Friday, October 9, 2015


From the inception of the No Surrender Breast Cancer Foundation, we have stressed the importance of early detection. Some people are very lucky and find their tumors while they can be removed and the rest of the body can be treated depending on the extent of the disease. Does that mean that all small tumors are not deadly? No.

My first breast cancer's pathology revealed it began as DCIS, meaning it was contained within the milk duct. But it broke through the duct and became invasive. Invasive triple negative breast cancer. Because of this I had to do chemotherapy and radiation. That was in 2001. Over the next few years I met some wonderful women through my foundation. One young woman became a dear friend. Her name was Ferne Dixon. Her picture is on the right of this blog and always will be in eternal memory. She had triple negative breast cancer, too. But she did not get screened early and because of this the tumor was found after it became quite invasive.

Like Ferne, young, black women are at a higher risk of developing triple negative breast cancer while they are in their 30s. If they wait to be screened until they are 40 - or now as the new guidelines suggest 50 -  it will be too late. I promised Ferne as she was dying of this horrible disease, that I would do everything in my power to spread the word about the importance of early screening so young women would have a chance to become old women and not die of a disease that could have been treated and possibly overcome.

Now, after an exhaustive study, the experts are stating that early detection does, indeed, prolong life.
They have proof. It can be found here.

What the study shows is that the smaller the tumor, the longer the survival. The more lymph nodes involved and the larger the tumor the long term survival is not as favorable.

With new targeted treatments and the effectiveness of hormonal medications, even women with a more advanced disease are living longer. This applies only to women who are responsive to endocrine therapy.

My second cancer was estrogen receptor positive and it was large and involved the lymph nodes. Reading the graph is frightening knowing my pathology. But I am glad I did a year of strong chemo and had extensive radiation and am taking Femara. At least I am fighting it. What about the women who haven't been screened so they do not know they have to fight?

As everyone knows, we are firmly anti-pink at No Surrender. Sometimes that message is misunderstood to mean that we are anti-early detection. That has never, ever been the case. Look at our program The Before Forty Initiative - here - and you will see how strongly we believe in screening.  This screening is not just mammograms, which can miss some tumors. We encourage fighting for ultrasounds and breast MRI's - particularly for young women with dense breast tissue.

If you do anything in this pink month, set the record straight. Opposing pink greed is not opposing being smart and taking care of yourself and the ones you love. If you would like to start a Before Forty Initiative Outreach in your area, please contact us. We travel everywhere we can find women who don't know of their risks. We have made a difference. Tumors have been found in young women. And every time I am thanked by them or their mom or grandmother, I think of Ferne. I know she is smiling and telling me, "Keep it up, girl."

Early Screening Article:

Before Forty Initiative:

Thursday, October 1, 2015

Nothing to Say

It's October. Oh holy hell. Not again.

Everyone is asking me to either say something or  participate in something pink. Why? When have I ever been pink?

I was first diagnosed in September - so I had to go through the first horrifying month of chemo in a sea of pink ribbons and happy faces. In the real world, I slept on the bathroom floor because I was so sick from treatment I had to.

Breast Cancer is a cancer just as real as any other. But for some reason, this particular cancer is downgraded and infantilized. The focus is on  "Saving the Boobies!" not saving the lives of the 250,000 women who are diagnosed each year with over  40,000 dying of the disease annually. No. It is easier to make it pretty in pink. Easier for whom?

In the past week I was asked if my foundation, "Gets a lot of donations because it is October?"  Uh, no. People are too tapped out from buying pink toilet paper and pink fuel filters and pink shoelaces and pink ... everything. As I was checking out at a local store today the cashier asked if I would like to "Give to breast cancer?" Give what? What more can I possibly give? I asked her which breast cancer? She said, "You know, the one that you give to." I bit my tongue and said, no.

