Identification of a Factor Associated with Persistent Pain Following Breast Cancer Surgery

Only patients for whom sentinel lymph node biopsy is positive should undergo axillary dissection

Though patients who undergo breast cancer surgery have a 10-year survival rate of 83%, up to 60% of them suffer from persistent pain following surgery that may affect quality of life and level of functioning.1

Systematic reviews pointing to potential risk factors for postsurgical persistent pain–such as demographic and postoperative variables–lack assessment of data quality and fail to include recent searches.2-4 In an article published in the Canadian Medical Association Journal in July 2016, results from a systematic review and meta-analysis are reported. With this study, researchers from Wayne State University School of Medicine in Detroit, Michigan, and numerous international universities, sought to address these issues, in an effort to identify patients at higher risk of developing persistent pain.5

From a search of multiple databases, the authors identified 29 cohort studies and 1 case-control study that examined the link between risk factors and pain lasting at least 2 months following breast cancer surgery (the definition of persistent postsurgical pain proposed by the International Association for the Study of Pain) in a total of 19813 patients. 

According to their findings, moderate-quality evidence suggests an increased risk of persistent pain in patients with preoperative pain (odds ratio [OR] 1.29, 95% CI, 1.01-1.64), and high-quality evidence indicates that increased risk is associated with the following factors:

  • Younger age (OR for every 10-yr decrement 1.36, 95% CI, 1.24-1.48)

  • Radiotherapy (OR 1.35, 95% CI, 1.16-1.57)

  • Axillary lymph node dissection (OR 2.41, 95% CI, 1.73-3.35)

  • Greater acute postoperative pain (OR for every 1 cm on a 10-cm visual analogue scale 1.16, 95% CI, 1.03-1.30)

“Given the 30% risk of pain in the absence of risk factors, the absolute risk increase corresponding to these ORs ranged from 3% (acute postoperative pain) to 21% (axillary lymph node dissection),” wrote the authors, suggesting that axillary dissection, but not other factors investigated, constitutes a significant risk factor. 

Only patients for whom sentinel lymph node biopsy is positive should undergo axillary dissection, as risks of pain are significantly lower following biopsy compared with dissection.6 This recommendation is supported by the American Society of Clinical Oncology. In addition, preservation of the intercostobrachial nerves during dissection can also reduce the risk of pain and sensory deficits after surgery.7

The “modification of surgical procedures related to axillary dissection constitutes a promising stand-alone target for risk reduction,” wrote the authors. Additionally, clinician “awareness of nonmodifiable risk factors could influence management by allowing identification of women at high risk of postoperative pain who might then be targeted for interventions” such as psychotherapy or paravertebral blocks to complement general anesthesia, they noted.

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1. Haroutiunian S, Nikolajsen L, Finnerup NB, Jensen TS. The neuropathic component in persistent postsurgical pain: a systematic literature review. Pain. 2013;154(1):95-102.

2. Andersen KG, Kehlet H. Persistent pain after breast cancer treatment: a critical review of risk factors and strategies for prevention. J Pain. 2011;12(7):725-746.

3. Hidding JT, Beurskens CH, Van der wees PJ, Van laarhoven HW, Nijhuis-van der sanden MW. Treatment related impairments in arm and shoulder in patients with breast cancer: a systematic review. PLoS ONE. 2014;9(5):e96748.

4. Tsai RJ, Dennis LK, Lynch CF, Snetselaar LG, Zamba GK, Scott-conner C. The risk of developing arm lymphedema among breast cancer survivors: a meta-analysis of treatment factors. Ann Surg Oncol. 2009;16(7):1959-1972.

5. Wang L, Guyatt GH, Kennedy SA, et al. Predictors of persistent pain after breast cancer surgery: a systematic review and meta-analysis of observational studies. CMAJ 2016; pii: cmaj.151276.

6. Seki T, Hayashida T, Takahashi M, Jinno H, Kitagawa Y. A randomized controlled study comparing a vessel sealing system with the conventional technique in axillary lymph node dissection for primary breast cancer. Springerplus. 2016;5(1):1004.

7. Zhu JJ, Liu XF, Zhang PL, et al. Anatomical information for intercostobrachial nerve preservation in axillary lymph node dissection for breast cancer. Genet Mol Res. 2014;13(4):9315-23.