The management of chronic pain in patients with breast cancer [Clinical practice guidelines for the care and treatment of breast cancer]

• Published in: Canadian Medical Association journal (CMAJ) 1998-02, Vol.158 (3), p.S71
• Main Authors: MacDonald, R Neil, Hugi, Maria R, Graydon, Jane E, Beaulieu, Marie-Dominique
• Format: Article
• Language: English
• Subjects: Breast cancer; Health care; Pain
• ISSN: 0820-3946; 1488-2329

The distinction must be made between pain caused by the cancer, pain resulting from its treatment (including the severe discomfort and pain that can result from lymphedema) and pain due to comorbid syndromes such as osteoporosis or chronic disc syndrome. Some of the causes of pain syndromes associated with breast cancer are listed in Table 1. Three common syndromes deserve special mention and are discussed below: postmastectomy pain syndrome, brachial plexopathy and metastatic bone pain. Between 10% and 30% of patients will suffer persistent pain after breast surgery; it is more common after axillary dissection or total mastectomy than after breast-conserving surgery (BCS).(f.16,17) Postmastectomy syndrome is usually due to injury to the intercostobrachial nerve (a cutaneous branch of T1-2) in the course of surgery, and the subsequent pain and paresthesias occur in the nerve distribution. Although pain may be present immediately after surgery, more commonly the characteristic pain syndrome will develop 30 to 60 days postoperatively. The patient will complain of a burning pain in the chest wall, axilla and arm, with a sense of constriction in the axilla. Involved skin may be irritated by clothing, and the pain may be exacerbated by movement. In over half of affected patients the pain may be experienced in the arm and in 40% it may be related to movement.(f.17) This may cause the patient to restrict arm activity, with subsequent development of a frozen shoulder. Although pain is subjective, the dimensions of pain can be quantified. Since clinicians tend to underestimate the severity of pain, it is recommended that patient self-report assessment tools be used routinely in the diagnosis and follow-up of patients with breast cancer who have pain (level IV evidence).(f.24,25) The Edmonton Symptom Assessment Scale provides a simple model of a pain and symptom assessment form for institutional and outpatient use.(f.21) Regular assessment will reveal changes in the pattern of the pain or the development of new pain. When this occurs the evaluation of the source and type of pain must be repeated and the treatment plan modified appropriately.