Nevertheless, it is upon us. In its full pink glory. Everyone looks so happy. The idiotic glee celebrating rapidly duplicating cells that are attempting to claim your life. This misguided and dangerous joy is hurting the women who are afflicted with this cancer. It is devastating to the women who are dying from this cancer. How do you explain the giddy excitement of Pinktober to a child who lost their mom? I know a lot of kids who lost moms. Trust me. They aren't having as much fun as the pink zombies want you to believe they are.  But no matter, as long as one percent of your purchase price goes to "a breast cancer charity" you should feel really great about doing your bit for breast cancer.

I run a non-profit foundation for women trying to get through breast cancer and we have never exploited the month of October for fundraising purposes. Why? Because women have breast cancer twelve months a year. And we help women during every single one of them. Our care doesn't stop after Halloween.

I do not use profanity in my writing, I keep things clean and professional. But, sometimes, only someone who really gets it, can put things into perspective. I wish everyone took breast cancer as seriously as other cancers. Other cancers like the one that took Warren Zevon. He wrote this in response to his diagnosis and treatment. It's not pink. Neither is breast cancer. Cancer is cancer. And the next time someone asks you to wear a pink boa and act like a child, please remember that THIS is what having cancer feels like...

Friday, August 7, 2015

Use Caution With Supplements During Chemotherapy

We are advocates of a healthy, evidence-based CAM regimen. However, when undergoing chemotherapy, it is not advisable to supplement unless expressly permitted by your doctor. Of all the supplements out there, the only one that appears to be safe, and essential for the rest of our lives, is Vitamin D. All other "vitamins" can be detrimental to the effectiveness of your chemotherapy killing cancer cells.

To put it simply, vitamins and supplements are anti-oxidants, chemotherapy is an oxidant. By taking supplementation that fights oxidants- you are fighting the chemo.

One case in particular is fish oil. As this study from Clinical Oncology News reports, it decreases the effectiveness of your treatment. Please read and then go over all the extra supplements you are taking while you are enduring chemotherapy.

Supplements and Cancer Resistance:
A Word of Caution
By Maurie Markman
   There is considerable and understandable interest among cancer patients in a variety of strategies designed to optimize the quality of their lives during and after treatment. Patients and their families also are increasingly proactive in their search for approaches that may favorably affect clinically relevant outcomes. 
   For these reasons, a wide variety of supplement use is common in the cancer patient population. In fact, in my experience, it is now quite common for patients to bring information to their clinic visits that they, or their families, have discovered through their own Internet-based searches so that they can inquire whether the strategy or product highlighted in the material would be relevant in their management.
   The specific goals of supplement use vary but include the desire to prevent or alleviate cancer or treatment-related symptoms, enhance an individual’s nutritional status or general well-being, or favorably affect natural defense mechanisms.
   Unfortunately, there may be legitimate concerns associated with the use of particular supplements in this setting. It is important to note, the major issue here is not the lack of evidence-based data supporting the objective validity of claims that the supplement actually produces the desired favorable effect, but rather the potential that use of the product may cause harm.
   For example, it has been estimated that omega-3 fatty acids, delivered most commonly in the form of fish oil, may be used by as many as 20% of patients with cancer in the United States.1 Preclinical data have suggested that even low concentrations of certain fatty acids can result in resistance to chemotherapeutic agents.2 Furthermore, a recent study in normal volunteers showed that consumption of fish oil at doses that might be taken by patients with cancer resulted in plasma concentrations of these fatty acids that were in the range where preclinical studies had revealed the development of chemoresistance.3
   Thus, although these data do not prove that the intake of fish oil with cytotoxic chemotherapy seriously interferes with the clinical effectiveness of antineoplastic treatment, one must be concerned that this could happen. Of course, it would never be possible to know in patients with cancer whether their use of fish oil had anything to do with the development of chemotherapy resistance in their cancers. However, on the basis of these data, it would be prudent for oncologists to encourage patients who are self-administering fish oil while undergoing chemotherapy to discontinue this practice and resume use of the product—if they so desire—following the completion of the cytotoxic drug program.
1. Gupta D, Lis CG, Birdsall TC, et al. The use of dietary supplements in a community hospital comprehensive cancer center: implications for conventional cancer care. Support Care Cancer. 2005;13(11):912-919, PMID: 15856334.
2. Roodhart JM, Daenen LG, Stigter EC, et al. Mesenchymal stem cells induce resistance to chemotherapy through the release of platinum-induced fatty acids. Cancer Cell. 2011;20(3):370-383, PMID: 21907927. 
3. Daenen LG, Cirkel GA, Houthuijzen JM, et al. Increased plasma levels of chemoresistance-inducing fatty acid 16:4(n-3) after consumption of fish and fish oil. JAMA Oncol. 2015;1(3):350-358, PMID: 26181186.

