From the Guidelines
For a 36-year-old female with recurrent right shoulder bursitis and a history of breast cancer on Tamoxifen, I strongly recommend physical therapy, including stretching and exercises, as the first-line treatment to manage her symptoms, as it has been shown to be effective in managing postsurgical musculoskeletal symptoms 1. This approach is crucial in addressing the patient's recurrent bursitis, which may be related to her breast cancer treatment, including Tamoxifen therapy, which can cause musculoskeletal symptoms, including joint pain and inflammation in up to 50% of patients 1. Key components of the treatment plan should include:
- Gentle range of motion exercises to improve shoulder mobility
- Strengthening of the rotator cuff muscles to enhance stability and reduce pain
- Application of ice for 15-20 minutes several times daily during acute flares, followed by heat therapy between flares to reduce inflammation and promote healing For pain management, acetaminophen (up to 3000mg daily in divided doses) is recommended as the first-line medication since it has minimal interaction with Tamoxifen 1. If needed, consider a short course of NSAIDs like ibuprofen (400-600mg three times daily for 5-7 days) with caution due to potential increased bleeding risk with Tamoxifen 1. A corticosteroid injection (such as methylprednisolone 40mg with lidocaine) may be appropriate for severe symptoms, limited to 2-3 injections per year 1. Regular follow-up is essential to monitor both the bursitis and breast cancer treatment, ensuring that the patient's symptoms are adequately managed and her treatment plan is adjusted as necessary to minimize the risk of breast cancer recurrence 1.
From the Research
Bursitis and Breast Cancer
- The patient's frequent occurrence of bursitis in the right shoulder since her breast cancer diagnosis in 2016 may be related to her treatment with Tamoxifen, but there is no direct evidence to support this claim 2, 3.
- Bursitis is a common cause of musculoskeletal pain and can be managed with nonsurgical methods, including ice, activity modification, and nonsteroidal anti-inflammatory drugs (NSAIDs) 2.
- The use of NSAIDs has been associated with a reduced risk of breast cancer, particularly estrogen receptor-positive tumors 4, 5.
Management of Bursitis
- The management of bursitis typically involves conservative care, such as physical therapy, anti-inflammatory drugs, and injection therapies 3, 6.
- In cases of septic bursitis, oral antibiotics may be administered, and local corticosteroid injection may be used in the management of prepatellar and olecranon bursitis 2.
- Surgical intervention may be required for recalcitrant bursitis, such as refractory trochanteric bursitis 2.
Relationship between NSAIDs and Breast Cancer
- NSAIDs may reduce breast cancer risk by 20%, but the optimal type, dose, and duration are still undetermined 5.
- The use of NSAIDs in combination with endocrine therapies may have a role in the adjuvant or palliative treatment of women with established breast cancer 5.
- The biological mechanisms underlying the effect of NSAIDs on breast cancer are not well defined, but they may involve the inhibition of cyclooxygenases and the generation of reactive oxygen species 4.