1. Chronic Pain Following Breast Cancer Surgery Eric J. Visser, Churack Chair, UNDA

2. Chronic pain following breast surgery • Pain is common, but (thankfully) usually not severe • We don’t see many cases in the pain clinic • Patients may be learning to live with it? • Grateful to have survived? • Worried about the pain (recurrence)? Meretoja, Tuomo J., et al. "Pain at 12 months after surgery for breast cancer." JAMA 311.1 (2014): 90-92; Gartner R et al. JAMA 2009.

3. Chronic pain following breast surgery • Breast cancer surgery (overall): ~50% • Mastectomy: ~50% • Breast conserving surgery: ~50% • Breast augmentation: 10-40% • Abnormal sensory (neuropathic) symptoms: ~80% • Phantom breast pain: ~5-10% Meretoja, Tuomo J., et al. "Pain at 12 months after surgery for breast cancer." JAMA 311.1 (2014): 90-92; Gartner R et al. JAMA 2009.

4. Features of chronic pain after breast surgery Gartner R et al. JAMA 2009 • Daily pain 50% • Moderate-mild (≤4/10) 90% • Severe 10% • Site: -Breast or chest wall 70% -Axilla or arm 60% -Regional (neck & shoulder) 50% -Other sites (widespread) 40%

5. Chronic pain syndromes • Post-mastectomy syndrome (‘neuropathic pain’) -Inter-costo-brachial neuralgia (axillary dissection) -‘Scar pain’ (neuroma) • Reconstructive (flap/implant) surgery -No difference in pain; mastectomy alone ± plastics • Phantom breast pain

6. Chronic pain syndromes • Secondary pain syndromes (arm, shoulder) -‘Frozen shoulder’ -Neck & shoulder myofascial pain (trigger points) -Lymphoedema -Complex Regional Pain Syndrome • Cancer pain syndromes -Local invasion, metastases -Treatment effects (chemo-neuropathies)

7. Neuropathic pain (nerve pain) Pain due to a lesion or disease of the nervous system (IASP 2015)

8. Neuropathic pain (nerve pain) Neuropathic pain descriptors • ‘Electrical’ • Burning, shooting, stabbing ‘Positive’ signs & symptoms • Allodynia (touch, pressure, cold pain) • Dysesthesiae • Phantom sensations ‘Negative’ signs & symptoms • Numbness • Anaesthesia dolorosa

9. Allodynia (touch pain) & neuropathic pain

10. Post-mastectomy pain syndrome Jung BF et al. Pain 2003 • A neuropathic pain syndrome • Pain & altered sensation in breast, axilla, chest wall • Inter-costo-brachial neuralgia • Dissection of the axilla • Scar pain (neuroma) ~30-50%

11. Risk factors for chronic pain • High BMI • Younger age • Pre-op pain (breast, widespread pain, fibromyalgia) • Severe acute post-operative pain (>6/10) • Complex surgery: revision, reconstruction • Nerve injury: axillary dissection vs sentinel node • Radiotherapy (chemotherapy) • Limb immobilization (frozen shoulder, CRPS) • Lymphoedema Andersen, Kenneth Geving, and Henrik Kehlet. "Persistent pain after breast cancer treatment: a critical review of risk factors and strategies for prevention." The Journal of Pain 12.7 (2011): 725-746.

12. Risk factors for chronic pain: Psychosocial ‘Yellow Flags’ • C.H.A.M.P.S • Catastrophic thinking (hypervigilance, ruminating) • Anxiety, depression • Medically-focused • Passive coping style • Single (poor social support)

13. Risk factors with breast pain: ‘Red Flags’ • T.I.N.T • Tumour: cancer recurrence • Infection/inflammation: seroma • Neuropathic pain • Trauma: lymphoedema

14. Prevention of chronic pain • Avoid ‘unnecessary’ surgery & re-operations (cosmetic?) • Surgical technique (minimally invasive, nerve sparing) • Screen & monitor at ‘risk patients’ • ‘Preventive analgesia’ techniques • Multidisciplinary rehabilitation

15. Preventive analgesia techniques • Multimodal analgesia • Paracetamol (5/7) • Parecoxib or celecoxib (5/7) • Neuropathic pain drugs • Pregabalin (10/7) • Tramadol or tapentadol

16. Preventive analgesia techniques • Local anaesthetic infiltration • EMLA cream (5/7)? • Paravertebral block??? • Epidural??? • IV Lignocaine infusion? • IV Dexmedetomidine?

17. Breast pain management checklist • Provide education & information about breast pain • Always ask about neuropathic pain & phantom sensations • Test for allodynia, DN4Q • Check for lymphoedema • Check for shoulder pain & stiffness • Check for Complex Regional Pain Syndrome (CRPS)

18. Breast pain management checklist • Check for ‘red flags’ (TINT) (infection, cancer) • Check ‘yellow flags’ (CHAMPS) • Indentify those at risk of chronic pain & disability • Early referral to a pain management clinic • Start multimodal analgesia (paracetamol, coxibs) • Tramadol or tapentadol & pregabalin

19. Breast pain management checklist • Start Vitamin C 1000 mg/d & Vitamin E 500IU/d for 2M • Physiotherapy (TENS, trigger points) • Keep shoulder & arm moving • Scar or neuroma injections • Shoulder injections • Lignocaine patches • Behavioural pain management & social support

20. What’s new? • Genetic risk • Catecholamine (COMT) enzyme • Potassium channel in nerves • Cancer recurrence and analgesia technique • Opioids?

21. Chronic Pain Following Breast Cancer SurgeryThank you Eric J. Visser, Churack Chair, UNDA