Wednesday, June 24, 2015

The Mammography Debate

Our Chief of Research, Constantine Kaniklidis,  has just published two reports in "Current Oncology" presenting an evidence-based review of the mammography debate. We are so very fortunate to have Constantine as our partner, friend and guiding light.

Below we present two abstracts with links to the articles.

Both articles were just published in the Current Oncology journal, and available (hyperlink below) online at (I include the brief abstracts for each):
Through a glass darkly: the mammography debate
[Invited Editorial]

About the ongoing breast cancer screening mammography debate - less a controversy, because many points of consensus and convergence are present if not always apparent - we can make these points as prelude: that it is complex; that it is naïvely implausible to expect any decisive final resolution to the residual issues that will be convincing to the principle contending parties; and that behind it all, the devil is in the methodology. In this editorial we propose: (1) a greater focus on moving beyond the current borders of the mammography debate to secure superior screening technologies that will erode the central status currently occupied by conventional mammography; (2) making research advances that will minimize the harms, especially of overdiagnosis (overdetection); and (3) furthering research to provide validated markers for the discrimination of low-risk and indolent disease.

Beyond the mammography debate: a moderate perspective [Perspectives in Oncology Review]

After some decades of contention, one can almost despair and conclude that (paraphrasing) “the mammography debate you will have with you always.” Against that sentiment, in this review I argue, after reflecting on some of the major themes of this long-standing debate, that we must begin to move beyond the narrow borders of claim and counterclaim to seek consensus on what the balance of methodologically sound and critically appraised evidence demonstrates, and also to find overlooked underlying convergences; after acknowledging the reality of some residual and non-trivial harms from mammography, to promote effective strategies for harm mitigation; and to encourage deployment of new screening modalities that will render many of the issues and concerns in the debate obsolete.

To these ends, I provide a sketch of what this looking forward and beyond the current debate might look like, leveraging advantages from abbreviated breast magnetic resonance imaging technologies (such as the ultra fast and twist protocols) and from digital breast tomosynthesis—also known as three-dimensional mammography. I also locate the debate within the broader context of mammography in the real world as it plays out not for the disputants, but for the stakeholders themselves: the screening-eligible patients and the physicians in the front lines who are charged with enabling both the acts of screening and the facts of screening at their maximally objective and patient-accessible levels to facilitate informed decisions.

(Both as HTML (above) and as PDF. For convenience, I attached the PDF versions to this posting.) A third article of mine will be published in the August issue, and I will post that when available.



Constantine Kaniklidis
Research Director
No Surrender Breast Cancer Foundation (NSBCF)

Saturday, June 6, 2015

Controlling Pain in Breast Cancer Surgery

 The take-away:

Post operative pain in breast cancer surgery can be quite difficult for the patient particularly in the setting of sentinel node and axilla dissection. This scientific article shows ways to help control the pain.

It is most fortunate that acetaminophen is now available in an IV form because it can be given in the recovery room to enhance pain relief. Opioids are not always the answer or the best choice in controlling pain; their side effects often outweigh their benefits.

Localized (regional) pain relief with either a long acting numbing agent administered before the patient awakens from anesthesia and/or the insertion of a pain pump that delivers numbing action directly to the surgical site can “break the cycle” of pain before it begins for the patient. Thus, the patient feels better in recovery and is able to begin the healing process without pain being the main focus.

