Pain is a common problem in cancer survivors, especially in the first few years after treatment. In the longer term, approximately 5% to 10% of survivors have chronic severe pain that interferes with functioning. The prevalence is much higher in certain subpopulations, such as breast cancer survivors. All cancer treatment modalities have the potential to cause pain. Currently, the approach to managing pain in cancer survivors is similar to that for chronic cancer-related pain, pharmacotherapy being the principal treatment modality. Although it may be appropriate to continue strong opioids in survivors with moderate to severe pain, most pain problems in cancer survivors will not require them. Moreover, because more than 40% of cancer survivors now live longer than 10 years, there is growing concern about the long-term adverse effects of opioids and the risks of misuse, abuse, and overdose in the nonpatient population. As with chronic nonmalignant pain, multimodal interventions that incorporate nonpharmacologic therapies should be part of the treatment strategy for pain in cancer survivors, prescribed with the aim of restoring functionality, not just providing comfort. For patients with complex pain issues, multidisciplinary programs should be used, if available. New or worsening pain in a cancer survivor must be evaluated to determine whether the cause is recurrent disease or a second malignancy. This article focuses on patients with a history of cancer who are beyond the acute diagnosis and treatment phase and on common treatment-related pain etiologies. The benefits and harms of the various pharmacologic and nonpharmacologic options for pain management in this setting are reviewed.

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There are a variety of NMDAR antagonist agents that should be considered for treatment of NeuP. Nevertheless, continued and further investigation of the 8 pharmacologic agents is needed to continue to evaluate their efficacy for treatment of NeuP.

Introduction With the advancement of technology, peripheral nerve stimulation (PNS) has been increasingly used to treat various chronic pain conditions. Its origin is based on the gate control theory postulated by Wall and Melzack in 1965. However, the exact mechanism behind PNS’ analgesic effect is largely unknown. In this article, we performed a comprehensive literature review to overview the PNS mechanism of action. Design A comprehensive literature review on the mechanism of PNS in chronic pain. Methods Comprehensive review of the available literature on the mechanism of PNS in chronic pain. Data were derived from database searches of PubMed, Scopus, and the Cochrane Library and manual searches of bibliographies and known primary or review articles. Results Animal, human, and imaging studies have demonstrated the peripheral and central analgesic mechanisms of PNS by modulating the inflammatory pathways, the autonomic nervous system, the endogenous pain inhibition pathways, and involvement of the cortical and subcortical areas. Conclusions Peripheral nerve stimulation exhibits its neuromodulatory effect both peripherally and centrally. Further understanding of the mechanism of PNS can help guide stimulation approaches and parameters to optimize the use of PNS.

Postmastectomy pain syndrome is common after surgical treatment for breast cancer and may be challenging to manage. Currently, there are a wide variety of approaches to treat this type of pain, including medications, physical therapy, and interventional procedures. However, because of the complexity of innervation of the breast, the serratus plane block may better target the web of nerves innervating the anterior chest wall including the breast. We present a case series of 8 patients who were successfully treated with serratus plane block for pain after treatment for breast cancer. We feel that this particular application for the serratus plane block deserves further investigation, as it is relatively easy to perform and has good clinical utility for this type of pain.

Ultrasound technology has advanced regional anesthesia and pain management, by improving accuracy and reducing complication rates. We have successfully performed cryoablation of intercostal nerves with ultrasound guidance with no complications. Four patients with postthoracotomy pain syndrome had pain relief for at least 1 mo after selective cryoablation of intercostal nerves at the mid-axillary line. Visualizing the pleura during the procedure is the greatest benefit of using ultrasonography, especially in thin patients whose intercostal groove to pleural distance may be <0.5 cm. Although further studies are needed, we feel that this new technique should reduce the risk of pneumothorax as well as improve the success of cryoablation.

Prehabilitation benefits among patients undergoing various oncological surgeries have been demonstrated. However, the effects of presurgical exercise and fitness on postoperative ipsilateral upper extremity recovery outcomes in patients with breast cancer surgery are less evident. A systematic review was performed to assess the effects of preoperative exercise and fitness on postmastectomy recovery. Systematic literature search was performed in 12 electronic databases. Study eligibility was accessed using the PICOS (Participants, Interventions, Comparison, Outcome and Study Design) criteria. Six eligible studies were found: three cohort-control and three prospective observational studies. One randomized-controlled trial showed that prehabilitation was beneficial in shoulder range of motion (ROM) and upper extremity functional recovery. One cohort-control study demonstrated that preoperative exercises reduced postoperative pain without increasing the risk of developing a seroma. A prospective cohort study showed that preoperatively active individuals had a significantly better chance of feeling recovered physically at 3 weeks after surgery. Baseline ipsilateral grip strength, shoulder flexion, and abduction ROM were reliable predictors of shoulder flexion and abduction ROM and grip strength improvements at 1 month following breast cancer surgery. One study showed that preoperative conditioning alone without postoperative rehabilitation was insufficient to aid recovery. Implementing exercise program and optimizing preoperative fitness, especially shoulder ROM, before breast cancer surgery in conjunction with individualized rehabilitation program may benefit postmastectomy ipsilateral upper extremity recovery.

Clinical studies demonstrate that buprenorphine is a pharmacologic agent that can be used for the treatment of various types of painful conditions. This study investigated the efficacy of 5 different types of buprenorphine formulations in the chronic pain population. The literature was reviewed on PubMed/MEDLINE, EMBASE, Cochrane Database, clinicaltrials.gov, and PROSPERO that dated from inception until June 30, 2017. Using the population, intervention, comparator, and outcomes method, 25 randomized controlled trials were reviewed involving 5 buprenorphine formulations in patients with chronic pain: intravenous buprenorphine, sublingual buprenorphine, sublingual buprenorphine/naloxone, buccal buprenorphine, and transdermal buprenorphine, with comparators consisting of opioid analgesics or placebo. Of the 25 studies reviewed, a total of 14 studies demonstrated clinically significant benefit with buprenorphine in the management of chronic pain: 1 study out of 6 sublingual and intravenous buprenorphine, the only sublingual buprenorphine/naloxone study, 2 out of 3 studies of buccal buprenorphine, and 10 out of 15 studies for transdermal buprenorphine showed significant reduction in pain against a comparator. No serious adverse effects were reported in any of the studies. We conclude that a transdermal buprenorphine formulation is an effective analgesic in patients with chronic pain, while buccal buprenorphine is also a promising formulation based on the limited number of studies.