October is breast cancer awareness month and there is still a significant opportunity for ongoing education on diagnostic symptoms and treatment options for this devastating disease. An estimated 287,850 new cases will be diagnosed this year according to the American Cancer Society.
Most breast cancer patients will face ongoing pain as part of the treatment and recovery process. We recently spoke with Dr. Amitabh Gulati, a chronic and cancer pain physician in New York, to learn more about breast cancer pain management, and how peripheral nerve stimulation (PNS) may be an option for acute or chronic pain that may result from cancer or cancer treatments.
SPR: Dr. Gulati, are there symptoms, like pain, that can appear early, prior to diagnosis that women (or men) should be aware of in addition to completing regular self-checks and mammograms?
Dr. Gulati: What we notice in most of our patients, as well as in our standard preventative approaches to discover breast cancer early, is patients will have symptoms that are not necessarily very painful, but rather something is different. For example, a lump in their breast, a change in their skin, in their nipple, or something atypical about their breast may occur, but less commonly pain.
SPR: Can you tell us a little bit more about how, when and where pain can occur in breast cancer patients? Is it common to have pain, and when in the disease progression and treatment do patients typically experience pain?
Dr. Gulati: When we think about pain and breast cancer, the pain that patients might experience may occur after surgery or following radiation and/or subsequent reconstruction of the breast. We also notice patients experiencing pain if they undergo some form of chemotherapy, hormone replacement therapy, or other pharmacologic treatment.
Most likely breast pain is going to be a result of the treatment of the breast cancer, as opposed to the initial discovery of it. It’s our hope to help patients through the entire process from diagnosis all the way to completion of treatment, and to help them with their pain symptoms, should they arise. The pain patients may experience may present itself, not only in the breast, but in the shoulder, back, and surrounding areas.
SPR: What do you find are some of the more common causes of ongoing, chronic pain following breast cancer treatment?
Dr. Gulati: Our surgeons are phenomenal at taking out the cancer. Following surgery, the resulting remission rates of breast cancer are remarkably high. Unfortunately, as a result of the surgery some nerves that are around the breast and skin may get damaged. Sometimes those nerves can cause pain, especially if they remain damaged.
We see post-mastectomy pain either from the actual breast cancer surgery or the reconstruction surgery. The reconstruction may involve the placement of an implant or placement of an expander of the breast tissue before the implant is placed. Both options may cause some pain along the way. Fortunately, we have many strategies to help these patients.
SPR: Does your approach to the treatment of pain related to breast cancer vary versus other types of cancer pain or related oncologic pain?
Dr. Gulati: If you asked me this question 15 years ago, many of our patients were looking at end-of-life care, and we were mainly trying to help our patients manage or cope with their pain for a finite period of time.
Thankfully, this has significantly improved since I started my career, which is wonderful news. When it comes to breast cancer, the fact that we can detect the cancer very early means we’re often looking at a patient who has pain, but they may have a life expectancy of many decades. As a result, some of our therapies must be more geared towards how we help people without ablating (applying energy to destroy the painful nerves) the entire nervous system that goes to the breast. Whereas maybe 20 years ago, if I’m thinking one year of longevity for my patient, I might not be as worried about destruction of nerves. For someone who is potentially living another 30 to 50 years, I am thinking about other modalities for pain control, more like we do for chronic pain patients.
Treatments to help patients who are suffering that are not destructive in nature have become more common, whether injections, neuro-electrical stimulation, or psychological or coping strategies. We are adding these things on sooner in our treatment plan, as we expect our patients to be part of the community for a long time.
SPR: What are some of the first questions or concerns that patients have in creating a cancer pain management plan?
Dr. Gulati: I think for our breast cancer patients, just the fact that there are physicians and people involved to help them get through their pain journey can be a huge relief. Many times, our patients may not be aware that these kinds of options exist. They may not be getting appropriate treatments for pain control from their various providers. Seeing this visible sign of relief in patients after discovering there’s an opportunity for treatment of their pain is one of the most rewarding parts of my job.
Having good treatments that are either non or minimally invasive and providing treatments that have minimal chance of long term injury is another critical element.
SPR: How do you create cancer pain programs that consider both the physical pain that comes following treatment along with the nonphysical stressors that patients experience?
Dr. Gulati: Part of developing a comprehensive cancer pain plan is to know all the different aspects of the pain syndrome that you may be able to help them with. As a patient suffers through treatment of oncologic disease and subsequently their pain, it’s very helpful to have either a social worker or psychologist that you can collaborate with. This helps the patient in coping with their cancer, including their pain.
SPR: What are the most frequently used interventional pain treatment options for helping breast cancer patients?
