Controlling Pain During and After Breast Cancer Surgery

This podcast is made possible by the support of Pacira Pharmaceuticals.

Jamie DePolo: Hello, everyone. Welcome to this edition of the Breastcancer.org podcast. I’m Jamie DePolo, the senior editor of Breastcancer.org. Our guest today is Beth Baughman DuPree. She performs breast cancer surgery and is vice president at the Holy Redeemer Health System, as well as adjunct assistant professor of surgery for the University of Pennsylvania. Dr. DuPree is a board-certified general surgeon specializing in diseases of the breast. She also has obtained dual board certification in integrative and holistic medicine. She has won numerous awards for her medical work, as well as her humanitarian endeavors. Dr. DuPree’s skin-sparing mastectomies performed in conjunction with plastic surgeon Robert Skalicky were featured live on the internet. The webcast and subsequent documentary received a Gracie Award.

Today, Dr. DuPree is going to talk to us about managing pain during and after breast cancer surgery. Dr. DuPree, welcome to the podcast, and before we start, I know that you are going through a bit of a professional transition right now, so do you want to tell us a little bit about that?

Beth Baughman DuPree: First of all, Jamie, thank you for having me back again. As always, I love to support the educational process of Breastcancer.org because it is the go-to website for information that is valid for patients. I don’t want them to surf the web anywhere else except going to Breastcancer.org when they’re diagnosed because I want them to have very valid information. So thank you for doing what you do.

Jamie DePolo: Thank you. That was some very kind words.

Beth Baughman DuPree: Marisa [Weiss, M.D., Breastcancer.org’s chief medical officer] is a dear friend, and I love every aspect of what you guys do, and she actually has been aware of this little transition that I’m about to undergo. She’s a very dear friend, so I shared this with her a year ago when I was contemplating this transition. I have been given the great opportunity to actually move to Sedona, Arizona, which is where my spiritual heart has always been. I’ve been going there for 16 years. I had planned to retire there someday. And they want to develop a state-of-the-art comprehensive cancer program beginning with featuring breast cancer. And since it is my dream place to live, and it’s my dream job, I absolutely had to apply for it.

So I will be bicoastal for the next 2 years because I think you know my commitment to patient care. So I will be coming back and forth on a regular basis to be able to follow through with my patients that I’m currently treating and have treated over the past several years, and that way I’ll be able to shepherd them into survivorship completely as I begin to build a program and allow the women of Northern Arizona to have state-of-the-art breast care as well. So it’s kind of exciting.

Jamie DePolo: That is exciting. Congratulations.

Beth Baughman DuPree: Thank you.

Jamie DePolo: What types or classes of medicines are used during surgery to control pain? Can you give us some examples of each that people might be familiar with?

Beth Baughman DuPree: Absolutely. First of all, it depends what operation someone’s going to have, the type of or classification of medication we would use. For a diagnostic biopsy, such as I just did today, I do not prescribe narcotics or opioids, and I think everybody… You’d have to live under a rock to not understand that we are in the midst of an opioid and medication crisis in this country. The opioid classification of drugs are narcotics. They’re medications that can be addictive. They’re medications that we typically would not want people to be operating equipment or driving a car if they’re taking these medications. And they basically numb the pain receptors. So they work really well at pain control, but not every procedure, every operation requires that level of pain control.

So, for example, the biopsies that I performed today for my patients, I used lidocaine or local anesthesia for the procedure. So I numb them just as if you’d go to the dentist, and after the procedure I use compression, which helps to just keep gentle pressure on the area, and then I have them take either Tylenol [chemical name: acetaminophen] or Motrin, or ibuprofen, which is considered what we call a nonsteroidal anti-inflammatory. And those medications, Tylenol and NSAIDs, or Motrin, those pain medications, work to decrease the inflammatory response that the body gives, so they can be very effective at these breast biopsies. And I sometimes give narcotics for these breast biopsies, but I think that we as physicians need to really be conscious of not just today, what we’re giving our patient today, but what are the long-term potential effects of these medications.

The first thing is managing the patient’s expectations, and when I tell my patient, “Yes, it’s going to be sore, it’s going to feel like somebody sucker-punched you, but if you use ice and you use the over-the-counter medicines, you’re going to get through it.” And I will tell you… I mean, I may have had one phone call in the past 5 years from someone that had additional pain. And actually, if they do have additional pain, it could be a hematoma, like a collection of fluid. There could be some other problem that I’d want to know about that a narcotic could mask.

So, the classifications for outpatient surgery typically involve the Tylenol and Motrin, and depending upon how invasive we are, sometimes I will also use a narcotic for the short-term, such as Tylenol with Codeine, Percocet [chemical name: acetaminophen and oxycodone], Dilaudid [chemical name: hydromorphone]. These are the common medications that we will prescribe to our patients to get them through the first 24 to 48 hours until those pain receptors are no longer kind of crying out.

