Chronic Neuropathic Pain in Women after Breast Cancer Treatment

Fozia Bokhari, RN, BN; Jo-Ann V. Sawatzky, RN, PhD

Disclosures

Pain Manag Nurs. 2009;10(4):197-205. 

In This Article

Implications for Nursing

The HRTI model provides an appropriate organizing framework to gain knowledge and insight into the human response of chronic neuropathic PPBT in women after breast cancer treatment. Knowledge of the "normal" physiologic response of acute pain and the underlying pathophysiology of chronic neuropathic pain provides insight into optimal management strategies. The behavioral and experiential responses, as well as the personal and environmental factors establish a foundation for an accurate and holistic approach to the assessment of PPBT. Gaps in the research literature have also been identified. Thus, this model guides nursing practice, education, and research.

Practice

Assessment and management of the human responses to illness are central to nursing practice. Ideally, the response should be prevented, which begins by identifying individuals at risk. Specific to PPBT, this assessment should focus on the personal factors of age and BMI. As well, environmental risk factors for PPBT should be minimized. Prevention may include preoperative application of eutectic mixture of local anesthetics; (EMLA [AstraZeneca]), (Fassoulaki et al., 2000) preserving the nerves around the surgical site, minimizing invasive procedures, and decreasing injury to tissue and nerves through proper surgical technique. (Jung et al., 2005, Paredes et al., 1990, Selim et al., 2002) Prevention can also be achieved by minimizing the acuity of pain post surgery via adequate analgesia (Jung et al., 2003) or paravertebral blocks. (Iohom et al., 2006, Kairaluoma et al., 2006) Nurses can play key roles in establishing best practice guidelines to prevent PPBT. These guidelines can then be used to increase awareness of PPBT, which in turn would enable nurses in preoperative assessment clinics, in the operating room, and on postsurgical units to identify women at risk for PPBT and to advocate for strategies to optimize their treatment outcomes.

In situations where PPBT is not prevented, early detection should become the goal of patient care. Nurses working in outpatient settings are ideally situated to identify early signs of chronic neuropathic PPBT in their patient assessments. The patient history and physical examination should be guided by the knowledge of the behavioral and experiential responses to chronic neuropathic PPBT. For example, a comprehensive pain assessment may elicit early signs of PPBT, such as increased pain intensity on a pain scale and neuropathic pain descriptors such as hot, burning, sharp, stabbing, and cold as well as allodynia and common nonpainful sensations such as tingling, prickling, itching, numbness, and pins and needles. (Gilron et al., 2006) Although increased acute pain intensity is generally reported in the immediate postoperative period, the neuropathic pain descriptors tend to manifest later. If these early signs are identified, appropriate pain management interventions must be initiated by the clinical staff, with referrals to pain clinics or other resources, as appropriate.

Chronic pain management involves the use of early and effective pharmacologic and nonpharmacologic treatment strategies. No single pharmacologic agent is effective for relieving all neuropathic pain; (Galuzzi, 2007, Gilron et al., 2006, Stillman, 2006) treatments must be individualized to take into account the various pathophysiologic patient responses to pain. Unfortunately, there is still much discrepancy in the literature regarding the efficacy of pharmacologic management of chronic neuropathic pain, and further research in this area is needed. Nevertheless, drug regimes for PPBT must address the related pathophysiologic mechanisms underlying chronic neuropathic pain. These regimes generally include the use of antiinflammatory agents, opioid analgesics, antidepressants, antiepileptic/neuroleptics, and NMDA antagonists, alone or in combination. (Davis, 2006, Selim et al., 2002, Stillman, 2006, Stubblefield and Custodio, 2006)

Despite the dearth of rigorous clinical trials on antiinflammatory agents, commonly used analgesics such as nonsteroidal antiinflammatory drugs and nonopioids such as acetaminophen have shown some success as adjuvants in cancer pain treatment; (Stillman, 2006) however, they are generally ineffective for pure neuropathic pain. (Gilron et al., 2006) Although opioid analgesics are thought to inhibit central ascending pain impulses, (Stillman, 2006) their efficacy in neuropathic pain remains controversial. (Gilron, et al., 2006)

Antidepressants have been at the core of neuropathic pain therapy for almost two decades. (Stillman, 2006) Pain signal inhibition can be enhanced by antidepressants drugs that inhibit reuptake of serotonin, such as venlafaxine and duloxetine, and tricyclic antidepressant, such as amitriptyline, imipramine, nortriptyline, and doxepine. (Stillman, 2006) Antiepileptic drugs (i.e., neuroleptics, anticonvulsants) are also commonly used to treat neuropathic pain and include gabapentin, pregabalin, carbamazepine, topiramate, (Stillman, 2006) and lamotrigine. (Galuzzi, 2007) The NMDA antagonists, such as ketamine, hold promise owing to the role that NMDA plays in central sensitization, (Gilron, et al., 2006) but ketamine must be used with caution, owing to dose-related side effects that affect psychocognitive functioning. (Visser & Schug, 2006) Other drugs targeting neuropathies associated with radiation or chemotherapy include topical counterirritants, such as capsaicin cream, and local anesthetics and corticosteroid injections. (Selim et al., 2002) If these pharmacologic treatments fail, the use of nerve blocks may be recommended. (Selim et al., 2002)

Alternatively, adjunctive therapies, such as guided imagery, acupuncture, biofeedback, physiotherapy for arm movement limitations, and psychologic counselling have also been used in managing chronic neuropathic PPBT. (Selim et al., 2002) Although very few studies have been done on the efficacy of these treatments, and there is still much controversy regarding their benefits, nurses working with women who have PPBT should be prepared to provide information regarding these alternative therapies to their patients. More research is required to understand the underlying pathophysiologic mechanisms of neuropathic pain and to determine appropriate pharmacologic and alternative treatment regimes.

Education

Nurses play a key role in the education of patients, as well as other health care professionals, about chronic neuropathic PPBT. It is important for preoperative clinic nurses to inform their patients about the possibility of developing this syndrome. Perioperative nurses should be taught how to identify those patients who are at risk for PPBT. This can be accomplished with an accurate and thorough history and ongoing physical assessment. Nurses and other health care professionals should take careful note of the potential risk factors, such as younger age (<35 years), increased BMI, type of procedure, and acute postoperative pain, as they follow patients through the breast cancer surgery recovery trajectory.

Once the diagnosis of PPBT is confirmed, patients should be educated and reassured that the neuropathic pain is not a sign of the cancer recurring, but rather an adverse consequence of their cancer treatment. Additionally, nurses should routinely ask breast cancer patients about the presence of pain regardless of how long ago their surgery or other therapy was completed. Table 1 outlines a series of sample questions based on the four domains of the HRTI model that nurses can ask patients to gather information on PPBT. Neuropathic pain in this population may persist and go unrecognized and untreated for years; therefore, this can be an issue for long-term survivors of cancer, as well as those currently receiving cancer therapies. Educating both patients and health care professionals can increase the awareness of this often debilitating condition and optimize patient outcomes.

Research

The gaps in the research literature related to chronic neuropathic PPBT should be addressed through nursing research. It is important that nurses develop pertinent streamlined instruments to facilitate the assessment of chronic neuropathic PPBT. Nursing research should also focus on the existing limitations in the current PPBT literature related to study design; for example, small sample sizes and the use of retrospective studies have been issues in past studies. There is also a paucity of literature exploring the long-term effects of living with chronic neuropathic PPBT. An ongoing study, led by researchers in Aberdeen, Scotland, was initiated in November 2006 and aims to assess risk factors associated with PMPS (University of Aberdeen, 2007) and may address some of these limitations. Nevertheless, further research is required to address these gaps in knowledge, which will, in turn, improve the outcomes for this patient population.

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