There is even some evidence that avoiding opioid use may improve survival, but there needs to be more studies to investigate this further.

Improving Patient Outcomes Through State-of-the-Art Pain Control in Breast Cancer Surgery
Jacob L. Hutchins, MD

Acute post surgical pain continues to be difficult to manage in patients who undergo breast cancer surgery. Poorly controlled pain can lead to poor patient satisfaction, increased length of stay, and increased risk of opioid adverse events, and may be a factor in the development of chronic pain. A multimodal analgesic regimen that consists of 2 or more non-opioid medications and is initiated in the preoperative phase and continued during the intraoperative and acute postoperative phases may provide the best patient outcomes. These nonopioid medications include, but are not limited to, local anesthetics, acetaminophen, nonsteroidal anti-inflammatory drugs, antiepileptics, alpha-2-adrenergic antagonists, N-methyl-D-aspartate antagonists, and glucocorticoids. This multimodal approach can be a stand-alone protocol or a part of a more comprehensive enhanced recovery after surgery (ERAS) protocol.

Postoperative pain control remains a common problem for patients undergoing breast cancer surgery. A recent survey showed that patients’ number one concern leading up to surgery is pain.

Uncontrolled, acute postoperative pain can lead to an increased surgical stress response. This then has an effect on endocrine, metabolic, inflammatory, and immune functions, which can further stress various organ systems. Appropriate pain control can lead to improved postoperative outcomes as well as decreased pulmonary and cardiac complications.

In addition, uncontrolled acute postoperative pain is associated with longer stays in the postanesthesia care unit, longer hospital stays, decreased patient satisfaction and quality of life, and increased costs. Furthermore, while multifactorial in nature, the incidence of chronic pain may be decreased by an aggressive multimodal approach in the acute postoperative setting. As many as 4% to 63% of patients suffer chronic pain after mastectomy, and as such, effective acute pain control remains paramount to patient recovery following breast cancer surgery.

The mainstay of perioperative pain control has been opioids. However, opioids are associated with significant risks and adverse effects (AEs) such as pruritus, constipation, nausea/vomiting, urinary retention, oversedation, and respiratory depression. A recent sentinel event alert by The Joint Commission expressed the need for safe use of opioids in the hospital setting. This alert identified those most at risk for respiratory depression, including patients with obstructive sleep apnea or those who are opioid-naïve or obese, which are common characteristics of patients undergoing breast cancer surgery. Furthermore, opioid abuse is an ever-increasing problem in the United States. A recent survey in 2010 showed that 5.1 million US citizens had used opioids illicitly within the past month. Finding ways to minimize opioids in the treatment of perioperative pain may not only decrease AEs, but also decrease the exposure and subsequent misuse of opioids in society.

A multimodal approach has been used for perioperative pain control in various surgical procedures. Multimodal analgesia is the use of more than 1 class of nonopioid medication to reduce pain and minimize the AEs of any 1 class of pain medication. These medications act via different mechanisms and produce a synergistic effect on acute pain control. A successful multimodal protocol requires coordination between all phases of care: preoperative, intraoperative, and postoperative. Furthermore, the surgical, anesthesia, and nursing teams must all work together to ensure that all aspects of the multimodal plan are followed.

The Table lists a sample multimodal approach for breast cancer surgery. A preoperative regimen could consist of an antiepileptic medication, such as gabapentin or pregabalin, acetaminophen, and regional anesthesia. Preemptive analgesia ensures that the medication given is active before and during surgery. This also may decrease afferent transmission of pain signals and decrease acute postoperative pain. Several studies have shown opioid reduction and decreased acute and chronic pain using preemptive antiepileptics such as gabapentin or pregabalin. Regional anesthesia for breast cancer surgery could be either paravertebral blocks, pec blocks, or a thoracic epidural injection.  These blocks can be either a single-shot block or a continuous infusion via catheter. Several studies have shown  decreased  postoperative  pain  when these regional techniques are used for breast surgery. If a transverse rectus abdominis muscle (TRAM) or deep inferior epigastric perforator (DIEP) flap is performed, the use of transversus abdominis plane block (TAP) has also been shown to decrease postoperative opioid use and pain scores.

