Case of the Month #22: Post Mastectomy Pain by Dr Sonia Pierce

Mrs J was assessed by the patient’s local pain service’s multidisciplinary team. This was a joint initial assessment with a doctor in pain medicine and a clinical nurse specialist. She told them her story of pain, which began 2 years ago, following her mastectomy and axillary node clearance surgery and radiotherapy for breast cancer.

She explained she suffered with a constant ache throughout her anterior chest wall, with a sharp, prickling pain in the region of her mastectomy scar. She struggled to lift her right arm and described an intermittent shooting pain in her axilla, which was worse on movement on her arm. She found wearing tight clothes unbearable. It began soon after her operation, when she recalled feeling sore and ‘rough’ and needing extra painkillers whilst on the ward.

Mrs J took paracetamol regularly. Her other medication included and antihypertensive and letrozole. She had tried codeine-based medication but found it very constipating. Her GP had also previously trialled amitriptyline for her, but she found it made her very sleepy.

Her pain was impacting significantly on her quality of life. She found it more difficult to sleep at night; sleep initiation was difficult because she struggled to get comfortable. She told the team she woke feeling unrefreshed. She lived in a bungalow with her husband, and between them, they were able to manage household tasks, but shopping was a struggle. She avoided going out to meet friends or go shopping because of her pain. She disliked feeling low because of her pain and did not want to appear miserable in front of her friends. She explained she understood she was clear of cancer, but her pain was a constant reminder of her difficult two years. She wanted life to get back to normal now her treatment was completed. She recalled being upset and frightened following her cancer diagnosis, and she just wanted it all sorted out now.

On examination, Mrs J had an area of hyperalgesia over her anterior chest wall, extending beyond the region of her well healed surgical scar. There were some tattoo dots visible on her chest wall, indicating post-surgical radiotherapy. She had some restriction of shoulder movement, including abduction and an x-ray demonstrated some minor osteoarthritic changes. The surgical team had thoroughly investigated her prior to referral, and there was no sign of cancer recurrence, no free fluid or other signs of infection and no further surgical intervention was indicated.

What would you consider when formulating a management plan with Mrs J?