#PostMastectomyPain

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 Breast cancer is a common cancer among women worldwide. A variety of problems can occur during treatment, and persisting pain after surgery is one such issue. It can affect 20% to 50% of women after mastectomy (operation involving removal of breast) and is defined as pain in the chest, armpit, upper arm, and shoulder persisting for more than 3 months post-surgery. 

Treating this pain is important as persisting pain besides causing suffering, can negatively impact on mood, sleep, activities of daily living, social interactions, and overall quality of life. Reduced working ability and financial implications are obvious consequences as shown in one study where 54% of individuals reported reducing their workload to part-time as a direct result of pain.

 As the survivorship is increasing, enabled by the technological advancements in medicine, the focus needs to be equally on quality of life and reducing suffering. Phantom breast sensation (where one feels that the removed breast is still present) has an even higher incidence (60–80% of patients). 

The actual problem and pain may be underreported due to reasons such as worries about cancer reoccurrence, barriers in discussing personal issues, fear of being misconstrued etc.

Another subgroup of patients undergoing mastectomy are those who want to reduce their risk of developing breast cancer such as those with gene mutations (e.g., BRCA1, BRCA2) and a strong family history. Advances in surgical treatment like breast-conserving approaches have enabled patients to realistically consider this option.

Who are at risk of developing persisting pain ?

Some factors associated with increased risk of persisting pain include:

Type of surgery: Nerve preservation approaches are associated with reduced incidence of sensory deficits (53 % vs. 84 %) but may not be possible in all cases.

Different breast cancer surgery options include

Radical mastectomy — involves removing the breast, skin, fat, chest muscles (pectoralis major and minor), and all the lymph nodes of the affected side.

Modified radical mastectomy spares the chest (pectoral) muscles when compared to the surgery mentioned previously.

Lumpectomy with axillary node dissection involves removal of the tumour with surrounding margin of normal tissue and the axillary (armpit) lymph nodes.

Breast-conserving surgery (lumpectomy) also known as breast preservation, conservative breast surgery, wide local excision, partial mastectomy is generally used in early breast cancer and involves removal of the tumour and a margin of normal tissue.

Lumpectomy with sentinel lymph node biopsy involves removal and examination of the first axillary node (sentinel node) receiving drainage from the breast. The node is identified by injection of a special dye/ radiolabeled substance prior to the operation. If this node is free of disease, axillary dissection is not required.

Axillary nodes dissection leads to increased chances of lymphedema (arm swelling due to inadequate drainage) and poses risks to one of the nerves (intercostobrachial nerve) which is responsible for the sensation of the inner aspect of the upper arm. Both of these factors can become a source of persisting pain. The wide variation in the size, location, and branching patterns of the nerve make it more vulnerable to injury. Damage may occur as a result of stretching during surgery or direct nerve injury, presenting with numbness and pain in the area supplied by the nerve. As per one study women with axillary node dissection are 3.1 times more likely to experience moderate-to-severe pain at rest.

Other nerves in the area are also at risk of injury and can become a source of persisting pain. These include

Medial cutaneous nerve of the arm (provides sensation to the lower medial skin of the upper arm (damaged during section of the tributaries of the axillary vein)

Medial and lateral pectoral nerves (control the chest wall or pectoral muscles)

Long thoracic nerve (controls the serratus anterior muscle present along the side of chest wall close to armpit)

Thoracodorsal nerve (controls the latissimus dorsi muscle)

Other treatments like radiation therapy administered in conjunction with surgery increase risk of persisting pain. This may be due to increased tissue fibrosis, neural entrapment, and impaired shoulder movement. Moreover, radiotherapy also increases risk for lymphedema which is another reason for persisting pain. Later-stage disease also is likely to require more aggressive treatment (i.e., chemotherapy) and may be associated with higher rates of pain. Regardless these are necessary treatments and when indicated should be pursued.

Pre-existing pain prior to surgery is one of the most consistent factors related to increased risk of persisting cancer pain after surgery. Even those patients with unrelated pain conditions such as headaches or low back pain are more likely to develop chronic pain after surgery.

Severe pain after the operation requiring high doses of painkillers increases the likelihood of persisting pain.

Age: In several studies, younger age was seen to be associated with greater likelihood of persistent pain. Although the exact reason is not known, some postulated factors include presence of more aggressive cancers requiring more aggressive treatment, higher preoperative anxiety, and the need for adjuvant chemotherapy in this group.

Psychosocial distress can be both a risk factor for and a consequence of chronic pain. Preoperative anxiety has been found to be related with immediate postoperative pain levels. Numerous studies have found correlations between persisting pain after surgery and depression, stress, and psychological vulnerability.

What are the symptoms of postmastectomy pain syndrome?

Postmastectomy pain syndrome may cause persistent or intermittent burning, shooting, stabbing, pulling, tightness, heaviness sensation or aching pain. 

Other symptoms in addition to pain may include

Numbness

Tingling or prickling pain

Increased sensitivity in the area

Spasms

Severe itching

Phantom breast sensation & pain

Struggling with pain after Breast Cancer Sugery

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