Accreditation/Credit Designation

Physicians' Education Resource®, LLC is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Physicians' Education Resource®, LLC designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Acknowledgement of Commercial Support

This activity is supported by an educational grant from Pacira.

Community Practice Connections™: A Better Way to Stop Pain: Paths Toward Responsible Postsurgical Pain Management for Patients With Breast Cancer


Release Date: May 15, 2018
Expiration Date: May 15, 2019
Media: Internet - based

 

Activity Overview

Patients with breast cancer who undergo surgical procedures such as mastectomy and breast reconstruction are susceptible to postsurgical pain, which may adversely affect both acute and long-term outcomes. As clinicians involved in the postsurgical care of these patients, you can help them by providing pain management strategies that are both effective and responsible, given the contemporary opioid crisis that is claiming American lives every day. New multimodal approaches to pain management are being employed that may offer significant benefits to your patients. We have developed an educational activity to help you set and meet appropriate pain management goals at the preoperative, intraoperative, and postoperative stages. You will learn how these strategies can be applied to your patients and the types of procedures that they undergo.

We will address multiple key topics pertaining to pain management for your patients, as our multidisciplinary panel of clinical experts in surgical oncology and anesthesiology shares their perspectives on pain management options, techniques to provide pain relief, and the rationale for you to consider an opioid-sparing treatment regimen.

Acknowledgement of Commercial Support

This activity is supported by an educational grant from Pacira.

Instructions for This Activity and Receiving Credit

  • You will need to login to participate in the activity.
  • Each presentation may contain an interactive question(s). You may move forward through the presentation; however, you may not go back to change answers or review videos/content until you finish the presentation.
  • At the end of the activity, “educational content/video files” will be available for your reference.
  • In order to receive a CME certificate, participants must complete the activity.
  • Complete the posttest and pass with a score of 70% or higher, complete the evaluation and then click on request for credit. Participants may immediately download a CME certificate upon completion of these steps.


Target Audience

This activity is directed toward medical and surgical oncologists, fellows, nurses, nurse practitioners, physician assistants, and other healthcare professionals involved in the care of patients with breast cancer.

Learning Objectives

At the conclusion of this activity, you should be better prepared to:

  1. Determine the impact of uncontrolled postoperative pain and the goals for multimodal analgesia in breast cancer surgical settings
  2. Identify the rationale to apply opioid-sparing treatment regimens in the care of patients experiencing postsurgical pain, including in the context of key issues relevant to contemporary pain management
  3. Formulate perioperative pain management strategies for challenging patients with breast cancer
  4. Apply best practices pertaining to the administration of pain control interventions in preoperative, intraoperative, and postoperative settings in the care of patients with breast cancer

Faculty, Staff, and Planners' Disclosures

Faculty

Anoushka Afonso, MD
Anesthesiologist
Director, Enhanced Recovery after Surgery
Memorial Sloan Kettering Cancer Center
New York, NY
 

Disclosure: Grant Research Support: Pacira; Speakers Bureau: Pacira.

Patrick I. Borgen, MD
Chairman, Department of Surgery
Maimonides Medical Center
Director, Brooklyn Breast Cancer Program
Brooklyn, NY
 

Disclosure: Speakers Bureau: Genomic Health, Inc; Genentech; Pacira.

Eleni Tousimis, MD, FACS
Director, Betty Lou Ourisman Breast Health Center
Chief, Breast Surgery
Director, Breast Oncology Fellowship
MedStar Georgetown University Hospital
Washington, DC

Disclosure: No relevant financial relationships with commercial interests to disclose.

The staff of PER® have no relevant financial relationships with commercial interests to disclose.

Disclosure Policy and Resolution of Conflicts of Interest (COI)

As a sponsor accredited by the ACCME, it is the policy of PER® to ensure fair balance, independence, objectivity, and scientific rigor in all of its CME activities. In compliance with ACCME guidelines, PER® requires everyone who is in a position to control the content of a CME activity to disclose all relevant financial relationships with commercial interests. The ACCME defines “relevant financial relationships” as financial relationships in any amount occurring within the past 12 months that creates a COI.

Additionally, PER® is required by ACCME to resolve all COI. PER® has identified and resolved all COI prior to the start of this activity by using a multistep process.

