I am amazed at how well it has worked and how consistent that has been. The key is to know where these nerves are, and the surgeons should know where they are.
—Laura J. Esserman, MD, MBA
After presenting results of a study showing that injecting a standard analgesic combination into trigger points of pain along the inframammary fold relieved postmastectomy pain, Laura J. Esserman, MD, MBA, Director of the Carol Franc Buck Breast Care Center and Co-Leader of the Breast Oncology Program at the University of California, San Francisco, received a lot of phone calls. Some of those phone calls were from fellow physicians interested in possibly using the procedure with their own patients. Many more calls were from women who had read, heard, and/or seen media reports on the study.
“Our initial study was written up in The ASCO Post [February 15, 2014, volume 5, issue 3], and it generated an amazing response, mostly from women (or their families or friends) who were suffering and looking for a way to relieve their pain,” Dr. Esserman said in a recent interview. “We got so many calls from all over the country, from women who were feeling desperate” because of pain persisting weeks or more after their mastectomies were performed and interfering with their ability to wear a bra or to sleep.
That intense interest, along with additional positive study results, led Dr. Esserman and colleagues at the University of California, San Francisco, to publish the study and to produce a video detailing how to determine a patient’s trigger points for neuropathic pain and to inject the analgesic. Results from 19 patients were presented at the 2013 San Antonio Breast Cancer Symposium,1 and results from 35 patients are in press (Annals of Surgical Oncology). The video has been posted at cancer.ucsf.edu/breastcancercenter. Recent renewed interest resulted from an article in The New York Times.2
Postmastectomy Pain Is Complex
Postmastectomy pain occurs in 20% to 40% of patients and “is complex,” Dr. Esserman said. The pain can be burning, shooting, or radiating. Much less commonly, patients have intense itching.
“Although patients are often “sore and uncomfortable” following a mastectomy, “usually by 2 weeks, they are quite a bit better. Beyond 2 weeks, you may hear patients say, ‘I can’t wear my bra’ or ‘I have this intense point of pain that is really too much,’” Dr. Esserman added.
“One of the causes of postmastectomy pain is irritation to the nerves that have to be cut when you actually remove the breast,” Dr. Esserman said. These nerves “run along the chest wall going forward and backward,” she noted. “So, sometimes you can get this aching across the breast, and it may even reach into the back.”
Nerve pain, Dr. Esserman noted, “is not particularly responsive to narcotics.” Patients may have “pain that just can’t seem to get better or is not getting better with narcotics and is just persisting.” Such persistent pain led to the search for a more effective means of treatment.
The video presents a step-by-step approach to alleviate neuropathic postmastectomy pain, caused by damage to the cutaneous branches of the T4/T5 sensory nerves. The damage likely occurs when the blood vessels (branches off the intercostal vessels)—which are accompanied by nerve branches (off the intercostal nerves)—are cut as the breast is being removed from the chest wall. When vessels bleed, they are then cauterized to control the bleeding. You have to deal with the bleeding, and the nerve branches are quite tiny and very difficult to see,” Dr. Esserman said, but cautery can lead to the formation of painful neuromas.
This approach to postmastectomy pain examines the inframammary fold to identify trigger points, which correlate with the egress of the T4/T5 cutaneous branches. Since neuropathic pain involves both inflammatory and immune mediators, which sensitize pain receptors, the trigger points are injected with a combination of a local anesthetic and a steroid—a 2-mL mixture of equal parts 0.5% bupivacaine and 4 mg/mL of dexamethasone. The mixture is massaged in, and for most patients, that is all that is needed, although roughly 20% of the women receiving this treatment will require two injections, and 10% may require three injections.
If the patient does not experience significant reduction in pain soon after the first injection, “it is possible you are not in the right spot,” Dr. Esserman said. In such cases, Dr. Esserman would reassess the patient for a trigger point and try again. “You can try an ultrasound and look for a little neuroma,” she said. “If that doesn’t work, if someone got better, but not that much better, or got better and then a month later got worse, you go in and inject again. If you’ve done it three times and it is not working, you ought to try something different.”
