Beyond Survival: Chronic Pain In Breast Cancer Recovery

Breast cancer survivors often face a hidden struggle with chronic pain post-surgery, affecting 1 in 3 women. Dr. Khan, leading expert at the University of Toronto’s Persistent Breast Cancer Pain Clinic, shares insights on this overlooked issue and innovative treatments offering hope to those suffering in silence. —Noa Nichol

Could you share more about the prevalence and impact of chronic pain on breast cancer survivors, especially following successful surgeries, and why it’s often overlooked?

Recent studies indicate that persistent pain after breast cancer surgery affects nearly one in three survivors, whether they have undergone mastectomy or lumpectomy. For many of these individuals, the pain is mild, typically rated around three on a 0–10 pain scale (where 0 is no pain and 10 is the worst possible pain). However, a significant subset—approximately 15–20%—experience severe pain, scoring seven or higher, which can profoundly impact their lives. Persistent pain not only interferes with basic daily tasks but also hinders survivors from engaging in meaningful activities, such as returning to work, self-care, and supporting loved ones.

While cancer treatments have been remarkably successful in extending survival, the impact of chronic pain on quality of life is often overlooked. Many survivors report that ongoing pain interferes with their quality of life, a concern that deserves attention alongside survival outcomes. Unfortunately, pain following breast cancer treatment is often seen as an inevitable consequence of effective cancer management. Conversations with patients and surgeons reveal that some survivors may hesitate to report pain, especially soon after treatment, perceiving it as an expected part of recovery.

Recognizing this gap, we are working to raise awareness and have developed a dedicated pain clinic to encourage patients to address pain earlier. By encouraging them to speak openly with surgeons, primary care physicians, and other providers, we aim to identify chronic pain sooner and intervene promptly. Research clearly shows that untreated pain becomes more challenging to manage over time, making early recognition and treatment essential for improving outcomes in breast cancer survivors.

Your work with the Persistent Breast Cancer Pain Clinic addresses both the physical and psychological aspects of pain. Can you elaborate on the unique treatment approaches you use to support holistic recovery?

At the Persistent Breast Cancer Pain Clinic, our goal is to create a personalized, holistic treatment plan that addresses both the physical and psychological aspects of pain. Our interdisciplinary team includes specialist physicians, physical therapists, occupational therapists, psychologists, and dedicated nursing staff, all working together to provide comprehensive support. The clinic, which operates within the Wasser Pain Management Centre at Mount Sinai Hospital and is part of the Toronto Academic Pain Medicine Institute, offers a variety of unique therapeutic options.

We incorporate evidence-based psychological interventions, such as cognitive behavioural therapy (CBT), mindfulness-based stress reduction (MBSR), and emotion awareness and expression therapy (EAET), all of which play a crucial role in helping patients manage the emotional impacts of chronic pain. On the medical side, we provide advanced options like peripheral nerve blocks, radiofrequency nerve ablation (nerve burning), and implantable neurostimulation devices, including peripheral nerve stimulators, to target persistent pain effectively. 

In addition, our in-clinic occupational therapist works closely with patients to provide personalized recommendations for home and workplace modifications, supportive aids, and exercises. This integrated approach allows us to support the full spectrum of recovery needs, helping each patient achieve a better quality of life in physical, mental, and emotional health.

How have advanced peripheral nerve stimulators proven effective in managing chronic pain for breast cancer survivors, and what makes this treatment distinct from other pain management options?

The field of peripheral nerve stimulators is still in its early stages, especially in Canada, where access to these devices remains limited. While they are more commonly used in the United States, availability in Canada has been restricted due to limited regulatory approvals and a shortage of trained professionals to implant these devices. Having trained in the U.S., I am among the few clinicians able to offer this option, working with the only vendor that currently holds Health Canada approval.

What makes peripheral nerve stimulators unique is that it is a non-drug therapy that puts the ability to manage pain in the hands of the patient. The treatment includes implanting an electrode next to a nerve or nerves that may be responsible for the patient’s pain. The electrode sends small electrical currents to that nerve to disrupt pain signals travelling to the spinal cord and brain. The patient operates the electrode wirelessly via a remote, controlling how much electrical current is generated. As such, we are effectively using electricity to manage pain, which is much safer than some drugs or procedures, such as nerve blocks, which are known to have side effects and complications.

For some breast cancer survivors with persistent pain, peripheral nerve stimulators have shown significant benefits by targeting specific pain pathways. However, they are not a universal solution, and patient responses can vary. This underscores the need for further research to better understand which patients will most likely benefit from these devices. Our clinic’s mission is to provide access to innovative therapies, like peripheral nerve stimulators, while rigorously evaluating their effectiveness across diverse patient needs. By studying these novel interventions, we aim to expand the range of effective, evidence-based options for chronic pain management in breast cancer survivors.

With the recent collaboration with Augmend Health, how do you envision AI-assisted VR therapy reducing pre-surgery anxiety and improving recovery for breast cancer patients?

One of the things we have found in our studies is that pre-surgery anxiety can lead to increased pain after surgery. It is difficult to find a therapist for each individual prior to surgery to address anxiety, but that’s where innovative tech comes in. With Augmend Health’s AI-assisted VR therapy, we can significantly reduce pre-surgery anxiety and improve recovery for breast cancer patients by offering a personalized, supportive experience. The VR modules, which include cognitive-behavioural and exposure therapy techniques, help demystify the surgical process, enabling patients to familiarize themselves with each step in a safe, controlled setting. AI-powered companions provide real-time empathetic support, easing patients’ fears and making them feel heard.

Physiologically, personalized relaxation techniques, guided by real-time biofeedback, support stress management before surgery. Lower anxiety not only improves recovery times but also reduces reliance on post-surgery medication. The culturally adaptive design also ensures inclusivity, bridging accessibility gaps and reducing stigma. Augmend’s VR therapy offers a holistic, patient-centred approach that enhances mental readiness and recovery outcomes.

For breast cancer survivors experiencing chronic pain, what do you see as the most promising developments in pain management research, and how can they empower patients on their recovery journey?

As a chronic pain physician, I know firsthand that once chronic pain has developed, it can be extremely challenging to manage effectively. While several promising therapies are emerging, even the most advanced treatments are likely to reduce pain rather than eliminate it completely. This reality highlights the importance of focusing on prevention. I believe the most impactful advancements will come from innovations that can prevent pain from developing in the first place.

A prime example is the PLAN Trial, an international multicenter randomized controlled trial, that I lead. This is one of the largest studies of its kind in the world and aims to evaluate the ability of a simple and widely accessible drug—lidocaine—administered into the bloodstream during breast cancer surgery to prevent the onset of persistent pain altogether. We aim to include 1,602 patients and have already enrolled over 1,000 across Canada. The results, expected next year, could have far-reaching implications. If lidocaine proves effective, its low cost and availability could enable it to become a standard measure during breast cancer surgery worldwide. This kind of preventive approach has the potential to empower breast cancer survivors by reducing the risk of chronic pain and significantly improving their quality of life after treatments.