Top 4 Nerve Disorder Side Effects of Breast Cancer TreatmentBy: Lindsay Davey, MScPT, MSc, CDT
August 28, 2015
Editors: Ryan Davey, PhD and Lindsay Davey, MScPT, MSc, CDT
A variety of upper body pain and function disorders are common in patients treated for breast cancer. Nerve disorder side effects can be some of the most severe and difficult to diagnose, due in part to their broad and variable symptoms. Patient awareness, self-advocacy, and cancer rehabilitation is needed to overcome these side effects and recover quality of life.
Pain and other physical changes and limitations presenting in the chest, back, abdomen, breast and arm are common side effects of breast cancer treatment. The aggressive nature of surgery, chemotherapy, radiation therapy, and hormonal therapies can create significant unintended consequences on normal tissue and body function. These side effects frequently manifest as acute or chronic pain, or functional disorders, that collectively are very common; arm disorders have been reported to affect as many as 7 in 8 women following breast cancer treatment (ref1).
Nerve disorders can hinder a patient’s ability to return to normal activities, and significantly impact quality of life. Common nerve disorders can begin to show symptoms as early as immediately post-operatively or in the first few months following cancer treatment, but some conditions may only appear many years later. Unfortunately there is little general awareness of the breadth of nerve disorders resulting from breast cancer and its treatment, the chronic nature of many of these side effects, nor the impact of them on survivor quality of life. This is particularly true for newly diagnosed breast cancer patients and their support network of family and friends.
For more side effects of breast cancer treatment, please see: Top 3 Musculoskeletal Side Effects of Breast Cancer Treatment
The major upper body nerve disorders resulting from breast cancer and its treatment are significant, but with appropriate diagnosis and rehabilitation they can be effectively managed or eliminated.
Here I review the top four nerve disorder side effects arising from breast cancer treatment, their causes, their symptoms, and how they can be treated.
1. Chemotherapy-induced peripheral neuropathy
Description and cause:
Damage or dysfunction of the peripheral nerves, known as peripheral neuropathy, is a very common side effect of breast cancer chemotherapy. Common chemotherapeutic agents used to treat both early and advanced breast cancer have known neurotoxic effects, these include taxanes, vinca alkaloids and platinum analogues (ref2). These neurotoxic effects result in damage to motor, sensory and autonomic nerves, producing a range of variable symptoms. Neuropathy due to taxane and vinca alkaloid toxicity appears immediately after exposure to the agent, and is typified by weakness, pain and other sensory changes. Neuropathy due to platinum agents typically appears later, and can continue to worsen for months following exposure (ref2).
The incidence of chemotherapy-induced peripheral neuropathy depends on the chemotherapeutic agent used. For example, incidence rates for patients treated with vinca alkaloids is within the range of 30%-47%; for the common taxanes paclitaxel and docetaxel incidence has been estimated to be within the range of 57%-83% and 11-64%, respectively; and for the platinum analogue cisplatin the range is from 28%-100% (ref3). Risk of neuropathy is believed to be higher in breast cancer patients that have had chemotherapy previously, previous peripheral neuropathy, or radiculopathy (see nerve disorder number 2 below) (ref2).
The symptoms of chemotherapy-induced peripheral neuropathy typically include severe pain that may be intermittent or constant, and sensory abnormalities such as burning or tingling sensations, loss of feeling (numbness, or loss of sensitivity to temperature and pressure). Difficulties picking up and holding objects with the fingers can also be common. Muscle weakness is not typically associated with this condition. For some, chemotherapy-induced peripheral neuropathy can be progressive and irreversible, while other patients experience improvement of these symptoms over time, in some cases with full resolution.
The diagnosis of chemotherapy-induced peripheral neuropathy in the upper body is usually uncomplicated for patients who experience the expected symptoms over the expected time course for the chemotherapy agents they have been treated with. If patients are experiencing abnormal symptoms or the expected symptoms over an abnormal timeline, then alternative diagnoses should be ruled out.
Using patient history, neurological examinations, electrodiagnostic studies and lab testing, a peripheral neuropathy diagnosis can be readily determined for the majority of patients.
