in the PMPS group were reduced in the PMPS group (P < .05), while the difference in emotional function score and cognitive function score showed no statistical significance (P > .05). Besides, patients with PMPS have worse body image, sexual enjoyment, and more breast symptoms. In conclusion, PMPS is linked with a high incidence among breast cancer patients, and has a considerable negative influence on the quality of life. In addition, age, total mastectomy, ALND, and history of chronic pain are the independent risk factors of PMPS.

Impact of preoperative pectoralis plane nerve blocks for mastectomy on perioperative opioid consumption: a retrospective study

Aim: To compare perioperative opioid consumption for patients undergoing mastectomy surgery with or without pectoralis nerve (PECS) plane blocks. Patients & methods: Retrospective study evaluating 152 adult females with mastectomies. Demographics, postanesthesia care unit stay duration and opioid consumption data at three time points were collected and analyzed for statistical significance. Results: 98 patients were included in the PECS block group, 54 patients were in the general anesthesia only group. Age and BMI were comparable. Total perioperative intravenous opioid consumption was less in the PECS block group (50.88 mg) compared with the general anesthesia only group (67.83 mg), p < 0.001. Conclusion: Acute pain after mastectomy is often severe. PECS plane block may decrease perioperative opioid consumption after mastectomy surgery compared with general anesthesia alone.

Impact of Perioperative Hypnosedation on Postmastectomy Chronic Pain: Preliminary Results

Objectives: The main aim of this prospective nonrandomized study was to evaluate if mastectomy performed with perioperative hypnosedation led to a lower incidence of chronic pain compared with mastectomy under general anesthesia. Methods: Forty-two breast cancer patients who underwent mastectomy either under GA (GA group, n = 21) or HYP (HYP group, n = 21) associated with local and/or regional anesthesia were included. The type of adjuvant therapy as well as the number of reconstructive surgical procedures were well balanced between the 2 groups. The average age of the patients and the type of axillary surgery were also equivalent. Incidence of postmastectomy chronic pain, lymphedema, and shoulder range of motion (ROM) were evaluated after a mean 4-year follow-up. Results: The study shows a statistically significant lower incidence of postmastectomy chronic pain in HYP group (1/21, 1 patient out of 21 experiencing pain) compared with GA group (9/21) with 9 patients out of 21 experiencing pain (P = .008). ROM for shoulder was also less frequently affected in the hypnosedation group, as only 1 patient had decreased ROM, instead of 7 in the other group (P = .04). Conclusions: Our study is the first to hint at the potential benefits of hypnosedation on postmastectomy chronic pain. Despite the limitations of this study (nonrandomized, small sample), preliminary results merit further study of hypnosedation.

Quality of life in "chronic" cancer survivors: a meta-analysis

PURPOSE

Cancer survivors are now living longer giving rise to a new concept-chronic cancer as survivors continue to face long-term consequences of cancer and its treatment. For these survivors, QOL becomes a vital consideration in understanding their survivorship and the long-term impact of cancer and its treatment. The primary aim of this review is to describe QOL in cancer survivors two or more years from diagnosis.

METHODS

A meta-analysis was completed of relevant studies assessing QOL in long-term cancer survivorship using PubMed, CINHAL, and PsycINFO. A total of 64 articles met inclusion criteria and included in the analysis. Standardized effect sizes and errors were calculated using previously published standard QOL pass rates to compare QOL across measurement tools and calculate cumulative effect sizes (CES). Fixed-effect or random-effects models were used based on the presence of significant heterogeneity of ≤ 0.10.

RESULTS

Physical health (CES = - 0.894; CI, - 1.472, - 0.316), role-physical health (CES = - 2.039; CI, - 2.643, - 1.435), and mental health (CES = - 0.870; CI, - 1.447, - 0.292) had large, negative cumulative effect sizes signifying worse QOL compared with acceptable QOL rates. Tested moderators, cancer type, average age, country of origin, time since diagnosis, or decade of diagnosis, were not significant to explain heterogeneity between included studies.

CONCLUSION

QOL is significantly impacted 2 to 26 years after cancer diagnosis. More research is needed to determine possible moderators of QOL in long-term cancer survivors.

IMPLICATIONS FOR CANCER SURVIVORS

QOL continues to be significantly impacted in long-term cancer survivorship. More research is needed to understand the impact of these findings on care needs for survivors with chronic cancer.

