Approaches to Pain Management and Breast Cancer

1. Approaches to Pain Management and Breast Cancer John Liszka-Hackzell, MD, PhD University of Arizona Anesthesiology and Pain Medicine

2. Educational Objectives 1- Discuss the etiology of pain in breast cancer survivors 2- Describe the multidisciplinary approach to pain management assessment and treatment 3- Outline the appropriate use of pain evaluation tools

3. Reasons Why Breast Cancer Patients May Have Pain • Acute postoperative pain • Chronic pain • Neuropathic / Phantom Breast Pain • Bone pain / Metastatic Cancer

4. Surgical Procedures for Breast Cancer • Radical Mastectomy (breast, skin, pectoralis, lymph nodes) • Modified radical Mastectomy (pectoralis left intact) • Lumpectomy with/without axillary nodes. • Lumpectomy with Sentinel node biopsy

5. Surgical Procedures for Breast Cancer

6. Choice of Surgical Procedure or Technique May Influence the Occurrence of Chronic Pain • Not shown that breast-conserving treatment vs. modified radical mastectomy decreases risk of chronic pain • Evidence of more chronic pain following breast-conserving surgery and axillary node dissection (Wallace et al, Pain 1996)

7. Choice of Surgical Procedure or Technique May Influence the Occurrence of Chronic Pain • Increased risk of chronic pain after breast-conserving procedure may be related to increased use of chemo/radiation • Women who have breast prosthesis may have an increased incidence of chronic pain

8. Breast Cancer Surgery – Innervation • Third through sixth Intercostal nerves • Lateral cutaneous branch of T2 (ICB) – upper, medial portion of the arm • Lateral and anterior branches – anterior chest, upper back • T3 innervates the axilla, anterior and posterior torso • T4 and below innervates the torso. Nipple is primarily T4

9. Acute Post-Operative Pain Following Breast Surgery • Relationship between intensity of acute post-operative pain and Chronic post-treatment pain (Tasmuth et al, Acta Oncol, 1997). • Severity of acute postoperative pain is the best predictor of chronic pain in Breast Cancer

10. Increased Postoperative Pain May Be Related to: • Unrecognized preoperative neuropathic pain • Poor postoperative pain management • Pre-existing depression/anxiety • Surgical technique (nerve sparing procedures) • Postoperative complications (infection / bleeding) • Pre-existing chronic pain

11. Regional anesthesia techniques in combination with general anesthesia may decrease the incidence of long-term pain Thoracic epidural Paravertebral block

12. Postoperative Pain and Pre-emptive Pain Management • Evidence that effective preoperative and intraoperative pain management reduces postoperative pain • Pre-emptive pain management may reduce risk of chronic pain

13. Chronic Pain Following Breast Surgery • Risk Factors • Age? <35 worse prognosis in general • Chemo, Radiation – not associated with Phantom breast pain, but other chronic pains • Chronic Pain possibly greater in patients with pre-existing anxiety/depression • (Tasmuth et al, Pain, 1996)

14. Chronic Pain Following Breast Surgery • May be seen in up to 50% of mastectomy patients • “Postmastectomy pain syndrome” has four components: 1) Phantom breast pain 2) ICB neuralgia 3) Neuroma pain (scar pain) 4) Other nerve injury pains (Jung et al, Pain, 2003)

15. Intercostobrachial Neuralgia - Arises from the lateral cutaneous branch of the second intercostal nerve • Occurs more frequently with axillary node dissection (Jung et al, Pain, 2003) • Technically difficult to preserve the nerve • Neuropathic pain • Involves axilla and medial upper arm • Neuroma formation (macro/micro)

16. Chronic Pain FollowingBreast Cancer Surgery • Sensory abnormalities in the intercostobrachial nerve distribution in 60-80% of women following breast cancer surgery (breast conserving vs. radical) • 25% of these women will develop intercostobrachial neuralgia (Maunsell et al, Can J Surg, 1993)

