Pain may be the last thing on your mind when dealing with a new diagnosis of breast cancer. Your doctors may tell you that you’ll need a mastectomy, yet you may not have a clear idea of what happens after surgery.
Most women expect to have some pain right after surgery. However, few expect to have persistent (chronic) pain, several months after the surgical procedure. Due to the nature of cancer-related breast surgeries, the likelihood of having chronic pain is as high as 20-40%. Chronic pain is difficult to explain to family and friends. It is a frustrating experience that makes you feel like there are no treatment options after the surgery.
There is hope! If you are still having moderate or severe pain 2-3 months after your breast surgery, visit a pain specialist. He or she can offer treatments to ease your pain.
What breast surgeries cause the most pain?
Studies show that lymph node removal and not a mastectomy itself, increases the chance for chronic pain. The more lymph nodes are removed, the more pain you will have. To a lesser degree, chronic pain is also linked to breast reconstruction. Lumpectomies and lymph node biopsies are unlikely to cause chronic pain.
The main reason for pain after breast surgery
Chronic pain after a breast surgery, such as a mastectomy with lymph node removal, causes considerable distress and disability. A major reason for this, is the development of neuropathic pain. You are likely to have chronic neuropathic pain if you continue to hurt 2-3 months after surgery. The medical community has a specific name for this type of pain: Post Mastectomy Pain Syndrome (PMPS).
Causes for PMPS:
- Neuropathic pain after surgery – When a peripheral nerve (such as a nerve in the breast area) is injured during surgery, it triggers changes in the spinal cord and brain. This increases pain levels. Surgery in the upper part of the breast and underarm area can injure nerves that provide feeling in the breast, chest wall, and arm. This causes burning, tingling, shooting, stinging, or stabbing sensations, typical for neuropathic pain. You may also develop an increased sensitivity to normal things. For example, you may have pain when your shirt brushes against your chest.
- Nerve pain after chemotherapy or radiation – Some chemotherapy agents are toxic to nerves and make breast pain worse. They also affect nerves throughout your body, causing tingling, burning, or stabbing pain in your hands and feet. Radiation directed to the breast area also damages nerves.
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Other surgery-related pain problems
- Scar tissue – Scar tissue forms under the incisions, the place where the surgeons cut into the skin. It feels like a tense and sore area under your skin.
- Neuroma – This is a painful, ball-shaped mass that grows at the place where a nerve is cut during surgery. Surgeons do their best to protect nerves during surgery. However, this is not always possible.
- Muscle pain – Muscle soreness and spasms can start in the chest area soon after surgery and may continue for months, if untreated. You’ll feel painful knots directly under the skin.
- Frozen shoulder – If breast pain is severe and long-lasting, you will avoid moving your arm. This can lead to shoulder adhesive capsulitis (frozen shoulder). This inflammation and scarring in the shoulder tissues, becomes painful and interferes with movement.
- Lymphedema – This is a painful swelling of the arm, on the same side as the surgery. It can also affect the breast, underarm, chest, trunk, and back. It starts when lymph fluid leaks, following lymph node removal. Lymph is the clear fluid that travels through the body in ducts and nodes, removing waste and bacteria. Lymphedema can start after a sentinel lymph node biopsy, an axillary lymph node dissection, or after radiation.
- Complex Regional Pain Syndrome (CRPS) – This severe pain starts after a specific nerve injury (i.e. a nerve is cut in surgery) or after a widespread trauma. After breast surgery, this type of pain can start in the chest wall, underarm, or upper arm. There are several signs: swelling, skin scaling, changes in skin color (redness or blanching), skin temperature changes. The sooner you see a pain specialist, the better your chance for a successful treatment.
Risk factors for pain after a mastectomy
Multiple studies examined what increases a woman’s chance to develop pain after breast surgery.
- Younger age – Younger women feel more pain than older women. Younger patients also undergo more aggressive chemotherapy and radiation treatments that can cause nerve damage and pain.
- Type of surgery – Surgery that removes lymph nodes is more invasive and more likely to cause chronic pain.
- Pain control measures for surgery – Patients who receive nerve numbing (blocks) before a mastectomy, are less likely to have pain right after surgery and in the long term. The nerve blocks that help prevent breast pain are: paravertebral blocks and pectoral nerve blocks.
- Genetics – Some people inherit an increased sensitivity to pain. This causes them to feel more pain than other people undergoing the same surgery.
A diagnosis for your pain
Most causes for pain after breast surgery (i.e. scar tissue, myofascial pain, frozen shoulder) are easily identified. However, neuropathic pain often goes unrecognized. One reason for this is that you usually stop seeing your surgeon soon after the surgery is done. A link between surgery and pain is not made.
If you continue to have pain several months after surgery, it helps to see a pain specialist. There are no tests that can “show” you have neuropathic pain. Your pain specialist uses their clinical experience, based on your pain symptoms and physical exam, to make this difficult diagnosis.
Treatment for PMPS
PMPS treatments try to decrease neuropathic pain. This requires special medications and minimally invasive (non-surgical) procedures that are not part of a patient’s routine care after surgery. Treatment is through a pain clinic. The sooner treatment starts for PMPS, the better your chance to improve.
- Antiseizure medications and antidepressants. They stop pain signaling in the nerves and increase “feel-good” chemicals like serotonin and dopamine.
- Analgesics. Anti-inflammatories may help. Opioids don’t work well for treating nerve pain.
- Local anesthetics. Numbing medicines like Lidocaine or Bupivacaine reduce acute and chronic nerve pain. They come in patch or cream form and are applied over skin areas that “burn” or feel “sensitive”. They are also injected around painful nerves, using a peripheral or central nerve block. Two peripheral nerve blocks that decrease breast pain are the paravertebral block and the pectoral nerve block. Your anesthesiologist performs them the day of surgery, to prevent pain. However, they can also be used in someone with chronic pain, in order to break the pain cycle.
- Capsaicin is a cream made from chilly peppers. It goes over a skin area that burns or feels overly sensitive. It works by desensitizing you to pain (you become used to it).
Treatment for other mastectomy-related pain problems
- Scar tissue treatments – Your physical therapist (or you) can break up the rough scar tissue with a skin massage. Your pain specialist can inject pain-numbing medicine to the scar tissue, for temporary pain relief.
- Neuroma treatments – Neuroma pain is treated with anti-inflammatories and pain-numbing injections. More advanced treatments involve Radio Frequency Ablation or surgery to remove the neuroma.
- Muscle pain treatments – Muscle spasms can start soon after surgery. They are treated with muscle relaxants (i.e. Flexeril) or trigger point injections. Transcutaneous electrical nerve stimulation (TENS) and over the counter remedies such as magnesium supplements or Epson baths, also help.
- Frozen shoulder treatments – Injecting steroids and/or pain-numbing medicine (local anesthetics) into your shoulder joint decreases pain and inflammation. You’ll be able to complete your physical therapy exercises, to increase shoulder mobility.
- Lymphedema treatments – Treatment is not provided in a pain clinic. Treatments include massage, wearing an arm brace, or corrective surgery.
- Complex Regional Pain Syndrome (CRPS) treatments – Treatment for this type of pain is very specialized. Your pain specialist can offer antidepressants, anticonvulsants, sympathetic blocks, spinal cord stimulation, and others.
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