Jamie DePolo: What about somebody who’s having a lumpectomy or a mastectomy or reconstruction? Those are obviously bigger surgeries. I’m assuming more pain.

Beth Baughman DuPree: Absolutely. They’re bigger operations that in the operating room there are certain things that we do to prevent that initial zing of postoperative pain. First of all, in my patients I recommend that they use arnica, which is a homeopathic. We can use it perioperatively. It’s incredibly safe. Plastic surgeons have been using it for years for face lifts. There’s a lot of research in the plastic surgery literature that it decreases bruising and hematoma, you know, the swelling after surgery. So, that’s kind of like a preemptive strike. The other thing that I like to do and many surgeons will do, when we’re doing a lumpectomy and sentinel node biopsy, before we even cut the skin, we can inject the breast or the axillary tissue with local anesthesia. And that also helps to take the edge off that postoperative pain.

And then before my patients wake up from surgery, many times I will give them additional injections with Marcaine [chemical name: bupivacaine hydrochloride and epinephrine], which is a long-acting local anesthetic that will last about 4 or 5 hours. And so that way, even before they leave the operating room, they have gotten a good amount of postoperative pain management. So, I prefer postoperatively to use a medication called Toradol, or ketorolac. Again, it’s in the classification of a nonsteroidal anti-inflammatory, and that also works really, really well for postoperative pain.

And right after surgery I will always have a narcotic available for a patient in the event that sometimes we get very near nerves, and they can be incredibly sensitive, and we don’t know that until the patient’s awake after surgery.

So, that’s kind of the soup to nuts from the beginning. We can do some preemptive strike with the arnica. We can intraoperatively use the local anesthesia, and postoperatively add on the nonsteroidal and the narcotic.

Now, there are two other things that with mastectomies and in patients that are having a more extensive axillary surgery, such as an axillary lymph node dissection. There are two other options that we will offer our patients, and lots of different doctors use different things for different reasons. There are some… a type of local anesthetic that actually is what we call lipophilic. It’s attached to a carrier, so it stays in the system much longer, and we can use that for local blocks. And in addition, there is a pain management system that’s actually like a pump that will — my patients call it a cue ball because it looks like a big cue ball filled with Marcaine — and that delivers that Marcaine on a regular basis into the surgical cavity.

So, using either the long-acting injection or that pump will give the patients pain management for the first 1 to 3 days postoperatively. And what that does is it decreases the need for the opioid-type medications, the Dilaudids, the Demerols [chemical name: meperidine], the Tylenol with Codeines. And you know, I don’t know about you, but when I watched the, I think it was the Super Bowl this year? And there were three commercials for opioid-induced constipation? I literally was taken aback because, number one, those are very expensive ads, and number two, isn’t it a shame that we have to now have medications to help alleviate the constipation that we’ve created with this opioid crisis?

Jamie DePolo: You gave us some examples of non-opioid options. I know that some people, maybe upfront going into surgery, are concerned about that. Maybe they’ve had a friend or a family member that’s had an issue with opioids, so if somebody says, “Absolutely not, I do not want to take an opioid,” it sounds like there are good options for that.

Beth Baughman DuPree: Absolutely. I take care of patients who are in recovery, and I honor that completely. I will get my anesthesiologist to do a non-narcotic anesthetic, and we will maximize our local pain management with either the Exparel [chemical name: bupivacaine], the long-acting lipophilic anesthesia, or we’ll use the ON-Q pump so that we can give them the Marcaine, and we’ll also give them… They’ll have the opportunity to, again, use ice for… When we use ice, people think it’s just to make it cold, but actually what ice does is it constricts the blood vessels so that you don’t get that vasodilation, that kind of throbbing sensation after procedures. Just like you put ice… You ever see those little boo-boo bunnies they have for kids where you can put an ice cube, and it looks like a little wash cloth, the boo-boo bunny? Well, when you do that on the breast, you’re just constricting the blood vessels to decrease that zinging sensation that you get when those blood vessels get dilated. So it works for multiple different ways.

And I will tell you that my patients that have been in recovery have been very, very happy because they think that we, as physicians, if we don’t honor that and pay attention to that, we could end up putting them into a slide, back into a place where once you ping those receptors again, those patients with the narcotics, we could potentially hurt them from staying in their recovery process. And it doesn’t mean that someone in recovery can’t get narcotics, it just means that we have to be really conscious of what we’re giving them because our goal is to shepherd them through this cancer process without sliding them back into a place that they don’t want to be.

Jamie DePolo: Absolutely. Now, you mentioned the pump that you give to some of your patients. Is that something that they can take home with them as well, or is that just used in the hospital during recovery?

