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Persistent pain a+er breast cancer s urgery .
Prevalence and physical consequences Kenneth Geving Andersen, MD, PhD Sec<on for surgical pathophysiology & Department of breast surgery, Rigshospitalet, University of Copenhagen Defini<on Persistent pain a+er breast cancer surgery: 1.  New or worse pain in the breast, side of chest, axilla or arm 2.  more than 3 months a+er last treatment 3.  when other causes such as recurrence have been ruled out SEEK-B
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Clinical picture Dis<nct pain triggerpoint Hypoesthesia Allodynia for cold (25°C) Pain during movement Andersen et al. – in prepara<on 2009;302:1985-1992
Rune Gärtner, Maj-Britt Jensen, Jeanette Nielsen, Marianne Ewertz,
Niels Kroman, Henrik Kehlet
•  n = 3,253 •  47% with pain, 20% moderate and 6% severe •  pain pa<ents: -­‐ 65% with sensory disturbances -­‐ 28% used analgesics -­‐ 20% used other treatments -­‐ 20% GP contact for pain < 3 months Recent studies on prevalence Prospec(ve studies 6-­‐12 months Cross-­‐sec(onal studies 1-­‐10 years 80 80 70 70 60 60 50 50 40 40 30 30 20 20 10 10 0 0 Any pain % Moderate to severe pain % Any pain % Moderate to severe pain % SEEK-B
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Pain development in 537 pa<ents Andersen et al. in revision 2015 •  Repeated cross sec<onal study (N=2411) (vs. Gärtner et al. JAMA 2009) •  PPBCS may progress or regress with <me 100%
Pain development from 2008 to 2012
90%
80%
64%
698
1087
70%
36%
185
60%
389
50%
15%
40%
30%
1271
20%
85%
1086
10%
0%
2008
2012
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Change in func<on from before surgery to one year a+er SEEK-B
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Correla<on NRS vs. ac<vi<es with reduced func<on (baseline – 1 year) Causes of reduced func<on Percentages of pa<ents with difficul<es performing ac<vi<es due to breast cancer sequelae ~ 20% have reduced physical func<on due to pain a+er surgery
From Andersen et al. Clin J Pain 2014 Gene<cs Preopera<ve pain Nocicep<ve func<on Psychosocial Young age Adjuvant treatment Acute pain Surgery/nerve injury Treatment related risk factors Surgery Nerve damage •  Intercostobrachial nerve à Division causes higher prevalence of sensory disturbances à Rela<on to pain? ICBN: intercostobrachal nerve MPN: medial pectoral nerve LPN: lateral pectoral nerve Bruce et al. PAIN 2013, Warrier et al. The Breast 2014 Andersen et al. in revision 2015 Neural blockade •  Sparse evidence •  RCT warranted Pec maj Pec min Serratus anterior 2nd Rib Pleura 3rd Rib Summary •  High prevalence: 15-­‐20% moderate-­‐severe pain •  Dynamic state •  Treatment factors: –  ALND, adjuvant treatment(?) –  but not mastectomy or reconstruc<on •  Pa<ent related factors: –  Age –  Pain repor<ng –  Psychosocial •  Research needed on preven<on / treatment