Chronic pain after mastectomy: current knowledge and knowledge gaps

Post-mastectomy pain syndrome (PMPS) is a frequent and burdensome complication of breast cancer surgery, manifesting as persistent pain following mastectomy, typically with neuropathic characteristics. This review synthesizes current knowledge on the epidemiology, prevention, and treatment of PMPS, and highlight knowledge gaps to inform future research. PMPS occurs in 28-52% of patients. It is associated with impairment in quality of life, and reductions in physical and psychosocial functioning. Consistently identified risk factors include younger age, extensive axillary surgery, total mastectomy, and preexisting chronic pain. Perioperative preventive strategies, such as topical EMLA cream, pregabalin, PECS II block, i.v. dexmedetomidine and flurbiprofen axetil, show potentially promising effects in reducing the incidence or severity of PMPS. Treatment options for established PMPS with potentially promising effects include topical capsaicin, amitriptyline, venlafaxine, multimodal pharmacological therapy, thermal radiofrequency of the stellate ganglion, and mindfulness-based cognitive therapy. For both preventive and therapeutic strategies, heterogeneity in study design, dosing regimens, and outcome frameworks, as well as the small sample size of most studies, limit the strength of evidence. Large knowledge gaps exist in the understanding of the molecular mechanisms associated with PMPS. Future research focusing on the molecular mechanisms promoting PMPS can facilitate the development of novel effective preventive and therapeutic strategies. Large-scale well-powered clinical trials on interventions aiming to prevent and treat PMPS are highly needed to inform evidence-based clinical practice. Future clinical studies should also aim to identify biomarkers that predict the efficacy of interventions in individual patients, thereby supporting personalized medicine.