A Risk Assessment Tool for Pain Following Mastectomy

A preoperative assessment tool was found to effectively identify patients at increased risk of experiencing moderate to severe pain following mastectomy, according to the results of a study published in the Annals of Surgical Oncology.

Data from patients (N=1195) who underwent mastectomy at Memorial Sloan Kettering Cancer Center in the United States between 2019 and 2020 were retrospectively reviewed for demographic, psychosocial, and clinical variables. Pain outcomes on postoperative days 1 through 5 were used as the outcome variable. A model was trained to evaluate which presurgical variables predicted pain using a training cohort of 956 individuals. The efficacy of the model was evaluated using the remaining 239 patients as the validation cohort.

The median age of study participants was 50 (interquartile range [IQR], 42-60) years, 71.2% were White, 43.8% had clinical T stage 2-4, 75.6% had clinical N stage 0, 48.2% underwent bilateral mastectomy, and 30.6% received neoadjuvant chemotherapy.

Patients in the training and validation cohorts reported their postoperative pain as none (3.5% vs 2.5%), mild (27.6% vs 21.3%), moderate (48.4% vs 51.9%), or severe (20.5% vs 24.3%), respectively.

Stratified by pain status, patients with moderate to severe pain were younger, had higher body mass index (BMI), more consumed alcohol, had depression and distress, experienced preoperative pain, took preoperative medications, received neoadjuvant chemotherapy, and underwent bilateral mastectomy and prepectoral or subpectoral reconstruction (all P ≤.044) compared with the cohort reporting no or mild postoperative pain.

In the multivariate model, bilateral mastectomy (odds ratio [OR], 2.23; 95% CI, 1.31-3.83; P =.003), Distress Thermometer score ≥4 (OR, 1.94; 95% CI, 1.16-3.30; P =.012), and BMI (OR, 1.05; 95% CI, 1.00-1.10; P =.042) remained significant predictors of postoperative pain. These predictors were combined with the a priori variables of age, depression, preoperative pain medication use, neoadjuvant chemotherapy, Distress Thermometer score, bilateral procedure, and implant-based reconstruction. The formulated score was calculated using a nomogram, in which clinicians drew a straight line from the variable scales to a “Points” axis that ranged from 0 to 100. All variable points were summed and the value on the “Total Points” axis, ranging from 0 to 380, was connected in a straight line to the “Risk of Moderate-Severe Pain” axis to obtain a patient’s risk score.

The final model had an area under the curve for predicting moderate to severe postoperative pain of 0.726 among the training cohort and 0.735 among the validation cohort.

This study may have been limited by the fact that some of the patients underwent surgery during the COVID-19 pandemic, which may have affected some procedural-related or distress-related factors.

In this study, a tool for evaluating patients at risk for pain following mastectomy was found to be effective. The study authors conclude, “Identification of patients at high risk of moderate–severe postoperative pain may allow for tailored pain management strategies and early interventions targeted at patient education and appropriate opioid cessation.”

Disclosure: One study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.