The effect of special attention to preserving the intercostobrachial nerve was studied in a group of 120 patients, who were randomized to either sacrifice or preservation of the nerve. The number of patients who experienced pain, numbness, and altered sensation was halved in the preservation group postoperatively but not at follow-up 3 months later.111
The role of axillary dissection is highlighted by a study comparing 85 patients who underwent axillary dissection to 65 patients who had sentinel node dissection. Patients with sentinel node dissection showed significantly better scores for pain, edema, and range of motion as measured with a symptom disability summation
A possible role for postoperative pain management is suggested by one study of 110 breast cancer patients who were interviewed 3-4 years after breast surgery. Twenty-eight patients (25%) reported chronic pain. Of these, 21 (75%) had received conventional postoperative analgesia whereas 53% of the original cohort had received conventional analgesia.113
Following the model of preemptive pain management, a randomized trial of perioperative venlafaxine vs. placebo showed significant reduction in the incidence of chest wall pain, arm pain, and axilla pain between the treatment and control groups at 6 months after the surgery.114
Other interesting determinants of pain were suggested from telephone surveys of a national sample of 1812 Medicare beneficiaries who had been treated up to 5 years previously for early stage breast cancer. Axillary dissection was a predictor for arm problems, which in turn affected quality of life. Having a choice in treatment was associated with less bodily pain, implying that processes of care may affect perceptions of pain.115
7.2.3.a. Lymphedema. Lymphedema refers to swelling in an extremity, and is associated with painful sensations of swelling, heaviness, aching, tenderness, and numbness. These symptoms may be mild and not volunteered to health care professionals. In one review, the incidence of lymphedema in breast cancer patients ranged from 6% to 30%.116 In a cohort of 263 breast cancer survivors who had undergone axillary dissection 20 years previously, 128 patients (49%) reported a sensation of swelling, and 33 patients (13%) had severe lymphedema, defined as a difference in arm circumference of greater than 2 cm. While 98 patients (77%) developed within the first 3 years of diagnosis, onset could occur up to 17 years later.117 The incidence of lymphedema may decrease in the future as axillary dissections become more limited, and radiation techniques advance. In a telephone survey of 148 breast cancer survivors, 15% reported moderate to severe pain, and pain severity and swelling explained 25% of the variance in arm function.118 Pain from lymphedema can cause significant psychological distress.119,120
7.2.3.b. Treatment. A randomized comparison of manual lymphatic drainage to simple lymphatic drainage in 31 patients found a reduction in pain in patients who had manual lymphatic drainage, as well as other symptoms and quality of life parameters.121 Benzopyrones have been an area of interest. A large randomized study of 140 women compared either coumarin 200 mg or placebo twice a day for 6 months and did not find any effect on arm volume or symptoms.122 A Cochrane Database review concluded that the current evidence available is too weak to draw any conclusions.123
7.3.2.a. Post thoracotomy pain syndrome. In this syndrome, pain recurs or persists along a throracotomy scar at least 2 months following the surgical procedure.125 The prevalence varies. It has been estimated that 50% of patients who undergo thoracotomy will have mild to moderate pain and 5% of patients will have severe post thoracotomy pain.126 Pain at postoperative day 1 is predictive of pain 1 month and 1 year after thoracotomy.127 Physical exam usually shows sensory abnormalities such as absence of sensation or allodynia. Tumor recurrence should be excluded if the character of the pain changes, or becomes increasingly severe. Earlier reviews found little evidence for effective interventions.128 Capsaicin was effective in a trial for surgical neuropathic pain (see above),36 and topiramate was active in a small series of patients.129 This remains a difficult problem.130
One group compared transdermal nitroglycerin to transdermal nitroglycerin 5 mg/day with etodolac in an open label trial in patients with etodolac insensitive pain. These workers found an improvement in VAS pain severity, breakthrough pain, and sleep efficiency at on day 14 of treatment.131
Interest in preventing post thoracotomy pain has led to a comparison of videoassisted thoracoscopy (VATS) with thoracotomy. In the largest study to date, with a median follow-up of 36 months, 27 VATS and 24 thoracotomy survivors completed a telephone survey with the EORTC QLQ-C30, LC-13 and a chest pain subscale. No difference was found between the two arms for any of the pain items. Only one third of the original pool was able to participate in the study because of other medical conditions, illustrating the difficulty of recruiting patients.132 An extensive body of work has been done and is ongoing regarding the use of perioperative epidural analgesia. Findings have shown some improvement in postoperative pain, and conflicting results regarding chronic pain.
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