Left untreated, chemotherapy-induced peripheral neuropathy is typically progressive, and can be long-lasting or permanent, although in some cases the condition may improve spontaneously.
Treatment of chemotherapy-induced peripheral neuropathy involves education, physiotherapy including exercise therapy, and occupational therapy. Medications can be beneficial for relieving pain and tingling/burning sensations (ref3), but not weakness, numbness or loss of proprioception (perception of the spatial position of the limb). Medications may include local anesthetics, opiods, anticonvulsants and antidepressants.
Improving general health and physical function through exercise may also help improve the symptoms, as well as alternative therapies including meditation, massage therapy, dietary supplements and acupuncture (ref2)
2. Cervical radiculopathy
Description and cause:
Cervical radiculopathy is a nervous system disorder resulting from damage or disturbance of the nerve roots originating in the cervical spine (the neck). Damage may be caused by nerve compression (a “pinched nerve”) arising from degenerative changes or a ruptured disc, or from tumor growth in this area of the spine. In cancer patients where symptoms of cervical radiculopathy are worsening, imaging should be immediately performed to rule out tumor growth.
Cervical radiculopathy is relatively common in the general population, and accordingly, most cases in women with breast cancer are unrelated to their cancer or its treatment. However, peripheral nerve disorders such as radiculopathy can emerge or worsen in response to chemotherapy with neurotoxic agents (ref2). Cervical radiculopathy is also important in the breast cancer population because it can mimic or exacerbate other cancer related upper extremity disorders.
The symptoms of cervical radiculopathy are similar to other peripheral nervous system disorders, namely: weakness in the shoulder, arm, and/or hand; and pain, numbness, tingling or burning sensations in the neck, shoulder, arm or hand.
Electrodiagnostic testing may be helpful to rule out symptomatically similar brachial plexopathy and peripheral neuropathy disorders.
Treatment of non-tumor related cervical radiculopathy involves physiotherapy and medication with anti-inflammatory drugs. For more advanced cases steroid injections may be beneficial. Surgical interventions may be considered for some severe cases, although outcomes are mixed (ref4). Cases of radiculopathy that arise due to tumor growth may require cancer treatment. Even in these patients, physiotherapy and occupational therapy can be used to increase strength, reduce pain, improve range of motion of the neck and/or shoulder, and increase dexterity and coordination for performing daily activities.
3. Postmastectomy pain syndrome and phantom breast syndrome
Description and cause:
Postmastectomy pain syndrome typically presents as a persistent pain in the chest, armpit, surgical scar, and upper inner arm that continues beyond the normal expected length of time for post surgical pain, in other words, beyond the normal length of time for tissue healing.
Postmastectomy pain syndrome affects somewhere between 4% and 56% of patients, depending on the study and how the condition is diagnosed (ref5). The exact cause of this syndrome is not clear, but it is typically believed to be a result of nerve damage arising from surgery (breast removal or breast reconstruction) or radiation damage, and /or from the developing scar tissue gradually compressing a nerve. Damage to the intercostobrachial nerve is very common during mastectomy (affecting an estimated 20-50% of patients) and may therefore be the most frequent cause (ref6).
Phantom breast syndrome (sensations and/or pain perceived in the breast even though the breast has has been removed), can also be very common in patients who have undergone a mastectomy, and may occur for 10-66% and 0-53% of patients, respectively (ref 7).
Postmastectomy pain syndrome has been described as a burning, aching or stabbing pain or tightness, which may be exacerbated by movement of the shoulder/shoulder blade. This pain and sensory dysfunction may also contribute to secondary complications such as reduced range of motion in the arm.
Patients with postmastectomy pain syndrome experience symptoms analogous to stump pain in limb amputees, and similarly, they may also experience phantom breast sensations and pain analogous to phantom limb syndrome. Symptoms of phantom breast syndrome tend to occur irregularly, and onset may begin within a few months or years after mastectomy.
Pain that is atypical of postmastectomy pain syndrome, or that is progressive in nature, should be investigated to rule out the possibility of tumor recurrence or other complication such as infection or deep vein thrombosis.
