Event 6: Cancer Related Breast Pain

Meet Sharon

Sharon suffers from pain following a mastectomy.

Postmastectomy Pain Syndrome (PMPS)

  •  >12% of women will be diagnosed with breast cancer within their lifetime 
  • After receiving breast cancer treatment, 90% of survivors report physical problems that: 
    • Reduce function 
    • Cause emotional problems 
    • Negatively impact body image
    • Effect quality of life
  • PMPS 1st discovered in the 1970’s 
    • The Association for the Study of Pain defined it as chronic pain resembling neuropathic pain 
  • A chronic neuropathic pain that affects the axilla, medial arm, breast, and chest wall following breast cancer surgery 
  • Pain is not caused by an infection 
  • According to Caviggioli, Maione, Klinger et al., exact pathogenesis of PMPS remain unclear
  • Affects 25%-60% of patients 
    • Prevalence is higher after lumpectomy than after mastectomy
  • Can last for years following surgery/treatment and negatively influence a patient’s life 
    • Reduces physical function
  • Can seriously affect patients’ emotions, daily activities, social relationships
  • Major economic burden for health systems

Sharon's Doctor Said Nothing Was Wrong


  • Dunne & Keenan, 2016
  • Andersen, KG, et al., 2015; Beyaz SG, et al., 2016; Meijuan Y, et al., 2013; Vilholm OJ, et al., 2008; 
  • Caviggioli F,  et al., 2016).

Patient Related Risk Factors for Postmastectomy Pain Syndrome (PMPS)

  • Age
  • Gender
  • Body mass index (BMI)
  • Genetic polymorphisms
  • Psychosocial status
  • Pain before surgery
  • Psychological factors: anxiety, depression


Andersen KG, et al., 2015; Beyaz SG, et al., 2016; Vilholm OJ,  et al., 2008; Caviggioli F,  et al., 2016

Etiology of Chronic Pain From Postmastectomy Pain Syndrome (PMPS)

  • Dissection of the axillary lymph nodes 
  • Procedure reduced over past years after the introduction of sentinel node biopsy 
  • Dissection of the intercostobrachial nerve or damage to axillary nerve pathways could influence development of chronic pain especially with axillary lymph node dissection 
  • Scarring from surgeries can lead: 
    • fibrosis
    • possible trapped nerve with potential for persistent pain from scarring


Vilholm OJ, et al., 2008; Caviggioli F, et al., 2016

Location of Sensory Disturbance After Breast Cancer Surgery

Bar chart showing the location of sensory disturbance after breast cancer surgery. Axilla was most commonly reported at 72 out of 144 women, followed by arm at 47, 34 for breast area, and 4 for scar.
Adapted from graph by Mijuan, et al., 2013


Meijuan Y, et al., 2013

Signs and symptoms of PMPS

  • Neck pain
  • Shoulder pain (frozen shoulder)
  • Reduced mobility
  • Negative boy image (PMPS affects both psychological and physical aspects of life)
  • Described as "burning pain, shooting pain, pain evoked by pressure, and deep blunt pain"

Sharon Describes Her Pain


Vilholm OJ, et al., 2008; Caviggioli F,  et al., 2016

Postmastectomy Pain Syndrome (PMPS) and Development of Frozen Shoulder

  • Usually develops within 2-9 months 
  • Symptoms: 
  • Pain and stiffness 
  • Pain may decrease but range of motion may be limited 
  • Range of motion decreased 
  • Raising the arm may be difficult or nearly impossible

Sharon Describes the Sensation of Frozen Shoulder


How to release a frozen shoulder, 2004

Treatment of Postmastectomy  Pain Syndrome (PMPS)

  • Should be referred to pain specialist
  • Considered challenging
  • Medications such as opioids can be ineffective in treating neuropathic pain

Description of PMPS

Treatment of PMPS


Vilholm OJ, et al., 2008; Caviggioli F,  et al., 2016

Hyperalgesia and Allodynia from Postmastectomy Pain Syndrome (PMPS)


Increased pain from a stimulus that normally provokes pain.


  • A pin prick on the skin feels like a jab from a knife


Pain due to a stimulus that does not normally provoke pain.


  • Pain is present when wearing shirts, blouses, bras, or a prosthetic breast
Chart showing the area under a curve related to hyperalgesia and allodynia. Both responses are skewed outside the normal range of pain response.
Compliments of Gottschalk A, Smith DS, 2001


Gottschalk A, Smith DS, 2001; Merskey H, Bogduk N, 2011

Questions and Answers With John Farrar, MD, MSCE, PhD

Teaching Students About Postmastectomy Pain Syndrome (PMPS)

Question 1: Prevent Postmastectomy Pain Syndrome (PMPS)

Question 2: Follow Up

Question 3: Typical Course of Postmastectomy Pain Syndrome (PMPS)

Treatment of Postmastectomy  Pain Syndrome (PMPS)

Pharmacological Treatments

  • Antidepressants
  • Antiepileptics
  • Topical Anesthetics (lidocaien patches, opioids)

Non Pharmacological Treatments

  • Physical therapy
  • Interventional therapy
  • Spinal cord stimulation
  • Surgical procedures
  • A combination of treatment may be most effective

Follow Up with Sharon


Vilholm OJ, et al., 2008; Caviggioli F,  et al., 2016

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