Cancer Rehabilitation:: Acute and Chronic Issues, Nerve Injury, Radiation Sequelae, Surgical and Chemo-Related, Part 2

Cancer affects millions of individuals, and approximately half will develop functional impairments. Cancers that commonly, either from direct effects or from its treatments, result in functional impairments include breast, head and neck, brain, and spinal cord tumors. There is a plethora of potential impairments including pain, spasticity, dystonia, weakness, and neurogenic bowel or bladder. This article reviews the functional impairments frequently encountered in breast, head and neck, brain, and spinal cord tumors. The authors also discuss management and treatment options incorporated in comprehensive cancer rehabilitation to address these impairments to maximize and maintain function and quality of life.

Cancer Rehabilitation: Acute and Chronic Issues, Nerve Injury, Radiation Sequelae, Surgical and Chemo-Related, Part 1

Individuals with cancer commonly experience functional impairments. Symptoms may present immediately or years to decades following their treatment. These impairments may include fatigue, pain, neuropathy, lymphedema, or radiation fibrosis syndrome and have the potential to deleteriously impact their function and quality of life. Cancer rehabilitation is a comprehensive resource that facilitates maximizing and maintaining cancer survivors' physical, social, psychological, and vocational functioning. This article covers the common functional impairments experienced by cancer survivors and the treatment strategies used in cancer rehabilitation. Application of these services can enhance the ongoing care for cancer survivors.

Erector spinae plane versus paravertebral nerve blocks for postoperative analgesia after breast surgery: a randomized clinical trial

Background

Paravertebral nerve blocks (PVBs) are frequently used to treat pain during and following breast surgery, but have various undesirable risks such as pneumothorax. The erector spinae plane block (ESPB) also provides perioperative breast analgesia, but is purported to be easier to administer with a favorable safety profile. However, it remains unknown if the new ESPB provides comparable analgesia as the decades-old PVB technique.

Methods

Subjects undergoing unilateral or bilateral non-mastectomy breast surgery were randomized to a single-injection ESPB or PVB in a subject-blinded fashion (ropivacaine 0.5% with epinephrine; 20 mL unilateral or 16 mL/side for bilateral). We hypothesized that (1) analgesia would be non-inferior in the recovery room as measured on a Numeric Rating Scale (NRS) with ESPB, and (2) opioid consumption would be non-inferior in the operating and recovery rooms with ESPB.

Results

Both pain scores and opioid consumption were higher in subjects with ESPBs (n=50) than PVBs (n=50; median NRS 3.0 vs 0; 95% CI −3.0 to 0; p=0.0011; and median morphine equivalents 2.0 vs 1.5 mg; 95% CI −1.2 to −0.1; p=0.0043). No block-related adverse events occurred in either group.

Conclusions

PVBs provided superior analgesia and reduced opioid requirements following non-mastectomy breast surgery. To compare the relatively rare complications between the techniques will require a sample size 1–2 orders of magnitude greater than the current investigation; however, without a dramatic improvement in safety profile for ESPBs, it appears that PVBs are superior to ESPBs for postoperative analgesia after non-mastectomy breast surgery.

Trial registration number

NCT03549234.

Chronic pain, health-related quality of life, and employment in working-age cancer survivors

PURPOSE

This study estimated the prevalence of cancer-related pain in working-age cancer survivors (age 25-64 years) and evaluated differences in demographic and clinical variables in those with and without pain. We also investigated the impact of cancer-related pain on health-related quality of life (HRQoL) and employment outcomes in this population.

METHODS

We used cross-sectional data from the 2016 Behavioral Risk Factor Surveillance System (BRFSS). Analyses were conducted with a sample of 1702 cancer survivors who completed treatment. All analyses were conducted using procedures to account for the complex sampling design of the BRFSS.

RESULTS

Nearly 17% (95% CI [13.94-19.58]) of working-age cancer survivors reported experiencing cancer-related pain. Among those who experienced pain, the majority were female, white, non-Hispanic, married/partnered, and non-employed, with breast as the most common cancer disease site. Those with cancer-related pain experienced more physically unhealthy days (adjusted rate ratio [aRR] 1.63, 95% CI [1.16-2.28]), mentally unhealthy days (aRR 1.52, 95% CI [1.02-2.26]), and activity interference (aRR 2.15, 95% CI [1.53-3.02]). Cancer-related pain decreased the odds of being employed, but only in female survivors (adjusted odds ratio 0.34, 95% CI [0.22-0.54]).

CONCLUSION

Cancer-related chronic pain is a prevalent, long-term condition that is negatively associated with HRQoL and employment in working-age cancer survivors.