Postmastectomy pain syndrome and its complications can be treated through physiotherapy for skin desensitization, range of motion, scar tissue release and strategies aimed at promoting nerve regeneration/healing, as well as pharmaceutically with pain killers and nerve stabilizers. Treatment strategies for phantom breast pain are the same as for postmastectomy pain syndrome.
4. Brachial plexopathy
Description and cause:
The brachial plexus is a collection of nerve fibers that originates at the spine and travels through the neck and armpit, into the arm. This collection of nerve fibers supplies nerves to the skin and to the majority of the muscles of the arm. Consequently, dysfunctions can result in a wide variety of functional losses and sensation changes. Brachial plexopathy is a dysfunction of the brachial plexus that may be transient or permanent in nature. In breast cancer patients brachial plexopathy is most commonly observed as a result of radiation therapy (called “radiation induced brachial plexopathy”) or tumor growth in the brachial plexus region. Neurotoxicity from chemotherapy agents, damage to blood vessels supplying the brachial plexus, and fibrosis (scarring) around the nerves are likely causes of the disorder in this population.
The probability of developing brachial plexopathy increases with the radiation dose per fraction and the total dose received (ref1). Due to recent improvements in the delivery of radiation therapy, lower dosages are currently in use, and the incidence of this condition is consequently decreasing. Unfortunately the recent changes to “standard” radiation dosing make it difficult to estimate the current incidence of this condition (ref8), but it is likely that the incidence rate is now near 1%.
The symptoms of brachial plexopathy are varied, a consequence of the myriad of functions this bundle of nerve fibers controls. In one study, symptoms were found to appear anywhere between 6 months to 20 years after radiation therapy, the median time being 1.5 years (ref9). Common symptoms may include: pain, loss of sensation, tingling or burning sensations in the arm or hand; weakness in the shoulder, arm and/or hand; or new-onset lymphedema.
A clinical assessment including MRI and PET scans can be used to differentiate between brachial plexopathy arising from radiation therapy or from tumor growth. Electrodiagnositc tests may be used to differentiate this disorder from cervical radiculopathy and peripheral neuropathy. Of note, electrodiagnostic tests are not considered to be unsafe for patients with lymphedema (ref10).
Without treatment a sizable proportion of patients suffering from radiation-induced brachial plexopathy will progressively deteriorate to having a limb without mobility or sensation (a “flail arm”), the remaining patients may stabilize, or in some cases spontaneously resolve. There is no medical cure for brachial plexopathy, but prescription drugs may be beneficial for pain control (ref11). However, early physiotherapy can help prevent muscle atrophy, frozen shoulder syndrome and lymphedema (ref12). Physiotherapy treatment should focus on adaptation and compensation techniques, muscle strengthening, proprioception (perception of the spatial position of the limb) and skin desensitisation.
For more side effects of breast cancer treatment, please see: Top 3 Musculoskeletal Side Effects of Breast Cancer Treatment
- McCredie M.R., Dite G.S., et al. Prevalence of self-reported arm morbidity following treatment for breast cancer in the Australian Breast Cancer Family Study. Breast 2001;10:515-522. https://doi.org/10.1054/brst.2000.0291
