Factors that increase risk of persistent pain after breast cancer surgery are identifiedBMJ 2016; 354 doi: https://doi.org/10.1136/bmj.i3898 (Published 14 July 2016) Cite this as: BMJ 2016;354:i3898
The biggest risk factor for persistent pain after breast cancer surgery is node removal, a study has found. Younger age, radiography, and greater acute postoperative pain and preoperative pain were also associated with persistent pain.1
Some 25-60% of patients who have surgery for breast cancer experience persistent post-surgical pain, which is linked to reduced quality of life and functional impairment.
For the study, researchers from Brazil, Canada, China, Ireland, Spain, and the United States conducted a systematic review and meta-analysis of 30 observational studies, including data on 19 813 patients who underwent surgery for breast cancer. They published their findings in the Canadian Medical Association Journal.
The study found 77 independent variables associated with persistent pain. High quality evidence showed increased odds of persistent pain with younger age (odds ratio for every 10 year decrement 1.36 (95% confidence interval 1.24 to 1.48)), radiotherapy (1.35 (1.16 to 1.57)), axillary lymph node dissection (2.41 (1.73 to 3.35)), and greater acute postoperative pain (odds ratio for every 1 cm on a 10 cm visual analogue scale 1.16 (1.03 to 1.30)). Moderate quality evidence showed an association with the presence of preoperative pain (1.29 (1.01 to 1.64)).
Given the 30% risk of pain in the absence of risk factors, the absolute risk increase corresponding to these odds ratios ranged from 3% (acute postoperative pain) to 21% (axillary lymph node dissection). High quality evidence showed no association with body mass index, type of breast surgery, chemotherapy, or endocrine therapy.
No single non-modifiable risk factor changed the risk sufficiently to define a target population for an intervention to prevent persistent pain. Axillary lymph node dissection provided the only high yield target for a modifiable risk factor.
“Although we found a 21% increase in risk for chronic post-surgical pain associated with cutting nerves to access breast tumors, nerve sparing may not always be possible, and when possible may not reduce the risk of chronic pain as much as the current evidence suggests,” said a principal investigator, Jason Busse, of McMaster University in Hamilton, Ontario, Canada. “Furthermore, implementing nerve sparing techniques adds extra time to surgery, and that extra time has cost, and possibly complications.”
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