IMPLICATIONS FOR CANCER SURVIVORS

Clinical interventions targeting chronic pain may improve HRQoL in working-age cancer survivors and employment outcomes, particularly in women.

Treating Persistent Pain After Breast Cancer Surgery

Breast cancer is one of the most commonly diagnosed cancers among women, and since the prognosis of breast cancer has substantially improved in past decades, complications of management are becoming increasingly apparent. Persistent pain lasting greater than 3 months after breast cancer surgery is unfortunately a common complication affecting approximately 30% of patients after tumour resection. Persistent breast cancer pain has neuropathic features and is typically mild-to-moderate in intensity, with approximately 10% suffering from severe pain. There is an increasing need to prevent persistent pain through the use of transitional pain programmes and perioperative interventions, and to identify novel treatment modalities to reduce suffering in those who unfortunately develop persistent pain. This review serves to provide an overview on persistent pain after breast cancer surgery, its pathophysiology, and current management strategies.

The Jacki Jacket after mastectomy with reconstruction: a randomized pilot study

BACKGROUND

Breast cancer patients undergoing mastectomy with reconstruction (TM + R) often experience post-operative discomfort from surgical drains. Despite a variety of garment options for use in the post-operative period, high-quality data assessing the impact of specific garments on post-operative pain are lacking. We report the results of a prospective randomized trial assessing the impact of the Jacki Jacket (JJ), a long-sleeve jacket with inner drain receptacle pockets, on post-discharge pain and quality of life (QOL) after TM + R.

METHODS

Breast cancer patients undergoing TM + R at a single institution were randomized post-operatively to receive a JJ or usual care (UC). Participant-reported demographics, pain intensity, and QOL were collected on post-operative day 1 (T1). Following discharge, participants completed a daily pain and medication dairy (T2); on day of drain(s) removal (T3), participants again completed pain and QOL questionnaires. Linear models were used to evaluate associations between JJ use, post-operative pain, and QOL.

RESULTS

From 3/8/17 to 12/20/17, 139 women were randomized. All participants completed T1 measures, 102 returned the T2 diary, and 118 (84.9%) completed T3 questionnaires. There was no significant difference in pain scores between JJ and UC arms at any timepoint. Adjusting for surgery type, age, marital status, depression, and obesity, participants randomized to JJ reported significantly better body image scores (estimate = 12.94, p = 0.009). There were no adverse events.

CONCLUSIONS

Although JJ garment use did not impact post-operative pain intensity scores, the significant impact of JJ use on body image supports consideration for inclusion of such garments in post-operative care for patients undergoing TM + R.

CLINICAL TRIAL REGISTRATION INFORMATION

Registered with ClinicalTrials.gov, NCT number NCT02976103, November 18, 2016.

Development of a Simple Preoperative Risk Score for Persistent Pain After Breast Cancer Surgery: A Prospective Observational Cohort Study

OBJECTIVES

Persistent postoperative pain is reported by 30% to 50% of patients following breast cancer surgery. Studies testing preventive measures, however, have so far failed to produce consistent positive results. If preventive measures could be targeted to a subgroup of patients at high risk of persistent pain, positive results would be more likely. Our aim was to develop a simple risk score predicting persistent pain after breast cancer surgery.

MATERIALS AND METHODS

In a prospective observational cohort study, we tested the predictive ability of a 4 simple items score for persistent pain in 200 patients scheduled for breast cancer surgery. A multivariable logistic regression model was created for the outcome of clinically important pain at 4 months.

RESULTS

On the basis of literature review and univariable analysis of our data, 4 parameters were selected: preoperative pain at the surgical site, history of depression, age below 50 years and expected pain of high intensity (>6/10). Points for the score are based on the coefficients of the logistic regression model. A total score ≥2 points/5 predicts a risk of developing clinically important pain at 4 months >30%, with an area under the curve-receiver operating characteristic of 0.81.

DISCUSSION

We studied known risk factors for persistent pain in patients scheduled for breast cancer surgery and constructed a preoperative risk score simple enough to select high-risk patients in future prevention studies.

Re-visiting post-breast surgery pain syndrome: risk factors, peripheral nerve associations and clinical implications

Aesthetic and reconstructive breast surgery is among the most common operations performed by plastic surgeons. The prevalence of persistent pain after breast surgery remains underappreciated by plastic surgeons. Post breast surgery pain syndrome (PBSPS) is reported to range between 20-60%. It is the purpose of this paper to revisit chronic pain as a combination of the breast intervention and relate this to the peripheral nerve(s) transmitting the pain message, in order to understand the underlying etiology and to improve breast pain treatment outcomes.