- Galecki J., Hicer-Grzenkowicz J., et al. Radiation-induced brachial plexopathy and hypofractionated regimens in adjuvant irradiation of patients with breast cancer – a review. Acta Oncol. 2006;45:280-284. https://doi.org/10.1080/02841860500371907
- Stubblefield M.D., McNeely M.L., et al. A prospective surveillance model for physical rehabilitation of women with breast cancer: Chemotherapy –induced peripheral neuropathy. Cancer. 2012;118(8 supplement):2250-2260 https://doi.org/10.1002/cncr.27463
- Stubblefield M.D., Burstein H.J., et al. NCCN Task Force Report: Management of neuropathy in cancer. J Natl Compr Canc Netw. 2009;7:S1-S26. abstract
- Basho R., Bhalla A., et al. Neck pain from a spine surgeon’s perspective. Phys Med Rehabil Clin N Am. 2011;22:551-555. https://doi.org/10.1016/j.pmr.2011.03.007
- MacDonald L., Bruce J., et al. Longterm follow-up of breast cancer survivors with post-mastectomy pain syndrome. Br J Cancer. 2005;92:225-230. http://doi.org/10.1038/sj.bjc.6602304
- Ramesh, Shukla N.K. et al. Phantom breast syndrome. Ind J Palliative Care. 2009;15:103-107. http://doi.org/10.4103/0973-1075.58453
- Dijkstra P.U., Rietman J.S., et al. Phantom breast sensations and phantom breast pain: A 2-year prospective study and a methodological analysis of literature. Eur J Pain. 2007;11:99-108. https://doi.org/10.1016/j.ejpain.2006.01.002
- Stubblefield M.D., Keole N. Upper body pain and functional disorders in patients with breast cancer. PM R. 2014;6(2):170-183. https://doi.org/10.1016/j.pmrj.2013.08.605
- Fathers E., Thrush D., et al. Radiation-induced brachial plexopathy in women treated for carcinoma of the breast. Clin Rehabil. 2002;16(2):160–5. https://doi.org/10.1191/0269215502cr470oa
- American Association of Neuromuscular & Electrodiagnostic Medicine. Needle EMG in certain uncommon clinical contexts. Muscle Nerve. 2005;31(3):398-9. https://doi.org/10.1002/mus.20238
- Kori SH. Diagnosis and management of brachial plexus lesions in cancer patients. Oncology (Williston Park). 1995;9(8):756–60. article
- Schierle C., Winograd J.M. Radiation-induced brachial plexopathy: review. Complication without a cure. J Reconstr Microsurg. 2004;20(2):149–152. https://www.thieme-connect.de/DOI/DOI?10.1055/s-2004-820771
SMALL BREAST CANCER LUMP AND ONE LIMPH NODE WITH CANCER REMOVED . RIGHT ARM
OPERATION DONE DEC 2/2013
16 RADIATION TREATMENTS (8 GREYS) DONE FEB 188.8.131.52.26.27.28.MAR2.
RIGHT ARM ACHED AFTER 3 RD TREATMENT
ATTENDING RADIOLOGIST TRIED TO HELP BY TAPING ACHING ARM OVER HEAD SO I COULD FOLD ARMS TOGETHER BEHIND MY NECK.
WITH MY HUSBAND’S HELP WE REPORTED IT TO DR. ON DUTY. HE WAS NOT A SPECIALIST. HE RECOMMENDED TYLENOL THINKING IT WAS SHORT TERM PAIN FROM ARMS BEHIND.
PAIN HAS NEVER STOPPED AND ONLY GOTTEN WORSE WITH TOTAL BRACHIAL PLEXOPHY. IT GETS AS BAD AS AN ABCESS TOOTH ACHE.
CANCER CLINIC AT ABBOTSFORD HOSPITAL HAVE PUT ME THROUGH MANY
MACHINES TO SEE DAMAGE HAS BEEN DONE. SPECIALIST IN NERVE DAMAGE
HAVE TRIED TO HELP BUT WHEN NERVES HAVE BEEN BURNED WITH RADIATION ITS TOO LATE.
MY FAMILY DR GIVES ME PRESCRIPTION FOR GABAPENTEN. ECT TO HELP WHEN PAIN GETS BAD. ALSO SLEEPING PILLS TO GET REST AT NIGHT.
ALL PILLS ARE RESTRICTED TO HOW MANY DAYS OF THE MONTH ECT.SO
PATIENTS DON’T OVER/DOSE.
I AM FORTUNATE TO HAVE A LOVING HUSBAND WHO TAKES CARE OF ME
WARMING BEAN BAGS OR ICE BAGS TO EASE PAIN.
HE ALSO NOW HAS TO DO ALL COOKING AND SHOPPING FOR FOOD ECT.
I AM FORTUNATE TO BE LEFT HANDED , BUT TOO MUCH USE EVERY DAY
CAUSING PAIN TO RADIATE ACROSS MY SHOULDER AND DOWN MY RIGHT ARM. I KEEP SEARCHING FOR A MIRACLE.
