Common side effects of breast cancer treatment – 1

Treatments for breast cancer can have local effects on muscles, nerves and lymph vessels in the upper body. They can also have whole body effects, such as fatigue.

People living beyond breast cancer often experience multiple overlapping symptoms. Some common side effects of treatment are described below. We discuss management of these side effects in steps 3.12 – 3.17.

The impact of breast cancer treatment on shoulder function

Upper limb problems are common after breast cancer treatment and mostly occur within the first 12 months after surgery. Although they can persist for many years after treatment has finished.

Common functional problems include combing hair, reaching overhead, carrying or pushing objects, leading to limited participation in work and social life.

Extensive scar tissue can restrict movement e.g. skin and subcutaneous tissue can adhere to underlying muscles. Fibrotic changes to soft tissues as a result of radiotherapy can also restrict soft tissue extensibility. Together these changes may cause pain or stiffness and restrict arm movement and function. Shoulder pain is often characterised by pain at the shoulder and neck regions, it can restrict overhead and loaded arm activities. Some women may develop adhesive capsulitis (frozen shoulder). Frozen shoulder can occur as a result of injury or surgery to the upper arm or the cause may be unknown. Frozen shoulder presents with intense and constant pain, often with pain at night.

Wound infection and Seroma

As with any surgery, there is a risk of postoperative wound infection. Around 9% of women develop a wound infection within 30 days after breast surgery. After mastectomy, the majority of wound infections develop after the second postoperative week. Usual care is to give information on wound management and instruct women on checking their wound(s) for signs and symptoms of wound infection: redness, swelling, purulent discharge, pain or warmth at or near the wound site, and increased body temperature.

Seroma is a clear fluid that leaks from damaged blood and lymphatic vessels into tissues and is common after breast surgery (see schematic illustration below). Seroma can sometimes build up around the wound or in any cavity space. Most seromas will be re-absorbed but it they persist then they may need to be drained.

Pain and altered sensation

Pain is to be expected after any surgery, it is important that women take painkillers in this immediate postoperative period to ensure that they can mobilise without too much discomfort.

Chronic or persistent pain is where the postoperative pain lasts for longer than expected. This is broadly defined as pain that wasn’t there before surgery but has lasted for more than three months after surgery. Breast cancer studies show that many women report different sensations at or near the wound/scar site e.g. pain, discomfort, numbness or altered sensations; sometimes lasting for months or years. Symptoms may arise because of disruption to the nerve pathways in the axilla or breast area. Sensory loss or numbness is common, for most women, these symptoms do settle over time.

Neuropathic (nerve) pain is a specific type of pain which can be described as burning, pins and needles, electric shocks or tingling sensations. A subset of women may have neuropathic characteristics after surgery, and if severe, this pain can be difficult to treat.

Some patients may also experience side-effects from medication such as Tamoxifen which cause painful joints. If this is very problematic then you should advise your patient to consult their Specialist Cancer Nurse or Consultant.

Cording

Cording is a complication of axillary surgery. Cording is also referred to as axillary web syndrome, vascular strings or Mondor’s cords. Cording presents as taut, stretched fibrous bands underneath the skin in the affected arm, either at rest or on movement. It can also occur in the trunk. Below are pictures of cording in the axilla and in the trunk.

It usually occurs in the early weeks after surgery but can develop at any time after treatment. Cording is assumed to be a lymphovenous injury as a result of axillary surgery and radiotherapy although its exact pathophysiology is not well understood.