ASSESSMENT AND EDUCATION

Patients’ subjective and reported pain experiences appear to correlate with objective electroneurophysiologic measures of nerve impulse transmission near sites of pain, according to a recent pilot study.11 If confirmed in larger studies, this may provide a rationale for diagnostic nerve testing in assessing PMPS. Current clinical examinations for suspected PMPS include manually assessing for sensory changes and muscular weakness, as well as reduced range-of-motion in the shoulder and arm.


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Patients undergoing breast cancer surgery and adjuvant radiotherapy should be advised to tell their health care providers if they have persisting chest, armpit, or upper-arm pain 3 months after treatment, or if they experience changes in how they can use their arms (such as arm weakness, or worsened pain associated with shoulder movement).1,10 Nurses should note risk factors (patient age, procedure, preoperative headache, postoperative acute pain) and the need to monitor for signs of PMPS throughout recovery and in survivorship planning.10 During posttreatment recovery, patients should be asked about pain and discomfort in the chest and upper arm, and whether some activities make that pain or discomfort worse.10

Importantly, patients should be reassured that PMPS is not a sign of tumor recurrence but rather a late effect of treatment.10

TREATMENT OPTIONS

The evidence base for PMPS treatment interventions remains sparse, and studies have not established whether optimal management of PMPS is different for patients who have undergone adjuvant radiotherapy than for those who have not.10 Proposed treatment strategies range from topical lidocaine for mild symptoms to antidepressants and opioid and nonopioid pain medications, even nerve-block injections with steroids or anesthetics, for severe cases.

Lidocaine 5% topical ointment is often recommended to women with PMPS, and preliminary clinical research suggests that perioperative lidocaine infusion, and possibly also piritramide, might be preventive, reducing the risk of subsequent development of PMPS.8,9

Other treatment options include lifestyle changes and physical therapy. Lifestyle accommodations such as using a cane or walker and physical activity regimens involving walks and stretching exercises.

Recent, preliminary research suggests that autologous fat grafting at surgical scar sites might reduce PMPS-associated pain in women who have undergone BCS plus radiotherapy.12

References

1. Post-mastectomy pain syndrome. American Cancer Society website. http://www.cancer.org/treatment/treatmentsandsideeffects/physicalsideeffects/pain/post-mastectomy-pain-syndrome. Last revised February 12,2016. Accessed August 22, 2016.

2. Alves Nogueira Fabro E, Bergmann A, do Amaral E Silva B, et al. Post-mastectomy pain syndrome: incidence and risks. Breast. 2012;21(3):321-325.

3. Gärtner R, Jensen MB, Nielsen J, Ewertz M, Kroman N, Kehlet H. Prevalence of and factors associated with persistent pain following breast cancer surgery. JAMA. 2009;302(18):1985-1992.

4. Pfaff LG. When pain persists after breast cancer surgery. New York Times. June 8, 2015. http://well.blogs.nytimes.com/2015/06/08/pain-after-breast-cancer-surgery-pmps/. Accessed August 22, 2016.

5. Belfer I, Schreiber KL, Shaffer JR, et al. Persistent postmastectomy pain in breast cancer survivors: analysis of clinical, demographic, and psychosocial factors. J Pain. 2013;14(10):1185-1195.

6. Schreiber KL, Martel MO, Schnol H, et al. Persistent pain in postmastectomy patients: comparison of psychophysical, medical, surgical, and psychosocial characteristics between patients with and without pain. Pain. 2013;154(5):660-668.

7. Courceiro TC, Valença MM, Raposo MC, Orange FA, Amorim MM. Prevalence of post-mastectomy pain syndrome and associated risk factors: a cross-sectional cohort study. Pain Manag Nurs. 2014;15(4):731-737.

8. Steyaert A, Forget P, Dubois V, Lavand’homme P, De Kock M. Does the perioperative analgesic/anesthetic regimen influence the prevalence of long-term chronic pain after mastectomy? J Clin Anesth. 2016 Apr 6. doi: 10.1016/j.jclinane.2015.07.010. [Epub ahead of print]

9. Terkawi AS, Sharma S, Durieux ME, Thammishetti S, Brenin D, Tioririne M. Perioperative lidocaine infusion reduces the incidence of post-mastectomy chronic pain: a double-blind, placebo-controlled randomized trial. Pain Physician. 2015;18(2):E139-E146.

10. Bokhari F, Sawatzky JA. Chronic neuropathic pain in women after breast cancer treatment. Pain Manag Nurs. 2009;10(4):197-205.

11. Hojan K, Wojtysiak M, Huber J, Molińska-Glura M, Wiertel-Krawczuk A, Milecki P. Clinical and neurophysiological evaluation of persistent sensory disturbances in breast cancer women after mastectomy with or without radiotherapy. Eur J Oncol Nurs. 2016;23:8-14. doi: 10.1016/j.ejon.2016.03.007.

12. Maione L, Vinci V, Caviggioli F, et al. Autologous fat graft in postmastectomy pain syndrome following breast conservative surgery and radiotherapy. Aesthetic Plast Surg. 2014;38(3):528-532.