Off-Label Disclosure and Disclaimer

This CME activity may or may not discuss investigational, unapproved, or off-label use of drugs. Participants are advised to consult prescribing information for any products discussed. The information provided in this CME activity is for continuing medical and nursing education purposes only, and is not meant to substitute for the independent clinical judgment of a physician relative to diagnostic, treatment, or management options for a specific patient’s medical condition. The opinions expressed in the content are solely those of the individual faculty members and do not reflect those of PER®.

PER Pulse™ Recaps

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PER Pulse™ Recap

The Contemporary Challenge of Pain Management for Patients Undergoing Breast Cancer Surgery

Acute postsurgical pain is frequently experienced by patients who undergo mastectomies and reconstructive procedures, and it is imperative for clinicians to be cognizant of not only the importance of timely, effective pain control, but also the need for opioid-sparing techniques to deliver that control. Several studies have assessed the susceptibility of patients to the iatrogenic complication of prolonged opioid use following surgery. An analysis of 4113 opioid-naïve patients who underwent mastectomy and immediate breast reconstruction found that 10% of all patients continued to fill opioid prescriptions more than 90 days after their procedures.1 Several patient- and procedure-related factors were identified that influenced the likelihood of prolonged or excessive use of postoperative opioids. Greater morphine equivalent prescription use was seen among patients with depression, and greater duration of opioid prescription use was seen among patients with anxiety.1 With respect to the nature of procedures performed, those receiving autologous free flap reconstruction were less likely to have a longer duration of postoperative opioid prescription use (5.9% vs 10.2%; <.01).1

Another study of 68,463 patients who underwent curative-intent surgery for a variety of different malignancies (including breast cancer) and filled prescriptions for opioids found a 10.4% risk for new persistent opioid use (95% CI, 10.1%-10.7%).2 For patients who continued to fill opioid prescriptions a year after procedure completion, the daily dosages used were similar (=.05) to those seen among chronic opioid users (approximately 30 mg of hydrocodone).2 Higher dosages were seen among patients who received adjuvant chemotherapy (=.002).2

Several key guidelines support the use of opioid-sparing regimens to reduce opioid-associated complications, such as postoperative nausea, vomiting, and constipation.3 They may also help to reduce other challenges such as hypotension, respiratory depression, and, ultimately, addiction. Options such as opioid therapy have been noted to inhibit immune function, and morphine has been noted to promote vascular growth and release of other factors that may enhance breast tumor growth.4

Key Points

  • Opioid-sparing multimodal analgesia regimens address multiple challenges associated with traditional pain management approaches.
  • Many options are available to help improve outcomes for patients undergoing surgery for breast cancer. 

References

  1. Marcusa DP, Mann RA, Cron DC, et al. Prescription opioid use among opioid-naïve women undergoing immediate breast reconstruction. Plast Reconstr Surg. 2017;140(6):1081-1090. doi: 10.1097/PRS.0000000000003832.
  2. Lee JS, Hu HM, Edelman AL, et al. New persistent opioid use among patients with cancer after curative-intent surgery. J Clin Oncol. 2017;35(36):4042-4049. doi: 10.1200/JCO.2017.74.1363.
  3. Temple-Oberle C, Shea-Budgell MA, Tan M, et al; ERAS Society. Consensus review of optimal perioperative care in breast reconstruction: Enhanced Recovery After Surgery (ERAS) Society recommendations. Plast Reconstr Surg. 2017;139(5):1056e. doi: 10.1097/PRS.0000000000003242.
  4. Exadaktylos AK, Buggy DJ, Moriarty DC, et al. Can anesthetic technique for primary breast cancer surgery affect recurrence or metastasis? Anesthesiology. 2006;105(4):660-664.

