Feasibility and safety of outpatient breast cancer surgery.

INTRODUCTION: Improvement in perioperative care programmes has facilitated post-operative recovery and use of short-term or outpatient procedures. The aim of this study was to assess the feasibility and safety of an outpatient breast cancer programme in patients referred to a large breast cancer unit. METHODS: After an introduction period involving 554 consecutive patients, all patients operated from 1 November 2015 to 30 June 2016 (a total 483 patients) were treated with multimodal oral analgesia, preoperative high-dose glucocorticoids and no routine use of drains. Planned inpatient surgery included patients with mastectomy > 70 years, < 8 h in post-operative observation and < 2 h of observation after mobilisation. RESULTS: Of the 382 patients who were planned for outpatient surgery (79%), 90% received surgery in an outpatient setup. Among the 101 patients (21%) who were planned for inpatient surgery, 17% returned home on the day of surgery. Consequently, the overall outpatient rate was 72% and the overall mean length of stay was 0.3 days, ranging from 0.1 days for breast-conserving surgery to 0.8 days for mastectomy. About 2% were readmitted within < 30 days, mostly due to wound problems.
Conclusion: Outpatient breast cancer surgery is feasible and safe in most patients in a socialised healthcare system. FUNDING: none. TRIAL REGISTRATION: not relevant.
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The Relationship Between Sensory Loss and Persistent Pain 1 Year After Breast Cancer Surgery.

Moderate to severe persistent pain after breast cancer surgery (PPBCS) affects 10 to 20% of the patients. Sensory dysfunction is often concomitantly present suggesting a neuropathic pain state. The relationship between various postoperative pain states and sensory dysfunction has been examined using quantitative sensory testing (QST), but only 2 smaller studies have examined PPBCS and sensory dysfunction in the surgical area. The purpose of this prospective study was to assess the relative importance of sensory function and PPBCS. QST consisted of sensory mapping, tactile detection threshold, mechanical pain threshold, and thermal thresholds. Two hundred ninety patients were enrolled and results showed that 38 (13%) had moderate to severe pain and 246 (85%) had hypoesthesia in the surgical area 1 year after surgery. Increased hypoesthesia areas were associated with pain at rest as well as during movement (P = .0001). Pain during movement was associated with a side-to-side difference of 140% (P = .001) for tactile detection threshold and 40% (P = .01) for mechanical pain threshold as well as increased thermal thresholds in the axilla (P > .001). Logistic regression models controlling for confounders showed larger areas of hypoesthesia as a significant risk factor, odds ratio 1.85 per 100 cm2 for pain at rest and odds ratio 1.36 per 100 cm2 for pain during movement. PERSPECTIVE: PPBCS is associated with increasing areas of hypoesthesia as well as intraoperative nerve preservation. Thus, we hypothesize that PPBCS is associated with an interaction between a peripheral nociceptive drive in macroscopically preserved nerves and the central nervous system causing PPBCS as well as hypoesthesia. QST may identify patients suitable for intervention.

Pain, sensory disturbances and psychological distress are common sequelae after treatment of ductal carcinoma in situ: a cross-sectional study.

Sequelae such as pain, sensory disturbances and psychological distress are well known after treatment for invasive breast cancer (IBC). Patients treated for ductal carcinoma in situ (DCIS) receive a similar treatment as low-risk IBC. The aim of this cross-sectional study was to describe prevalence of postoperative pain, sensory disturbances, psychological distress and rehabilitation needs among Danish women with DCIS. METHODS: A total of 574 women treated for DCIS in Denmark in 2013 and 2014 were enrolled and 473 (82%) completed a detailed questionnaire on demographic factors, pain, sensory disturbances, psychological aspects and rehabilitation needs 1-3 years after surgery. RESULTS: Median age was 60 years. A total of 33% of patients reported any pain and 12% reported moderate to severe pain in the area of surgery. Younger age (<50 years OR 4.7 (95% CI: 1.6-14.0, p = 0.006)), aged 50 to 65 years OR 2.8 (95% CI: 1.1-7.0, p = 0.02) and anxiety and depression (measured by HADStotal >15 OR of 3.1 (95% CI: 1.5-6.3, p = 0.003)) were significantly associated with moderate to severe pain. Approximately one-third of the patients reported sensory disturbances such as pins and needles (32%), numbness (37%) and painful itch (30%) and 94 women (20%) reported anxiety ≥8, 26 (6%) depression and 51 (11%) reported distress. CONCLUSIONS: This cross-sectional study showed that women treated for DCIS suffered from pain, sensory disturbances and psychological impairment and had unmet rehabilitation needs. Further research is warranted, specifically addressing rehabilitation after diagnosis and treatment of DCIS.

Predictive factors for the development of persistent pain after breast cancer surgery.

Previous studies have reported that 15% to 25% of patients treated for breast cancer experience long-term moderate-to-severe pain in the area of surgery, potentially lasting for several years. Few prospective studies have included all potential risk factors for the development of persistent pain after breast cancer surgery (PPBCS). The aim of this prospective cohort study was to comprehensively identify factors predicting PPBCS. Patients scheduled for primary breast cancer surgery were recruited. Assessments were conducted preoperatively, the first 3 days postoperatively, and 1 week, 6 months, and 1 year after surgery. A comprehensive validated questionnaire was used. Handling of the intercostobrachial nerve was registered by the surgeon. Factors known by the first 3 weeks after surgery were modeled in ordinal logistic regression analyses. Five hundred thirty-seven patients with baseline data were included, and 475 (88%) were available for analysis at 1 year. At 1-year follow-up, the prevalence of moderate-to-severe pain at rest was 14% and during movement was 7%. Factors associated with pain at rest were age <65 years (odds ratio [OR]: 1.8, P = 0.02), breast conserving surgery (OR: 2.0, P = 0.006), axillary lymph node dissection with preservation of the intercostobrachial nerve (OR: 3.1, P = 0.0005), moderate-to-severe preoperative pain (OR: 5.7, P = 0.0002), acute postoperative pain (OR: 2.8, P = 0.0018), and signs of neuropathic pain at 1 week (OR: 2.1, P = 0.01). Higher preoperative diastolic blood pressure was associated with reduced risk of PPBCS (OR: 0.98 per mm Hg, P = 0.01). Both patient- and treatment-related risk factors predicted PPBCS. Identifying patients at risk may facilitate targeted intervention.