Thank you for writing, as I am sure it will help others to know they are not alone in their own journeys and challenges. You certainly sound fortunate to have such a partner as your husband to provide such supportive care. Hopefully the Gabapentin will help you manage your nerve symptoms, as I know how very painful that can be. If there are support services near you (such as a pool program, or yoga, or mindfulness, or meditation….) I wonder if they might be able to provide additional support. Cancer support networks often offer free sessions such as these to those with a cancer diagnosis and for some, it can really be beneficial to their quality of life. I wish you well Marjorie, and to your husband as well. Sincerely, Lindsay Davey
I was diagnosed with RIBP in March 2017, 6 months after receiving standard (U.S.A., Kaiser Permanente) 5 weeks of radiation therapy for locally invasive breast cancer ( right mastectomy and AC-T chemo). My radiologist said damage was visible in a brachial MRI with contrast. I was losing all use of my right arm and had intermittent sharp pains in the radiation field, right arm, and right shoulder blade. My radiologist put me on high dose prednisone which eliminated the pain until I tapered off the prednisone after 4 weeks. Now, daily 600 MG gabapentin and 10 MG nortriptylene relieve most symptoms. I have somewhat limited movement of right arm, but now I can cook and garden and dress myself , and I work full time in an office job. I had 6 weeks of occupational therapy which also helped a great deal.
Thank you for sharing your story. I am certain that this will be of great help to others experiencing similar symptoms stemming from their breast cancer radiotherapy treatments. I’m so sorry that your journey through breast cancer treatment involved this very unfortunately sequela involving the brachial plexus and associated nerves. Pleased to hear that you sought out help with an occupational therapist – OTs and physiotherapists are experts in upper extremity function and can certainly help in these cases of recovering brachial plexus injury/dysfunction. I hope the exercises they provided are continuing to prove meaningful in your arm’s functional level, and that with time, you will be able to wean off the Gabapentin and Nortyiptylene. I thank you again for your comment Nancy, very insightful for our readers indeed, and so grateful to hear you are improving. Best of luck!
Sincerely, Lindsay Davey
I have read the stories here and have had confirmed for me that, yes women do suffer after mastectomy and it’s not my imagination. My mastectomy was in spring 2009 and a lumpectomy in Dec. 2002. My tumors were all located left side outer quadrant. In the mastectomy one tumor was on top of another. I have had pain since the lumpectomy but after having to change insurance and leave the medical group where the surgery was performed, no doctors seemed interested in my PMPS so I just dropped the subject. I have severe lumbar/sacral disc degeneration so was getting pain medication and lidocain patches so they helped me. My pain radiates from my chest down past my waist and also to my shoulder up my neck and down my back to my shoulder blade. I also get swelling in my armpit, it gets very hard. It soumds like some of these women are getting help and that is what I need. I see a pain specialist, do I need to see someone with a different speciality? My doctor is useless, just a CDC robot who cuts mt med and does nothing else other than look at his watch to see if my 20 minutes are up. I need help from someone who believes in Post Mastectomy Pain Syndrome.
First of all I’m really sorry to hear of your long-standing and on-going pain challenges stemming from your breast surgeries. It sounds like you have a pain specialist on board, but in conjunction with seeing a therapist trained in soft tissue release post-mastectomy and swelling management, I would guess you would see additional benefit and (hopefully!) finally provide you with some meaningful relief. The pain experienced from mastectomy/radiation is typically localized to the chest, shoulder/arm, and upper/mid back, but can certainly involve the neck and lower back depending on confounding conditions at play, compensations made over an extended period of time, and so on. The release of the fascial and surgical restrictions and radiation tissue effects (if you had radiation) can provide striking results in terms of range of motion, decreased pain, and ultimately improved function in our breast cancer patients. I hope in addition, that the aspects of your pain derived from your lumbosacral deneration is also addressed, and perhaps even, your CDT therapist may be a physiotherapist themselves or work with one for a co-ordinated effort. Post Mastectomy Pain Syndrome is a real condition affecting many women following their breast cancer surgeries/treatments, and I sincerely hope you continue to pursue avenues of therapy with practitioners experienced in this area. Wishing you luck in finding a therapist to be your partner in recovery Dana. A worthy goal indeed! Sincerely, Lindsay Davey
Had a right breast lumpectomy 12/20/17. 4 lymph nodes removed. Negative for cancer. in recovery noticed right thumb, next 2 1/2 fingers numb. two one half weeks later numb in just thumb and one finger. any self help on how to relieve numbness. should I start radiation before numbness disappear completely.
