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 surgeons,” ­Laura J. Esserman, MD, MBA, said in an interview with The ASCO Post. “These women may feel like, ‘Hey, I’m cured. I shouldn’t be complaining.’ But people legitimately have problems with pain, so I think that physicians should also ask patients about pain and make sure that they are not suffering.”

Dr. Esserman is Director of the Carol Franc Buck Breast Care Center and Co-Leader of the Breast Oncology Program at the University of California, San Francisco. She is also co-author of a study finding that injections of a combination of bupivacaine and dexamethasone into trigger points of pain identified along the inframammary fold provided a safe and effective treatment option for neuropathic postmastectomy pain (in press, Annals of Surgical Oncology).

The authors concluded, “This technique should be added to the armamentarium of all surgeons who perform breast surgery.” To help physicians learn about and practice the technique, Dr. Esserman presented a step-by-step approach in a video available at cancer.ucsf.edu/breastcancercenter.

“Health-care providers should routinely screen their patients for the presence of postmastectomy pain syndrome,” the study authors added. This screening should include asking patients whether they have pain and whether the pain hinders their ability to wear a bra or to sleep on the affected side. A focused examination should be done to ascertain whether there are trigger points of neuropathic pain caused by damage during surgery to the T4 and T5 sensory nerves as they exit the chest wall.

Listen and Look

“You have to listen. You have to look. You have to work with people to keep trying to find a solution to the pain,” Dr. Esserman said. “You can try things like lidocaine patches. Pain is an important problem, and you have to try to pay attention to it, keep working to try to figure out what is wrong.”

If it does turn out that the pain is caused by damage to the T4 and T5 sensory nerves and trigger points of pain can be identified, an injection of a 2-mL mixture of equal parts 0.5% bupivacaine and 4 mg/mL of dexamethasone can be a safe, simple, and effective option for treating that pain.

As mentioned in the video, the technique is effective 90% to 95% of the time that trigger points can be identified. “I am amazed at how well it has worked and how consistent that has been,” Dr. Esserman stated. “This is something new that we have figured out that has made a really big difference.” ■

Disclosure: Dr. Esserman reported no potential conflicts of interest.