17. Other Nerve Injury Pains • Medial and Lateral Pectoral (maj/min pectoral) • Long Thoracic (post shoulder/scapula, winged scapula) • Thoracodorsal (latissimus) • Usually spared

18. Chronic Pain Distribution / Description • Nociceptive – injury to ligament, muscle etc. • Neuropathic. Originates in the nervous system • Arm, neck, shoulder, axilla, chest wall or breast “continuation of acute pain” • Paresthesia, Dysesthesia, Allodynia, Hyperalgesia

19. Chronic Pain Neuropathic Pain • Paresthesia: a sensation of tingling, pricking or numbness • Dysesthesia: a spontaneous or evoked unpleasant abnormal sensation • Allodynia: a painful response to a usually non-painful stimulus • Hyperalgesia: an increased sensititivity to pain

20. Chronic Pain Phantom Breast Pain and Neuropathic Pain • Neuropathic pain. Damage to peripheral nerve • “Regeneration” Neuroma formation • Spontaneous firing • Often pain is sharp, shooting and burning

21. Chronic Pain • Phantom Breast Pain • and Neuropathic Pain • - Phantom pain. Not referred, but perceived • - Different from Phantom sensation • - Sharp, often stabbing pain • - Similar to neuropathic pain • - Develops weeks to months after procedure • May be associated with • neuroma formation

22. Phantom Pain - Mechanisms • Not well understood • Peripheral changes. Ectopic discharges from peripheral and central neuron, sympatheric activation and loss of noiception • Cortical re-mapping: pre-existing pain creates a cortical pain memory Re-organization in somatosensory cortex following amputation (Flor et at, Pain Clin Update, 2000)

23. Chronic Pain and Breast Cancer • Postoperative radiation is a risk factor for chronic arm and breast pain • Correlation between axillary radiation and arm pain (Keramopoulos et al, Oncology, 1993) • Plexus injuries

24. Chronic Pain – Prognosis • Typically decreasing over the first year • 31% at 1-2 years to 20% at 4 years (Ivens et al Br J Cancer, 1992) • Chronic nociceptive pain better prognosis than neuropathic • Neuropathic pain / Phantom breast pain are more chronic and problematic • Association with depression/anxiety

25. Bone Pain / Metastatic Disease • Results in anemia, risk of infection, pain, fractures decreased mobility • Difficult to fully control (Mercadante, Pain, 1997) • May be osteolytic or osteoblastic • Osteoblastic tumors may provide more mechanical stability

26. Management of Acute Post-operative Pain • Pre-emptive analgesia (block, adjuvants) may decrease risk of chronic pain • Standard opioids • Postoperative PCA • Consider appropriate regional anesthesia for postoperative pain

27. Management of Chronic Pain Neuropathic Pain • Multidisciplinary approach • Physical therapy • Occupational therapy • Behavioral / Pain management • Acupuncture / Chiropractic • Medical Management

28. Management of Chronic - Neuropathic Pain

29. Management of Chronic - Neuropathic Pain

30. Management of Chronic - Neuropathic Pain

31. Neuropathic Pain Adjuvant Medications • Lyrica (Pregabalin) • Works on Ca channels • Approved for DPN, PHN, Fibromyalgia • Side effects: Drowsiness, Sedation, Blurred vision • 300-600 mg/day (bid-tid)

32. Management of Chronic Pain/ Neuropathic Pain

33. Management of Bone Pain • Opiods may attenuate bone pain • Biphosphonates may be helpful, however no data suggests effect on long-term survival (Fulfaro et al, Pain, 2001) • COX-2 inhibitors prevents inflammatory response, bone resorption and may reduce tumor burden

34. Conclusion • Chronic pain seen in many patients (Nociceptive vs. Neuropathic) • Surgical technique • Good peri-operative pain control • Multidisciplinary management • Multiple options for medical management