 
2 of 3
PER Pulse™ Recap

Multimodal Approaches to Pain Management

Enhanced recovery after surgery (ERAS) protocols center on the development of multimodal care pathways that can reduce patients’ stress response to surgery, support their physiologic function, and accelerate the return to normal daily function. These require effective methods to minimize pain at the preoperative, intraoperative, and postoperative stages. In the preoperative setting, patients should receive education to set procedure expectations, which has been associated with reduced need for analgesia in the postoperative setting. Medical and social issues should be explored prior to admission, with the setting of specific goals to help patients meet specific milestones.1

With respect to preoperative and intraoperative analgesia, women undergoing surgery for breast cancer should receive multimodal analgesia to reduce pain. Gabapentinoids have been shown to lessen pain and the need for postoperative analgesia in patients undergoing mastectomy.2 There is evidence that both gabapentin and pregabalin are beneficial for pain relief following breast surgery. One randomized controlled trial demonstrated that use of gabapentin 1 hour before surgery reduced postoperative narcotic needs as well as pain experienced with movement.3 In another randomized controlled trial, patients who received pregabalin both 1 hour before mastectomy and 12 hours after the initial dose had reduced pain relative to patients who received placebo at intervals of 1, 24, and 48 hours.4 

Nonsteroidal anti-inflammatory drugs (NSAIDs) have also demonstrated efficacy in the preoperative setting, decreasing chronic breast pain.2 There is increased risk for gastrointestinal adverse effects (AEs) with nonselective NSAIDs.Perioperative use of COX-2 inhibitors has also been shown to improve analgesia after breast surgery, although there is an increased risk for cardiovascular events with these agents, particularly in patients with ischemic heart disease.2,5

Other medication options that have been studied and demonstrated analgesic efficacy when given preoperatively include clonidine, venlafaxine, adenosine, and systemic magnesium; preoperative ketamine has not been shown to mitigate postoperative pain.2

Utilization of bupivacaine infiltration in mastectomy procedures has also helped to reduce pain and postoperative opiate demand.6 The efficacy of bupivacaine is somewhat limited by the duration of action, which is approximately 12 hours. A liposomal bupivacaine has been developed, which releases bupivacaine over days rather than hours. Several smaller studies have demonstrated benefits of liposomal bupivacaine, including evidence of reduced opioid consumption and hospitalization time.7

Key Points

  • A variety of nonopioid interventions have been studied and have demonstrated efficacy in the treatment of pain associated with surgery for breast cancer. 
  • Pinpointing the degree of benefit in breast cancer–related procedures from the use of ERAS protocols and the use of opioid-sparing analgesia regimens remains an active area of clinical investigation.
  • Postoperative pain management should be procedure-specific, with the concept that opioid reduction is key.

References

  1. Kahokehr A, Sammour T, Zargar-Shoshtari K, et al. Implementation of ERAS and how to overcome the barriers. Int J Surg. 2009;7(1):16-19. doi: 10.1016/j.ijsu.2008.11.004.
  2. Temple-Oberle C, Shea-Budgell MA, Tan M, et al; ERAS Society. Consensus review of optimal perioperative care in breast reconstruction: Enhanced Recovery After Surgery (ERAS) Society recommendations. Plast Reconstr Surg. 2017;139(5):1056e. doi: 10.1097/PRS.0000000000003242.
  3. Dirks J, Fredensborg BB, Christensen D, et al. A randomized study of the effects of single-dose gabapentin versus placebo on postoperative pain and morphine consumption after mastectomy. Anesthesiology. 2002;97(3):560-564.
  4. Kim SY, Song JW, Park B, et al. Pregabalin reduces post-operative pain after mastectomy: a double-blind, randomized, placebo-controlled study. Acta Anaesthesiol Scand. 2011;55(3):290-296. doi: 10.1111/j.1399-6576.2010.02374.x.
  5. Peterson K, McDonagh M, Thakurta S, et al. Drug Class Review: Nonsteroidal Antiinflammatory Drugs (NSAIDs): Final Update 4 Report. Portland, OR: Oregon Health & Science University; 2010.  https://www.ncbi.nlm.nih.gov/books/NBK53955. Accessed January 28, 2019.
  6. Zielinski J, Jaworski R, Smietanska I, et al. A randomized, double-blind, placebo-controlled trial of preemptive analgesia with bupivacaine in patients undergoing mastectomy for carcinoma of the breast. Med Sci Monit. 2011;17(10):CR589-597. doi: 10.12659/MSM.881986.
  7. Butz DR, Shenaq DS, Rundell VL, et al. Postoperative pain and length of stay lowered by use of exparel in immediate, implant-based breast reconstruction. Plast Reconstr Surg Glob Open. 2015;3(5):e391. doi: 10.1097/GOX.0000000000000355.

