TUESDAY, Nov. 10, 2009 (Health.com) — Almost half of women who have breast cancer surgery still have pain or numbness two to three years later, according to a new study. Women younger than 40 who receive lumpectomies are at the greatest risk.

In general, women are most likely to have pain or a loss of sensation in the breast region, followed by the armpit, the arm, and their sides. However, 40% of women with lingering symptoms have pain in parts of the body not affected by treatment, according to a report in the Journal of the American Medical Association.

“This is a very well-done study by very well-respected surgeons in Denmark,” says Allen Burton, MD, a professor and the chair of the department of pain medicine in the division of anesthesiology and critical care at M.D. Anderson Cancer Center, in Houston.

“This is a known phenomenon,” says Dr. Burton, who wasn’t involved in the study. “These women have pain and huge numb patches in their chest, underarm, down their arm, and in their back that never feels normal again.”

None of the women in the study had reconstructive breast surgery, which is commonplace in the United States. “It would be interesting to see if that changes the outcome,” Dr. Burton says. “Would they have more pain? Less pain? Different kinds of pain?”

In the study of 3,754 breast cancer survivors ages 18 to 70, 47% had pain in one or more area, and 58% reported problems in the treated breast, including burning and a loss of sensation for one to three years after their surgery. Overall, 13% of women with lingering problems said their pain was severe, 39% said it was moderate, and 48% reported light pain. And 76% of patients with severe pain said they ached every day.

Women at the greatest risk for chronic pain were ages 18 to 39 and had undergone breast-conserving surgery, or lumpectomy, in which doctors remove only the tumor and some surrounding tissue. Other risk factors for persistent pain included radiation therapy, which is directed at the breast area to destroy any remaining cancer cells after surgery.

There are several reasons that breast cancer survivors experience pain such as nerve damage or injury from the surgery or radiation, but in the future, nerve-sparing surgery may help take the sting out of this persistent pain, according to study authors led by Rune Gärtner, MD, of the University of Copenhagen.

The first priority is to always treat the breast cancer as effectively and aggressively as possible, Dr. Burton says. That said, a paravertebral block, which is an injection of local anesthetic into nerves of the spine to block the pain, may also help cut the risk of postsurgical breast cancer pain.

“We are studying it and trying to determine whether or not it impacts the prevalence of long-term chronic pain after breast cancer surgery,” he says. “We think it does because it makes sense that the better you control acute pain around the surgery, the less likely you are to get chronic pain syndrome later.”

For women who already have chronic pain from breast cancer surgery, help is available now, says Judy C. Kneece, RN, an oncology-certified nurse and the president of EduCare, a breast health education company in Columbia, S.C.

“Pain decreases quality of life and should be a cause to reach back out to the surgeon or radiologist and ask for a referral to a physical therapist for intervention,” says Kneece, who is also the author of Your Breast Cancer Treatment Handbook. “Most pain can be addressed and reduced or eliminated.”

Physical therapists can help women develop a plan to reduce or eliminate pain. In general, range-of-motion exercises after surgery can help reduce the risk of pain, according to Kneece. “If not performed, there will be a fibrous tissue which forms in the area restricting motion and causing pain when the arm is stretched,” she says.

One potential cause of pain is lymphedema, a swelling of the arm and hands. Lymphedema can occur after breast surgeons remove lymph nodes from a woman’s underarm region to test them for cancer.

Some women are candidates for sentinel node mapping, a technique that reduces the risk of lymphedema; dye is injected to see which lymph node is closest to the breast tissue (and therefore most likely to contain cancer cells.) If this node is cancer free, doctors don’t have to remove multiple lymph nodes, which reduces the risk of pain and swelling.

“If one notices increasing swelling accumulating in the affected limbs or trunk, it is likely an early warning sign of lymphedema and she should be evaluated by a fully certified lymphatic drainage therapist,” says occupational therapist Cathy Kleinman-Barnett, a lymphedema specialist at Northwest Medical Center, in Margate, Fla.

“The additional fluid buildup can cause abnormal sensations such as tingling, aching, [and] heaviness, and should diminish or stop with range-of-motion exercises, stretching, and massage to stimulate lymphatic flow,” she says. “There is help available, and women should not have to live in pain.”

Women should have a mammogram every two years starting at age 50—not 40, according to an expert panel’s new breast cancer screening guidelines, which are sure to cause confusion among women, particularly those in their 40s who routinely schedule a mammogram each year.

However, a number of prominent groups say they strongly disagree with the new advice, which was issued by the U.S. Preventive Services Task Force (USPSTF) on Monday.