Spreading the Word
Dr. Esserman has used this approach with patients whose mastectomies had been performed by her or other physicians. As mentioned in the video, the technique is effective 90% to 95% of the time if trigger points can be identified.
“I am amazed at how well it has worked and how consistent that has been,” Dr. Esserman told The ASCO Post. This high success rate has led her to encourage other physicians to use the technique. “That is why I did this video,” she said.
“The key is to know where these nerves are, and the surgeons should know where they are,” Dr. Esserman said. Then by watching the video, they should be able to successfully give the injections to patients with postmastectomy pain.
“Our pain management colleagues have identified ways in which you can be very successful in alleviating pain, and in fact they aren’t that mysterious. They are fairly easy to use, and one of the keys is to understand where the nerves are cauterized. These are things that are easy enough for us to learn and to integrate into our own day-to-day practice,” Dr. Esserman said.
Dr. Esserman has received calls about the treatment from interested physicians and sometimes initiates calls to colleagues to encourage them to try the procedure or at least to take a look at the video. “I’ve had some people e-mail me and say that they have done it. That’s exciting,” she added.
Dr. Esserman also has received calls from patients from other parts of the country who have heard about the procedure and are willing to travel great distances in the hope of becoming free of postmastectomy pain. “Someone may call me up from New York and say, ‘I want to come out there,’ and I say, ‘Don’t do that. Let’s get your surgeon to take a look at this video.’” In some cases, Dr. Esserman refers patients to physicians in their area who are already versed in the technique.
‘Not a Panacea’
However, Dr. Esserman stressed, “This is not a panacea for everything.” If the pain is not neuropathic or trigger points cannot be identified, “it is not going to help,” she said, and in such cases, she would not go ahead with the treatment. “Occasionally, you have someone where that is not the cause of pain or even if it is, the technique isn’t working for some reason. I don’t have an answer for that.”
The technique has been tried a time or two in women who have pain following lumpectomies, Dr. Esserman added, but “it has not been very productive. I doubt that it is going to be the solution there, and we just have to keep looking” for other means of dealing with that type of postsurgical pain.
For some people with neuropathic pain, “the best thing to do is to try some of the medicines that block neuropathic pain, like Neurontin [gabapentin], and that can be the solution,” Dr. Esserman said. “You can use lidocaine patches. There are a number of things that people can try, and this should just be one of the tools.”
No More Surgery Than Needed
Knowing that surgery and cautery can cause postmastectomy pain “is one of the reasons I am also motivated not to do more surgery than is needed, because some people get persistent pain,” Dr. Esserman said. And it can be very debilitating.
Working to prevent postmastectomy pain “is part of our ongoing learning and presents an opportunity,” Dr. Esserman said. “Nobody wants to cause pain or problems afterward. No one is doing it intentionally, but sometimes these things happen, and there is nothing we can do to stop it. But the more we understand it, the better we understand the source of pain and how to prevent long-term problems, we can even start to think about how to prevent the problems in the first place.”
For example, Dr. Esserman noted, “We are starting to work with our anesthesia team to think about doing thoracic nerve blocks” to avoid causing injury or pain. “If you use the anesthetic first, you may reduce the chance of pain postoperatively, and patients may never experience pain,” she noted. “There are lots of opportunities to continue to improve. That’s the great thing about medicine.” ■
Disclosure: Dr. Esserman reported no potential conflicts of interest.
1. Tang CJ, Eder SE, Lee DJ, Rabow MW: A simple intervention to relieve chronic neuropathic post-mastectomy pain. 2013 San Antonio Breast Cancer Symposium. Abstract P3-10-03. Presented December 12, 2013.
2. Pfaff LG: When pain persists after breast cancer. The New York Times, June 8, 2015.
Since postmastectomy pain occurs in an estimated 20% to 40% of patients undergoing the procedure, physicians who treat these women can expect questions about the pain and how to deal with it. However, some patients may be reluctant to ask about it.
“Sometimes, women don’t want to complain to their ...