Post-Mastectomy Pain Syndrome

By Constance M. Chen, MD, MPH

Pain after any type of surgery is expected, but up to 30% of women undergoing mastectomy as part of breast cancer treatment will experience long-term pain and discomfort known as Post-Mastectomy Pain Syndrome, or PMPS. Fortunately, several effective treatment options are available for this vexing and distressing condition.

Each year, more than 100,000 women in the United States undergo some form of mastectomy—the surgical removal of one or both breasts—which is typically performed to treat breast cancer but might also be done to prevent the disease. With more than 3.5 million women with a history of breast cancer in the U.S., that amounts to a large number who may live with PMPS, marked by nerve pain in the chest wall, armpit, and/or arm that doesn’t ease over time. Pain immediately after a mastectomy is normal, including stiffness or swelling. Discomfort and pain extending months and beyond, however, may signify more than a prolonged healing process – it could indicate PMPS. Sometimes, PMPS can be so pronounced that some women may have trouble using their arm or moving it in all directions. It can definitely take a toll on your mental wellness.

Risk factors  

The exact cause of PMPS isn’t well-understood, and the condition can happen after breast-conserving surgery such as lumpectomy as well. Often, PMPS is due to stiffness that can be alleviated with increased motion and physical therapy. Other times PMPS can be due to breast implants that are placed under the pectoralis muscle, which causes uncomfortable stretching and pressure to the muscles and nerves like a stone stuck in a shoe. Rarely, PMPS can occur due to nerve disruptions after surgery.

Who’s more likely to develop PMPS? Risk factors include the following:

• Age:Research suggests that younger women face higher odds of PMPS compared to older women, meaning someone who is 40 might have a higher risk of long-term post-mastectomy pain than a woman 20 or 30 years older.
• Treatment type:If your breast surgery removed tissue from the underarm or upper outside portion of the breast, PMPS may be more likely. This is also true if your surgery removed 10 to 14 lymph nodes around the underarm to check for cancer or if you underwent radiation therapy as part of treatment.
• Race/ethnicity:Post-mastectomy pain may be more likely to linger in women who are part of certain racial or ethnic groups, including Blacks and Latinos. This may be because these groups tend to be diagnosed when their breast cancer is at a later stage.
• Mental health challenges:Anxiety or depression may predispose you to experience persistent pain after surgery, according to research.
• Past pain:If you’ve dealt with chronic pain before, such as low back pain or headaches, you may have higher odds of experiencing lingering post-operative pain.

PMPS treatment options  

The first step for getting help for PMPS is to talk to your doctor or cancer care team if your pain is not improving over time. Several approaches can help ease the physical and mental effects of the condition. They include the following:Pain medications: Depending on how recently your breast surgery was performed, pain relief can come in the form of over-the-counter acetaminophen or NSAIDs (nonsteroidal anti-inflammatory drugs) to prescription low-dose opioids for short periods. For longer periods, you may need a referral to a pain specialist.Regional anesthesia: If oral medications don’t help, your doctor may refer you to a pain specialist for local or regional anesthesia such as nerve blocks.Steroid injections: These can help reduce nerve inflammation that contributes to pain.Implantable nerve stimulators: These devices can disrupt abnormal nerve signals leading to prolonged pain.Physical therapy: A focused course of physical therapy can target the reduced flexibility and strength that are hallmarks of PMPS. Physical therapy can also lessen scar tissue development around injured nerves that may also play a part in chronic pain development. \Surgery: Sometimes scar tissue forms around a nerve, or a divided nerve forms an overgrowth of scar tissue called a neuroma. Surgical exploration can help free up scar tissue or resect a neuroma.Constance M. Chen, MD, is a board-certified plastic surgeon with special expertise in the use of innovative natural techniques to optimize medical and cosmetic outcomes for women undergoing breast reconstruction. She is Clinical Assistant Professor of Surgery (Plastic Surgery) at Weill Cornell Medical College and Clinical Assistant Professor of Surgery (Plastic Surgery) at Tulane University School of Medicine. www.constancechenmd.com