The USPSTF panel has backed off a 2002 statement advising women to have a routine mammogram every year or two beginning at age 40. The panel now recommends that women undergo mammography screening every two years starting at age 50 and continue being screened through age 74.

The USPSTF concluded that the benefit gained by starting screening at 40 versus 50 is “small” and that the decision to start screening before 50 should be an individual one.

The new guidelines would seem to reopen a debate that raged in the 1990s, but seemed to have been settled years ago. The American Cancer Society (ACS) now recommends that women get an annual mammogram and have a clinical breast examination beginning at age 40.

Otis W. Brawley, MD, the chief medical officer of the ACS, said in a statement that the ACS would stick to its current guidelines.

Mammograms are the “one screening test I recommend unequivocally, and would recommend to any woman 40 and over, be she a patient, a stranger, or a family member,” Dr. Brawley said.

The USPSTF is an independent panel, sponsored by the federal Agency for Healthcare Research and Quality, whose members make recommendations about preventive-care services and published the new recommendations in the Annals of Internal Medicine.

The panel’s recommendations are based, in part, on a review of the latest scientific evidence on the benefits and harms of breast cancer screening. The pooled data show that mammography screening does reduce breast cancer death—by 15% for women ages 39 to 49. To prevent one cancer death in this group, 1,904 women would have to be screened. Among women 50 to 59, one death is avoided per 1,339 screenings.

Because breast cancer risk increases with age, younger women are at a somewhat lower risk of developing the disease, explains George W. Sledge Jr., MD, a professor of oncology at Indiana University’s Melvin and Bren Simon Cancer Center, in Indianapolis, and president-elect of the American Society of Clinical Oncology.

They’re also somewhat more likely to have a false-positive mammogram—a test result that triggers a biopsy or other tests, but turns out not to be cancer—because they tend to have denser breasts, he says.

“No one is saying, or no one should say, that screening mammography has no value for younger women,” he says.

What the task force is saying is that the absolute reduction in breast cancer deaths is much greater in an older population.

But the American Cancer Society’s Dr. Brawley reasoned that “the USPSTF is essentially telling women that mammography at age 40 to 49 saves lives; just not enough of them.”

The panel also considered data from a study using computer simulation models to compare expected outcomes of starting and stopping screening at different ages and screening at different intervals. The models suggest that screening average-risk women ages 50 to 74 every two years achieves most of the benefit of annual screening, but with less harm due to factors such as false-positive results, unnecessary biopsies, and “overdiagnosis” of cancers that wouldn’t have progressed or would have not led to the person’s death.

“[The models] only tell us what happens on average in the population. They do not tell us what will happen for an individual woman,” says Jeanne S. Mandelblatt, MD, the lead author of one of the studies commissioned by the USPSTF and a professor of oncology and medicine at Georgetown University’s Lombardi Comprehensive Cancer Center.

For an individual woman, the decision to have a mammogram “is one that she needs to consider with her providers based on her risks and her values for the balance of harms and benefits,” she adds.

But W. Phil Evans, MD, the president of the Society of Breast Imaging, questions the wisdom of biennial screening. “It doesn’t make any sense when you know more cancers can be found in the 50-year-old age group to lengthen the screening time, because the idea is to find the cancer early and to treat it while it’s small, because treatment can be less when the cancer is detected early,” says Dr. Evans, a professor of radiology and the associate vice president for clinical imaging services at the University of Texas Southwestern Medical Center, in Dallas.

“The Society of Breast Imaging and the American College of Radiology are not going to change their guidelines because of this,” he says. “We think it’s very important to begin screening at age 40 and screen yearly thereafter.”

The USPSTF panel did not make recommendations on screening women 75 and older because the current evidence is insufficient to weigh the additional benefits and harms. For the same reason, it did not weigh in on the value of clinical breast examinations, beyond mammography, in women 40 and older or on the value of other imaging techniques, such as digital mammography or magnetic resonance imaging.

However, it did recommend against teaching women how to perform breast self-examination, saying there’s no evidence that it reduces breast cancer deaths.

The critical thing is not to ignore this lifesaving procedure, says Dr. Sledge, who urges all women to discuss mammography with their doctor, beginning at age 40.

“What’s not mentioned in these discussions, but what’s incredibly important, is that in the United States, perhaps as many as even a third of all women just simply don’t follow even the most conservative of screening mammogram recommendations, just as a significant portion of the population doesn’t get screening for colorectal cancer or screening for cervical cancer,” Dr. Sledge notes.

“We could significantly reduce the number of cancer deaths if we applied even the most conservative of screening guidelines,” he says.

Breast cancer is the second-leading cause of cancer death in women, after lung cancer. In 2009, an estimated 254,650 breast cancer cases will be diagnosed, and 40,170 women will die from the disease.