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.
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: email@example.com.
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. http://www.jointcommission.org/ 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.
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