Dr. Gulati: Over the years, we’ve really understood how the neural innervation of the breast works, what damages might occur during surgery and how we can address the pain symptoms.
What I mean by that is that there is not just one nerve that goes to the breast. It’s a web of nerves in distinct locations between muscles and the soft tissue. Understanding the planes where these nerves reside, which can be localized with ultrasound or other imaging techniques, has allowed us to offer various kind of “blocks” with corticosteroids, local anesthetics, and other medications that are helpful for our patients.
There are some new tools that are available that we didn’t have access to 10-15 years ago. We’re trying to incorporate those options into our practice. Whether it’s neuromodulation, forms of acupuncture, transcutaneous electrical nerve simulators, or novel medications, we have developed algorithms that may help standardize the options available for our patients.
SPR: How has neuromodulation been applied for breast cancer patients living with pain?
Dr. Gulati: One of the things we’ve been working on with our patients is really trying to fine-tune where the problem is arising from. If they have shoulder pain, is it actually the pectoral muscles that got radiated, and now have scarring of tissue? Or is it a problem in the back of the shoulder? Obviously, we do not want to destroy these areas. Once you lose function of a muscle or nerve, you create a lot of other problems. What’s been very beneficial the last few years is either using neuromodulation systems, such as transcutaneous electrical nerve simulation, or utilizing devices such as peripheral nerve simulation to target the nerves that might trigger the pain.
My experience with other forms of neuromodulation, such as spinal cord simulation, has not been as fruitful as peripheral nerve stimulation. Using some of the targeted ability of the peripheral nerve stimulation systems on an individual nerve that might be going to the breast, axilla, or the shoulder girdle has been a much better approach to helping some of our patients. The “feeling” from the activation of a peripheral neuromodulation system occurs specifically where the injury is, as opposed to a kind of global “feeling” that might occur with the spinal cord stimulator.
SPR: What has been your experience with using the SPRINT PNS System to treat your patient’s pain?
Dr. Gulati: To be able to use a temporary stimulator for patients is much more palatable than implanting a permanent device that must stay in their body unless they have surgery to remove it. Most of our patients tend not to want a permanent type of system implanted if they could avoid it. They’re looking at longevity of many, many years, perhaps many decades. And it’s when you think along these lines, having a device that might be active for 60 days and then removed, seems to be much more palatable than having a permanent device. We have been successful in many instances of getting pain relief during the 60-day treatment, with some durable relief afterwards.
We should also consider that in the future, MRI is becoming more common for either evaluation or surveillance of the breast. And as an MRI becomes more standard practice, we may see that devices have to be MRI conditional in order to be used for our patients. When you think along those lines, a 60-day treatment with a removable peripheral nerve stimulator, such as the SPRINT system, would be much more practical in these patient populations.
SPR: What changes do you envision in the coming decade regarding the management of oncologic pain in patients?
Dr. Gulati: Our field really depends on how oncology is doing in managing the disease. What I’ve seen in the last 15 years is that oncology has advanced their field significantly. With diseases that were once deadly, patients were not living more than a year, and this has changed with those patients now living five to ten years. As a result, our therapies should be more tailored toward a patient that’s living for a decade or two, while they’re getting their oncologic management.
And these are the same changes we are seeing in our oncologic pain practices. We are going to see a practice more akin to a chronic pain practice in terms of regular pain management, whether it’s injections or device management.
You may also see changes in pharmacotherapies that are not opioid based, but instead are going to be multimodal therapies that use minimal or no opioids. Twenty years ago, the opioid was the mainstay of practice, and today, it’s only one aspect of practice. Today we have so many other alternative options for pain control that help patients limit or avoid the long-term use of opioids. That’s one of the biggest changes because we expect our patients to live longer so our treatments must be more varied and less dependent on opioids.
Dr. Gulati’s work is in interventional cancer pain management and research with a focus on diagnostic and therapeutic ultrasound and neuromodulation for treating for acute or chronic pain that may result from cancer or cancer treatments. Read more in our October 2021 interview with Dr. Gulati.
The SPRINT PNS System is indicated for up to 60 days for: (i) Symptomatic relief of chronic, intractable pain, post-surgical and post-traumatic acute pain; (ii) Symptomatic relief of post-traumatic pain; and (iii) Symptomatic relief of post-operative pain. The SPRINT PNS System is not intended to be placed in the region innervated by the cranial and facial nerves.
Physicians should use their best judgment when deciding when to use the SPRINT PNS System. For more information see the SPRINT PNS System IFU. Most common adverse events are skin irritation and erythema. Results may vary. Rx only.
Important safety & risk information: https://bit.ly/2FU92NH