Beth Baughman DuPree: The Marcaine pump lasts for about 3 days. So our patients typically will go home post-op day 1 or early post-op day 2, and so the [ON-Q pump] will continue to decrease and decrease and decrease as the Marcaine is bathed into the system.

For a lot of our patients, particularly those that are having implant reconstruction, it’s the stretching pain from the expander being behind the muscle. So we’ve been using a class of medications called a muscle relaxer, or the drug called Skelaxin, or metaxalone, I think it is. It’s a muscle relaxer that doesn’t make you goofy, and I only know that because if you pull a muscle in your back… I one time was given a class of medications, and my husband told me that if I ever took it again that he would divorce me, because it made me really awful to be around. And so I don’t like that classification of muscle relaxers. So, I like to use Skelaxin with my patients. And I actually had to go to my hospital’s Pharmacy and Therapeutics Committee because it was expensive, and I had to justify why my patients needed it. But by giving them the Skelaxin and the local anesthetic, we were able to decrease the... We used to use a thing called PCA, or patient-controlled analgesia, where they can give themselves an injection with morphine or Demerol. We don’t use that anymore, because with the combination of the ON-Q pump and the Skelaxin, we don’t need to use those pain pumps. And that’s huge for patients because it gets them up and moving faster, so it decreases the risks of getting clots in your legs because you’re moving. It decreases the risk of getting pneumonias because you’re breathing and you’re actually moving around. You’re not laying in bed, kind of in a vegetative state being gorked out on medications.

Jamie DePolo: That sounds great. So when a person is home, it sounds like in many cases, at least for you and your patients, you’re controlling their pain before they leave, so they’re good with Tylenol, NSAIDs, things like that when they get home. Is that accurate?

Beth Baughman DuPree: My goal is to get them as comfortable as possible before they leave so that they know that they can take the Tylenol or the NSAID, and they also have a prescription. I do give a prescription for some type of a narcotic if they needed that for management in the hospital. And the reason that I do that is, as they get more mobile and functioning and moving around, they may need something to take the edge off before sleep. But we try to educate them that the narcotic should be for the breakthrough pain, not for the, “Every 3 hours I’m going to take this medication.” Because there was a time when doctors would tell their patients, “Oh, you’re going to need this pain medicine every 3 hours.” So, they wouldn’t even let it get to the 3 hours, the patient was ready to take it, and that’s part of the reason why I think we have the opioid crisis that we have, is because we’ve programmed patients to believe that they need this medicine.

So, I think that we do a very good job with pain management, and rarely does a patient come back and need a refill of a prescription. And I usually only give 10 or 15 pills per prescription because I don’t think that they’re going to need more than that, and why have it laying around the house and paying for drugs that you don’t need?

Jamie DePolo: Now, you mentioned constipation. That’s a pretty well-known side effect of opioids. What about any of the other pain meds? Are there side effects that people need to be concerned about?

Beth Baughman DuPree: Obviously, if someone has liver issues, taking too much Tylenol can be an issue. If patients have concerns of gastric ulcers or other GI concerns, some patients may not be able to take non-steroidals like Motrin or ibuprofen or the Toradol. But besides that, unless someone has a specific allergy to that medication, there are lots of ways for us to be able to manage pain. And I think that in this day and age, it’s really about talking to your patient, finding out what their concerns are, preparing them ahead of time for the procedure.

I do a lot of stuff with my patients called “Prepare for Surgery.” There was a great clinical study done using guided imagery where they educated patients and had them using guided imagery, and they actually did the study. It was done by nurses, of course, because they’re very smart out in Southern California, and it was on patients having hysterectomies. And they had two different groups. They had standard care, and then they had the group that got the preoperative guided imagery. And the group that did the preoperative guided imagery had a shorter length of stay, about a 50% usage of narcotic, I believe, so their hospital charges were less. They had less pain postoperatively, and they were given a method to help to decrease the anxiety and decrease… And I think with the anxiety comes the cortisol, and you get in a fight or flight.

So, I think it all kind of plays into this pain factor where, if we manage our patients’ expectations, if we say, “You’re going to wake up and feel like you have an elephant sitting on your chest,” because that’s what my patients tell me, that they think that somebody like sat a cinder block on their chest, because when you put these expanders underneath the muscle, that’s what it feels like. For women that are undergoing a free-flap reconstruction called the DIEP reconstruction, they rarely complain of the pain on the chest. They more complain of the pain from the abdominal incision where the muscle and the abdominal tissue was removed, because on those patients the muscle flap is above the pectoral muscle directly underneath the skin. So they have less pain from the breast cancer surgery than they do from the abdominal surgery.