Intraoperatively, pain control should consist of zero to minimal short-acting opioids and a redose of acetaminophen if adequate time has passed. If the patient didn’t receive preoperative regional anesthesia, then the surgeon should perform infiltration with local  anesthetics.  This  can  be  liposomal bupivacaine, bupivacaine, or ropivacaine, or placement of a continuous wound infiltration catheter. The local anesthetic of choice for infiltration should be the one that provides the longest duration of action in order to provide maximal patient benefit. Liposomal bupivacaine, given via single-shot infiltration, may provide more prolonged or extended analgesia postoperatively than standard local anesthetics.  Recent data have shown liposomal bupivacaine given via infiltration to be an effective adjunct for postoperative pain  control  in  breast  augmentation  and reduction.

In addition, continuous peripheral or wound catheters can provide several days of pain relief using a continuous infusion of local anesthetic.

The postoperative pain regimen should consist of scheduled acetaminophen, scheduled antiepileptics, scheduled nonsteroidal anti-inflammatory drugs as soon as allowed, and intermittent short-acting opioids. This postoperative regimen should be continued for up to 1 week after surgery. In addition, complementary therapies such as acupuncture, aromatherapy, and healing touch can be offered to the patient. If a continuous catheter is in place, the infusion should consist of, at minimum, a local anesthetic and should be used in the acute postoperative period.

In  addition  to  the  medications  listed  in  the  preceding paragraphs and the Table, several other classes of medications can  also  be  used  pending  patient  selection.  Intravenous lidocaine has been used to decrease acute postsurgical pain in many surgical populations.  N-methyl-D-aspartate (NMDA) antagonists such as ketamine and magnesium may play a role in  central  sensitization.  The alpha-2-adrenergic antagonists clonidine and dexmedetomidine have been used in multimodal approaches in other surgical procedures with success, as they primarily act at the substantia gelatinosa of the spinal cord. Finally, glucocorticoids such as dexamethasone have been used to minimize inflammation and postoperative pain.

A comprehensive multimodal pain regimen will provide the patient with the most complete pain control. It will minimize opioids,  which  not only will  minimize  opioid-related  AEs and  opioid misuse, but may decrease  cancer  recurrence. 
A  retrospective  study  by  Exadaktylos  et  al showed  that paravertebral anesthesia and analgesia  decreased  breast cancer recurrence rates. Prospective studies have shown that paravertebral anesthetics, as opposed to general anesthetic with opioids and inhalation anesthetics, resulted in increased natural killer cell cytotoxicity as well as increased apoptosis in estrogen receptor–negative breast cancer cells.

In conclusion, this review of a multimodal approach to acute postsurgical pain can provide a framework for managing patients’ pain after breast cancer surgery. This could be used alone or in combination with an enhanced recovery after surgery (ERAS) protocol to improve patients’ postsurgical outcomes. However, future prospective randomized studies are needed to determine the exact combinations and dosages of multimodal medications to provide the optimal benefit for patients.

