When Pain Persists After Breast Cancer Surgery

I could hear the anxiety in my sister’s voice. A week after her double mastectomy and breast reconstruction for breast cancer, she had developed a burning sensation under her right arm where her surgeon had removed several dozen lymph nodes for a postoperative biopsy. The throbbing and itching were so intense it felt “like poison ivy lit by a blowtorch.”

The physician assistant at her reconstructive surgeon’s office told her it was probably “neuropathic in origin” — probably arising from nerve damage during surgery — and that the condition, known as postmastectomy pain syndrome, or PMPS, would subside over time. And luckily for my sister, five weeks out from surgery, the pain began to wane.

But for many of the estimated 20 to 50 percent of women who develop pain after a mastectomy, it may never go away.


Credit Keith Negley

“Quite frankly, women are not always informed of the risk or the strategies that are available to reduce the risk,” said Rosemary Polomano, a professor of pain practice at the University of Pennsylvania School of Nursing. “It’s a widespread problem.”

For women already facing the physical and emotional trauma of breast cancer, chronic pain after a mastectomy can be devastating. “Pain is a psychological trigger for worry about cancer recurrence,” said Julie Silver, an associate professor at Harvard Medical School who specializes in cancer rehabilitation. “Treating PMPS really helps to relieve that anxiety.”

PMPS is generally defined as nerve-related pain that persists for at least three months after breast cancer surgery, though it can take up to six months to develop. It tends to occur in the upper chest or the underside of the arm, causing pain that women often describe as burning or shooting, and it sometimes presents, as it did in my sister, as an unbearable itch.

A number of causes have been posited for the condition, primary among them damage to the intercostobrachial nerve, which extends from the outer edge of the breast and runs along the underside of the arm.

It is not certain how many women have PMPS, but studies indicate that in addition to affecting mastectomy patients, it can also affect women who have had a lumpectomy, in which only the tumor and a small amount of surrounding tissue are removed. A study published in 2012 in the journal Breast indicated that women who had had axillary lymph node dissection — removal of some or all of the lymph nodes adjacent to the cancerous breast — were at particular risk.

Not all breast and reconstructive surgeons are aware of the extent of PMPS, which may explain why many do not mention it to their patients as a possible complication of surgery. Dr. Laura Esserman, the director of the Carol Franc Buck Breast Care Center in San Francisco, said she was shocked to learn of the prevalence of the problem when one of the speakers at a 2011 symposium she led on the management of breast cancer symptoms said that 20 to 40 percent of women complained of persistent pain after breast surgery.

“I think that patients often don’t want to complain to their surgeon,” Dr. Esserman said, “so we weren’t as aware of the problem as we should be.” She says she now always asks about postmastectomy pain as part of her postoperative patient interviews.

Many patients also remain misinformed about the potential for treatment. Dr. Michael Stubblefield, the chief of rehabilitation medicine service at Memorial Sloan-Kettering Cancer Center in New York, said he often encountered patients who had severe pain for several years after a mastectomy and were astonished to discover that it was treatable.

Doctors often use injectable steroids or anesthetics such as lidocaine and bupivacaine to mitigate the pain of PMPS, though many patients have found that the relief from these injections is short lived.

In a 2011 study, Dr. Esserman and a colleague at the University of California, San Francisco, Dr. Cathy J. Tang, combined the nerve block bupivacaine and the steroid dexamethasone, delivered at the point of maximal tenderness, to create what appears to be a more effective intervention than either one alone. The combination had been used as an analgesic — to treat pain after orthopedic surgery, for example — but Dr. Esserman said it had never been tried for PMPS.

The treatment offered many women immediate and long-lasting relief. So far, 75 percent of patients in the 2011 study have found persistent relief after one injection. About 20 percent required a second injection, and the remaining patients needed three injections. Dr. Esserman said she was not sure that the relief would prove permanent over the long run, but she was nevertheless optimistic about the treatment’s overall effectiveness.

“Even if you had to do the injection every six months,” she said, “that’s so much better than having that pain.”

An instructional video on the technique is available at the Carol Franc Buck Breast Care Center website (cancer.ucsf.edu/breastcarecenter).

That a combination of two or more classes of analgesics should be effective at treating PMPS was not a surprise to Dr. Polomano. “You derive a greater benefit by targeting several different mechanisms for pain relief,” she said.

Indeed, a growing number of surgeons and other health care professionals are using such an approach before, during and after surgery — combining, for instance a nonopioid pain reliever like acetaminophen with an opioid like morphine — in an effort to prevent the pain of PMPS from becoming chronic.

Dr. Polomano and her colleagues are working to get the word out among surgeons, anesthetists, nurses and other health care professionals “to raise awareness of the consequences of poorly controlled pain and, ultimately, to prevent it.”