 
3 of 3
PER Pulse™ Recap

Techniques to Manage Pain Along the Surgical Continuum

Pain relief techniques for patients undergoing surgery for breast cancer have also evolved over the past 15 years. A variety of regional and local techniques to provide pain relief have been utilized, including paravertebral blocks. Paravertebral block has been shown to reduce postoperative pain significantly for patients undergoing surgery for breast cancer. In thoracic paravertebral blocks, which may be performed at 1 or more vertebral levels, a local anesthetic is injected into a potential space that lies on either side of the vertebral column. The boundaries of this space are the parietal pleura, the superior costotransverse ligament, the vertebrae and the intervertebral foramina, and the heads of the ribs.1 Clinicians should remain highly vigilant with each injection in order to minimize complications such as pneumothorax and hypotension.

Many field block infiltrations historically relied upon the use of local anesthetics, such as ropivacaine or bupivacaine hydrochloride (HCI). For surgical site infiltrations and field block infiltrations, longer-acting medications, such as liposomal bupivacaine, may be appropriate.2 Liposomal bupivacaine is a nonopioid, single-dose medication; the contents of the 20-mL vial may be expanded with sterile normal saline or lactated Ringer’s solution. Liposomal bupivacaine should be injected slowly using a 25-gauge or larger bore needle, with frequent aspiration to assess for blood and reduce the risk of accidental intravascular injection.3 A “moving needle” technique can help to optimize adequate distribution of liposomal bupivacaine, which does not spread as widely as bupivacaine HCl.4

Thoracic epidural anesthesia has also been studied and shown to deliver effective analgesia while reducing opioid requirements and opioid-related postoperative adverse events (AEs).5 Catheter use can also continue into the postoperative period. One randomized study has shown that the addition of a 48-hour thoracic epidural reduced pain, analgesic use, nausea, and vomiting, all while increasing patient satisfaction.6 Technique-related challenges are present, such as the potential for precipitating backache, postdural-puncture headache, neurologic injury, or epidural hematoma.4 

Other local anesthetic techniques include pectoral (PEC) I and II infiltration blocks, local infiltration, field block infiltration, and transversus abdominis plane infiltration.4 There are different types of interfascial plane blocks that have been employed in breast cancer surgery. In PEC I infiltration, a local anesthetic is injected between the pectoralis major and pectoralis minor muscles, in the plane where the pectoral nerves are located. In PEC II infiltration, local anesthetic is injected between the pectoralis muscles as well as between the pectoralis minor and serratus anterior muscles.4

Key Points

  • There has been a significant trend toward more minimally invasive surgical procedures for patients with breast cancer, with continued emphasis on minimizing postoperative pain through a variety of opioid-sparing techniques.
  • There is a role for strategies such as ERAS protocols to help decrease postoperative nausea, vomiting, pain, and other AEs.
  • New local and regional anesthetic techniques and multimodal analgesia may help patients to avoid the host of AEs associated with opioid use. 

References

  1. Cheng GS, Ilfeld BM. A review of postoperative analgesia for breast cancer surgery. Pain Manag. 2016;6(6):603-618. DOI: 10.2217/pmt-2015-0008.
  2. Motakef S, Wong WW, Ingargiola MJ, et al. Liposomal bupivacaine in implant-based breast reconstruction. Plast Reconstr Surg Glob Open. 2017;5(11):e1559. doi: 10.1097/GOX.0000000000001559.
  3. Exparel [prescribing information]. San Diego, CA: Pacira Pharmaceuticals. https://www.exparel.com/sites/default/files/EXPAREL_PI_Nerve_Block_Final_4-6-2018.pdf. Revised April 2018. Accessed January 28, 2019.
  4. Afonso AM, Newman MI, Seeley N, et al. Multimodal analgesia in breast surgical procedures: technical and pharmacological considerations for liposomal bupivacaine use. Plast Reconstr Surg Glob Open. 2017;5(9):e1480. doi: 10.1097/GOX.0000000000001480.
  5. Jones MR, Hadley GR, Kaye AD, et al. Paravertebral blocks for same-day breast surgery. Curr Pain Headache Rep. 2017;21(8):35. doi: 10.1007/s11916-017-0637-5.
  6. Wick EC, Grant MC, Wu CL. Postoperative multimodal analgesia pain management with nonopioid analgesics and techniques: a review. JAMA Surg. 2017;152(7):691-697. doi: 10.1001/jamasurg.2017.0898.

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