What are the challenges of treating breast cancer-related pain, including short- and long-term effects of interventions like surgery, chemotherapy, or Aromatase (AR) inhibitors on patient outcomes?

From the Guidelines

Treating breast cancer-related pain is a complex challenge that requires a multifaceted approach to manage short- and long-term symptoms, as well as the side effects of interventions like surgery, chemotherapy, and aromatase inhibitors, which can significantly impact patients' quality of life. Breast cancer survivors often experience difficulties with the ipsilateral upper extremity after surgery, including decreased range of motion, rotator cuff injury, adhesive capsulitis, and axillary web syndrome, leading to a decreased ability to perform activities of daily living and impacting employment 1. Systemic therapies for breast cancer have also been associated with the development of musculoskeletal symptoms, such as limited shoulder range of motion, musculoskeletal pain, upper limb weakness, and numbness, with varying prevalence rates among patients 1.

Some of the short-term challenges faced by patients include managing post-operative pain, inflammation, and tissue damage, while long-term challenges involve persistent neuropathic pain, lymphedema pain, and psychological distress that can amplify pain perception. Treatment interventions themselves contribute significantly to pain issues, with surgery leading to intercostobrachial neuralgia, phantom breast pain, and neuroma formation, and chemotherapy agents like taxanes and platinum compounds causing chemotherapy-induced peripheral neuropathy (CIPN) 1. Aromatase inhibitors frequently cause arthralgias and myalgias in up to 50% of patients, sometimes leading to treatment discontinuation and potentially compromising cancer outcomes 1.

Key considerations for managing breast cancer-related pain include:

• Using a multimodal approach that combines pharmacological and non-pharmacological interventions
• Implementing physical therapy, including stretching and other exercises, to manage postsurgical musculoskeletal symptoms 1
• Considering alternative treatments, such as acupuncture, which has been shown to result in a statistically significant improvement in aromatase inhibitor-associated symptoms 1
• Encouraging exercise programs, which have been demonstrated to decrease aromatase inhibitor-associated pain by 20% 1
• Balancing effective pain control with minimizing medication side effects and avoiding interference with ongoing cancer treatments, requiring individualized and often interdisciplinary approaches to optimize quality of life during and after breast cancer treatment.

From the Research

Challenges of Treating Breast Cancer-Related Pain

• Breast cancer-related pain is a significant problem that can negatively affect the functional status and quality of life (QoL) of patients 2.
• The actual cause of the pain must be recognized to tailor management to each patient, requiring thorough patient evaluation and critical assessment of pain 2.
• Pain management in breast cancer patients involves pharmacotherapy, including opioid and non-opioid analgesics, as well as non-pharmacologic therapies such as complementary and alternative medicine (CAM), procedural, and psychosocial interventions 2, 3.

Short- and Long-Term Challenges Faced by Patients

• Short-term challenges include managing pain during treatment, such as surgery, chemotherapy, or aromatase inhibitors, which can have varying degrees of effectiveness and side effects 4, 5.
• Long-term challenges include persistent pain after successful treatment of breast cancer, which can be a growing problem and require ongoing management and treatment 4.
• The biopsychosocial model of pain and the notion of variable sensitivity within the pain system can inform treatment selection and implementation for long-term pain management 4.

Influence of Interventions on Long-Term Outcomes

• Interventions such as surgery, chemotherapy, or aromatase inhibitors can influence long-term outcomes, including the risk of persistent pain and other side effects 6.
• The choice of systemic therapy for non-metastatic breast cancer is determined by subtype, and local therapy consists of surgical resection with consideration of postoperative radiation 6.
• Tailoring postoperative treatment based on preoperative treatment response is under investigation, and optimal therapy for each patient depends on tumor subtype, anatomic cancer stage, and patient preferences 6.