Affiliation: Dr Hutchins is from the University of Minnesota Department of Anesthesiology.
Disclosure: Dr Hutchins is on the speaker’s bureau, is a consultant for, and has received research funding from Pacira Pharmaceuticals and is on the speaker’s bureau for Halyard Health.
Address correspondence to: Jacob Hutchins, MD, B515 Mayo Memorial Building, University of Minnesota, 420 Delaware St, Minneapolis, MN 55455. Phone: 612-624-9990; fax: 612-626-2363; email:
    1.    Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg. 2003;97:534-540.
    2.    Kehlet H, Holte K. Effect of postoperative analgesia on surgical outcome. Br J Anaesth. 2001;87:62-72.
    3.    Liu S, Carpenter RL, Neal JM. Epidural anesthesia and analgesia. Their role in postoperative outcome. Anesthesiology. 1995;82:1474-1506.
    4.    Ballantyne JC, Carr DB, DeFerranti S, et al. The comparative effects of postoperative analgesic therapies on pulmonary outcome: cumulative meta-analyses of randomized, controlled trials. Anesth Analg. 1998;86:598-612.
    5.    Gandhi K, Heitz JW, Viscusi ER. Challenges in acute pain management. Anesthesiol Clin. 2011;29:291-309.
    6.    Lucas CE, Vlahos Al, Ledgerwood AM. Kindness kills: the negative impact of pain as the fifth vital sign. J Am Coll Surg. 2007;205:101-107.
    7.    Argoff CE. Recent management advances in postoperative pain. Pain Pract. 2014;14:477-487.
    8.    Oderda GM, Said Q, Evens RS, et al. Opioid-related adverse drug events in surgical hospitalizations: impact on costs and length of stay. Ann Pharmacother. 2007;41:400-407.
    9.    Buvanendran A, Kroin JS, Della Valle CJ, et al. Perioperative oral pregabalin reduces chronic pain after total knee arthroplasty: a prospective, randomized, controlled trial. Anesth Analg. 2010;110:199-207.
    10.    Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. Lancet. 2006;367:1618-1625.
    11.    Wallace MS, Wallace AM, Lee J, et al. Pain after breast surgery: a survey of 282 women. Pain. 1996;66:195-205.
    12.    De Vries JE, Timmer PR, Erftemeier EJ, et al. Breast pain after breast conserving therapy. Breast. 1994;3:151-154.
    13.    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.
    14.    Vila H, Smith RA, Augustyniak MJ. The efficacy and safety of pain management before and after implementation of hospital-wide pain management standards: is patient safety compromised by treatment based solely on numerical pain ratings? Anesth Analg. 2005;101:474-480.
    15.    The Joint Commission. Safe use of opioids in hospitals. Sentinel Event Alert. assets/1/18/SEA_49_opioids_8_2_12_final.pdf. Accessed February 1, 2015.
    16.    Manchikanti L, Helm II S, Fellows B, et al. Opioid epidemic in the United States. Pain Physician. 2012;15:ES9-ES38.
    17.    Buvanendran A, Kroin JS. Multimodal analgesia for controlling acute postoperative pain. Curr Opin Anaesthesiol. 2009;22:588-593.
    18.    Dahl JB, Kehlet H. Preventive analgesia. Curr Opin Anaesthesiol. 2011;24:331-338.
    19.    Tiippana EM, Hamunen K, Kontinen VK, et al. Do surgical patients benefit from perioperative gabapentin/ pregabalin? a systemic review of efficacy and safety. Anesth Analg. 2007;104:1545-1556.
    20.    Fassoulaki A, Triga A, Melemeni A, Sarantopoulos C. Multimodal analgesia with gabapentin and local anesthetics prevents acute and chronic pain after breast surgery for cancer. Anesth Analg. 2005;101:1427-1432.
    21.    Fassoulaki A, Patris K, Sarantopoulos C, Hogan Q. The analgesic effect of gabapentin and mexiletine after breast surgery for cancer. Anesth Analg. 2002;95:985-991.
    22.    Kim S Y, Song JW, Park B, et al. Pregabalin reduces post-operative pain after mastectomy: a double-blind, randomized, placebo-controlled study. Acta Anaesthesiol Scand. 2011;55: 290-296.
    23.    Ilfeld BM, Madison SJ, Suresh PJ, et al. Treatment of postmastectomy pain with ambulatory continuous paravertebral nerve blocks. Reg Anesth Pain Med. 2014;39:89-96.