And so it’s about managing those expectations, because if those patients believe that their pain’s going to be in their chest and then their belly hurts, they’re going to be confused and scared. So I think that preoperatively teaching our patients what to expect… A lot of times for our patients, when we do axillary surgery, they can get some what we call hyperesthesias, where you get intense pain behind the arm where the little nerve comes out, called the intercostobrachial nerve. And we try very hard to preserve that nerve, so you can feel when you shave your armpits for the rest of your life. But what happens is by saving that nerve, sometimes it gets very sensitive. And so I prepare my patients ahead of time so that they don’t think that something’s wrong. Because if a patient has a symptom that they can’t explain, they suddenly go to that scary place like, “Oh, my God, is this the cancer?” And that’s what I try to avoid.

Jamie DePolo: You mentioned a little bit about the guided imagery. Are there other non-medicinal ways to control pain or to deal with pain that you would recommend for breast cancer patients?

Beth Baughman DuPree: I’ve used acupuncture. I use acupuncture more for postoperative nausea management, but it really, for patients that are willing and open to it, it can do wonders. But not everybody has access to an acupuncturist. We have one that works with our foundation, which we’re very fortunate. But in the immediate post-op period, you pretty much have to have that set up beforehand to be able to get that. I would love to have an acupuncturist in the hospital because I think it would be fabulous.

We’ve also used other forms of healing, Reiki and guided imagery. I think another thing that every patient needs to be able to do is to learn how to get into that safe zone in their head, because if we have a patient who is preparing for surgery and they don’t have a practice of either meditation or guided relaxation or prayer or something to take their head out of the fear zone and into the healing space, then I think that that increased level of anxiety also kind of keeps them tense. And so being able to relax, and as I say, get into the Zen zone, is really important.

And when my patients go to sleep… I had a patient today going to sleep, and she was fabulous because I’ve known her for a long time. And we were having conversation where I was able to get her to laugh before she went directly under the anesthesia. And you shouldn’t be in two places at once. You can’t be in fear and in happiness and bliss at the same time. So if you go into the operating room and you’re in fear, you’re in fear. But what I do with my patients with guided imagery is I say, “Where do you want to go? Any place in the world. My anesthesiologist has the best drugs. We’re going to go first class. Let me know where you want to go.” So my patient today, she was like, “Well, could we go to Bali or Fiji or something?” I’m like, “Yeah, we’re going to go to Fiji on a Blue Lagoon cruise.” And so she’s undergoing, so she’s smiling, she’s laughing. So she’s not in the, “Oh my God, I’ve got cancer, and I’m going to sleep.” She’s like, “Hey, I’m on a Fiji Island cruise, and I’m going to the Blue Lagoon, and I’m going to relax and feel the sun on my face and the sand on my toes,” and it was funny.

Some of my anesthesiologists, years ago, used to think I was just totally crazy, and then when they see that the patients actually wake up better and that they are more at peace with it. And they realize that putting a patient to sleep who’s not scared… Because if you’re putting someone to sleep and they’re sitting there crying and they’re scared and they’re sad, that is not a good way to go to sleep. They should just go to sleep with the visualization, “clear nodes, clear margins, clear nodes, clear margins,” just put out to the universe exactly what you want.

Jamie DePolo: That sounds great. Dr. DuPree, thank you so much. This has been so helpful. I have one last question. So you were talking about the visualization as somebody’s going under. If somebody has a surgeon who, say, is not taking them to Fiji for their surgery, is that something that they can do themselves, like in their head? Like, “I’m going to Fiji. I’m going to the Blue Lagoon. I’m calm. I’m happy.”

Beth Baughman DuPree: Absolutely. And the thing that was interesting is, in that clinical study with the guided imagery, it wasn’t the doctors that were driving that train, it was the nurses. So, those nurses, those preop nurses, were not in the operating room with the patients. But what that process did of that guided imagery, it gives them intentions, and so they can repeat that in their head. Part of the guided imagery is taking that patient away from the fear. You can’t be in fear and love at the same time. And what I say is, “I would always rather move to love than fear.” So emotions are in that positive space in their head even if they’re the one that is putting it through there.

I have patients that come to the operating room with their 3 x 5 cards, their intentions on it. And so I have one particular nurse anesthetist. She happens to also be an amazing healer, and Jo Anne will sit up there. She’ll read the cards as they’re asleep under anesthesia. Because even though you’re asleep, you’re still aware. Even though you’re asleep, on some level, your conscience knows what’s going on, which, in my operating room, there’s no bad comments about… If anybody comes in with a bad attitude, you can take it out the door. Because you’ve got to stay in that healing space for that patient and hold that intention for them.

Jamie DePolo: That’s great advice. Dr. DuPree, thank you so much for being our guest today. I really appreciate it. If you enjoyed listening to the Breastcancer.org podcast, please rate, review, and subscribe to it on iTunes. It helps other listeners find our content, and your support allows us to continue podcasting. Thanks.