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| POST-MASTECTOMY PAIN: PREVALENCE, CHARACTERISTICS AND FUTURE RESEARCH DIRECTIONS Richard Payne, M.D., Professor of Neurology, Chief, Pain & Symptom Management Section, M.D. Anderson Cancer Center, Houston, Texas Chronic pain in women with breast cancer can have a number of causes which are related to tumor infiltration of tissues and distant metastasis or to complications of surgical, chemotherapy and radiation therapy for cancer. Pain following breast surgery for cancer characterized as constricting and burning in quality in the anterior chest, posterior arm and axilla, has been termed the post-mastectomy pain syndrome. Hyperpathia surrounding the mastectomy scar and extending in the chest wall and axilla is not uncommon, and a significant source of pain and morbidity. This syndrome has a prevalence of 4-33% following any surgical procedure on the breast, ranging from lumpectomy to modified radical mastectomy, and appears to be caused by injury to intercostobrachial nerve, a sensory cutaneous branch of the first and second thoracic nerve roots. This is an under-recognized syndrome and can cause substantial morbidity to women. The pattern of post-mastectomy pain may be intermittent or continuous, and is usually aggravated by movement of the affected limb. Several modalities of therapy are in clinical practice, including the use of opioid and non-opioid analgesics, tricyclic antidepresants, physical therapy and psychological and behavioral therapies. A recent small controlled trial demonstrated efficacy of amitriptyline in this disorder. Future research directions must involve careful prospective studies of pain, hyperpathia and functional impairments of women afflicted with this disorder. The intractable nature of this syndrome provides an opportunity for systematic trials of analgesic agents, including k opioid drugs, and adjuvant analgesic agents that might confer specific benefit for neuropathic pain: other tricyclic antidepressants, NMDA receptor antagonists and calcium channel antagonists. The uncontrolled clinical observations suggesting utility of psychological measures in this regional neuropathic pain syndrome, provides the opportunity to evaluate the efficacy and mechanism of action of these therapies by fMRI and other neuro-imaging modalities. References 1. Stevens PE, Dibble SL, Miaskowski C. Prevalence, characteristics, and impact of postmastectomy pain syndrome: an investigation of women’s experiences. Pain 1995; 61:61- 68. 2. Vecht CJ, Van de Brand HJ, and Wajer OJ. Post-axillary dissection pain in breast cancer due to a lesion of the intercostobrachial nerve. Pain 1989; 38:171-176. 3. Tasmuth T, von Smitten K, Kalso E. Pain and other symptoms during the first year after radical and conservative surgery for breast cancer. BR J Cancer 1996; 74:2024-31. 4. Eija K, Tiina T, Perti NJH. Amitriptyline effectively relieves neuropathic pain following treatment of breast cancer. Pain 1996; 64: 293-302.
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