    24.    Wahba SS, Kamal SM. Thoracic paravertebral block versus pectoral nerve block for analgesia after breast surgery. Egyptian J Anaesth. 2014;30:129-135.
    25.    Wu J, Buggy D, Fleischmann E, et al. Thoracic paravertebral regional anesthesia improves analgesia after breast cancer surgery: a randomized controlled multicenter clinical trial. Can J Anaesth. 2015;62:241-251.
    26.    Sidiropoulou T, Buonomo O, Fabbi E, et al. A prospective comparison of continuous wound infiltration with ropivacaine versus single-injection paravertebral block after modified radical mastectomy. Anesth Analg. 2008;106:997-1001.
    27.    Karmarkar MK, Samy W, Li JW, et al. Thoracic paravertebral block and its effects on chronic pain and health-related quality of life after modified radical mastectomy. Reg Anesth Pain Med. 2014;39:289-298.
    28.    Boezaart AP, Raw RM. Continuous thoracic paravertebral block for major breast surgery. Reg Anesth Pain Med. 2006;31:470-476.
    29.    Fahy AS, Jakub JW, Dy BM, et al. Paravertebral blocks in patients undergoing mastectomy with or without immediate reconstruction provides improved pain control and decreased postoperative nausea and vomiting. Ann Surg Oncol. 2014;21:3284-3289.
    30.    Zhong T, Wong KW, Cheng H, et al. Transversus abdominis plane (TAP) catheters inserted under direct vision in the donor site following free DIEP and MS-TRAM breast reconstruction: a prospective cohort study of 45 patients. J Plast Reconstr Aesthet Surg. 2013;66:329-336.
    31.    Albi-Feldzer A, Mouret-Fourme E, Hamouda S, et al. A double-blind randomized trial of wound and intercostal space infiltration with ropivacaine during breast cancer surgery. Anesthesiology. 2013;118:318-326.
    32.    Byager N, Hansen MS, Mathiesen O, et al. The analgesic effect of wound infiltration with local anaesthetics after breast surgery: a qualitative systematic review. Acta Anaesthesiol Scand. 2014;58:402-410.
    33.    Bouman EAC, Theunissen M, Kessels AGH, et al. Continuous paravertebral block for postoperative pain compared to general anaesthesia and wound infiltration for major oncological breast surgery. SpringerPlus. 2014;3:517.
    34.    Cohen SM. Extended pain relief trial utilizing infiltration of Exparel, a longacting multivesicular liposome formulation of bupivacaine: a phase IV health economic trial in adult patients undergoing open colectomy. J Pain Res. 2012;5:567-572.
    35.    Edwards MC, Sorokin E, Brzezienski M, et al. Impact of liposome bupivacaine on the adequacy of pain management and patient experiences following aesthetic surgery: results from an observational study. Plastic Surg. 2015;23:15-20.
    36.    Koppert W, Weigand M, Neumann F, et al. Perioperative intravenous lidocaine has preventive effects on postoperative pain and morphine consumption after major abdominal surgery. Anesth Analg. 2004;98:1050-1055.
    37.    Farag E, Ghobrial M, Sessler DI, et al. Effect of perioperative intravenous lidocaine administration on pain, opioid consumption, and quality of life after complex spine surgery. Anesthesiology. 2013;119:932-940.
    38.    Snyder GL, Greenberg S. Effect of anaesthetic technique and other perioperative factors on cancer recurrence. Br J Anaesth. 2010;105:106-115
    39.    Exadaktylos AK, Buggy DJ, Moriarty DC. Can anesthetic technique for primary breast cancer surgery affect recurrence or metastasis? Anesthesiology. 2006;105:660-664.
    40.    Buckley A, McQuaid S, Johnson P, et al. Effect of anaesthetic technique on the natural killer cell anti-tumour activity of serum from women undergoing breast cancer surgery: a pilot study. Br J Anaesth. 2014;113:i56-i62.
    41.    Jaura AI, Flood G, Gallagher HC, et al. Differential effects of serum from patients administered distinct anaesthetic techniques on apoptosis in breast cancer cells in vitro: a pilot study. Br J Anaesth. 2014;113:i63-i67.

- See more at: