From the Journals

Younger age, greater anxiety, affect pain after breast reconstruction

Key clinical point: Identifying women at increased risk for severe acute postoperative pain allows clinicians the opportunity to reduce postoperative morbidity and improve patients’ surgical experience.

Major finding: Younger age (P = .002), bilateral procedures (P less than .0001), higher levels of preoperative pain (P less than .0001), and higher levels of preoperative anxiety (P less than .01) were among the strongest factors significantly associated with acute postoperative pain.

Data source: A prospective study of 2,207 women who underwent several types of breast reconstruction procedures.

Disclosures: The researchers had no financial conflicts to disclose. The study was supported in part by a grant from the National Institutes of Health/National Cancer Institute.


 

FROM THE JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY OPEN

Younger age, bilateral procedure, and presurgery depression and anxiety are among the significant contributors to pain after breast reconstruction surgery, according to findings from a prospective study of 2,207 women who underwent several types of breast reconstruction procedures.

Although breast reconstruction is an important element of breast cancer treatment, and most acute postoperative pain resolves with time and pain management intervention, some patients suffer from persistent, severe postoperative pain that increases their risk for long-term pain and clinical morbidity, wrote Anita R. Kulkarni, MD, of Memorial Sloan-Kettering Cancer Center, New York, and her colleagues.

Breast cancer surgery scars Pradit_Ph/Thinkstock
To identify patients at increased risk for higher levels of acute postoperative pain, the researchers assessed pain, patient characteristics, and medical/surgical variables before surgery and 1 week after surgery. Pain was assessed using the McGill Pain Questionnaire (MPQ)–Short Form, Numerical Pain Rating Scale (NPRS), and BREAST-Q chest and upper body scale. Depression and anxiety were assessed using the Patient Health Questionnaire and Generalized Anxiety Disorders Scale (JPRAS Open 2016. doi: 10.1016/j.jpra.2016.08.005).

Overall, greater acute postoperative pain was significantly associated with younger age, bilateral procedures, higher levels of preoperative pain, and higher levels of preoperative anxiety and depression, the researchers said.

“Moreover, the degree of patients’ self-reported preoperative anxiety and depressive symptoms both appeared to bear a linear relationship with the magnitude of increased postoperative pain at 1 week” on the MPQ sensory pain rating, they noted.

Similarly, lower scores of physical well-being based on the BREAST-Q physical well-being scale were significantly associated with younger age, bilateral procedures, immediate reconstruction, and higher levels of preoperative pain, anxiety, and depression.

The average age of the women was 50 years, and 87% were white. Most patients (69%) had tissue expander (TE)/implant reconstruction procedures; 93% were immediate reconstruction; and 53% were bilateral reconstruction. The majority (90%) underwent surgery as part of breast cancer treatment.

“The comparative effect of procedure type on postoperative pain showed variable results across our multiple pain scales,” the researchers said.

The patients who underwent autologous flap reconstruction procedures – pedicled transverse rectus abdominis myocutaneous flap (PTRAMS), deep inferior epigastric perforator (DIEP), or superficial inferior epigastric artery (SIEA) – reported less-severe postoperative pain than did those who had TE/Implant procedures. Specifically, patients with SIEA and DIEP procedures reported significantly less pain 1 week after surgery than did those who had TE/Implant procedures, based on the MPQ sensory scale. In addition, patients with PTRAMS reported significantly less postoperative pain 1 week after surgery than did those who had TE/Implant procedures based on the NPRS scale. All three flap procedures were significantly associated with less-severe postoperative pain, compared with TE/Implant procedures.

The findings support data from previous studies that identified preoperative pain, mood disturbance, and age as factors for increased risk of acute postoperative pain, the researchers noted. In addition, “the findings have important implications for the identification of women who might be at risk for significant early postoperative pain following breast reconstruction, as acute postoperative pain is associated with poor functional outcomes, diminished quality of life, and the risk for development of persistent postsurgical pain,” they wrote.

The study results were limited by several factors, including the lack of standardization for postoperative pain treatment regimens, variability in the timing of preoperative assessment, and nonresponder bias, the researchers said.

However, “Once high-risk patients are identified, appropriate referrals can be considered to facilitate careful monitoring of postsurgical pain for selected patients,” they said. “Early intervention can give clinicians the opportunity to reduce postoperative morbidity and improve patients’ surgical experience and satisfaction with breast reconstruction outcome,” they added.

The researchers had no financial conflicts to disclose. The study was supported in part by a grant from the National Institutes of Health/National Cancer Institute.

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