Thank you for your comment. The distribution that you describe is that of the median nerve, and I’m pleased to hear that it sounds as though the numbness is lessening with time. It is likely to continue to improve, and I am certain your team members (specifically your radiation oncologist) would not recommend you to delay the next phase of treatment on account of this numbness which is likely to be temporary. It’s a valid question to be sure, and I would certainly suggest you discuss it with your physicians, of course. However, nerve recovery can take time, and often a symptom such as you describe does last throughout the acute phase of cancer treatment. The improving pattern already demonstrated in the extent to which the hand is affected, is encouraging! I hope that’s helpful Dinah. Best wishes for your next phase of treatment, and thereafter. Sincerely, Lindsay Davey
In 2008 had left breast lumpectomy and 5 weeks radiation. In 2015 started having chest pain when exerting, and when go to bed. It radiates to my neck and left arm like a heart attack. Three years later and no diagnoses. Heart perfect, Lungs okay, Gastro okay. Been through every test you can think of. Mentioned the radiation several times to different doctors with that wouldn’t do this. Yesterday at the Gastroenterologist I saw a NP and when I told her about the radiation she said I really think that is it. I am now starting to experience the pain when doing nothing. Am taking Tofranil and it helps about 25% of the time. How do I get the Doctors on board with this?
I’m so sorry to hear of such a long road this has been, and such a painful one. I have to say, it is indeed more rare to experience latent radiation effects so long after treatment – given that you didn’t experience symptoms until 7 years later, and it having such a dispersive referral pattern, I too would have been looking to rule out heart, lung, gastrointestinal systems as well. I presume since you do not mention it here, that you do not have shortness of breath? Given that it started with exertion, and when lying down. Pneumonitis is something that I have seen in a few patients over the years, stemming from the radiation they received for their lumpectomies, but again, they did not have delay in their symptom onset, or certainly, not on the order of several years. I am sure you have gone down these roads but perhaps you have considered a physiotherapist specializing in chronic pain, who may have other tools at their disposal to try to address this long-term pain you are experiencing? Also, to rule out any rib/fascial/biomechanical restrictions that may need to be released. I wish you the very best of luck Jeanette. With warmest regards, Lindsay Davey
In August 2017, I had a double mastectomy and removal of 9 lymph nodes under my right arm which were cancerous. Since then, I’ve suffered from intermittent pain in my right armpit and a tightness and heaviness across my chest from scar tissue after surgery. My surgeon thinks scar tissue is adhered to and is pressing on the nerve under my arm. I had no chemo, radiation or hormone suppression for my breast cancer, just the mastectomy.
Thank you for sharing your story. Indeed, we see a great number of women with adhesions and tightness affecting their chest and armpit attributable to their surgery, even in the absence of radiation (which can cause further tension and nerve effects). There is certainly reason to pursue a visit with an experienced massage therapist or physiotherapist who could address this tightness for you, and provide meaningful pain relief. I wish you luck in this pursuit and further recovery Patti! Wishing you well, Lindsay Davey
I had breast surgery 20 years ago and got nerve damage from lymph node removal, I experience alot of aches and pains in arm chest etc I also get pain in chest area where heart is but it also feels like wind, is this related to nerve damage?
Thank you for your comment. Lymph node removal, particularly 20 years ago, may have affected your nerve bundle that resides in the armpit, and yes, could cause on-going nerve effects in the arm and chest, etc. These days they do try to minimize the number of nodes removed when possible, but if your surgery was 20 years ago it’s possible that your surgery was more invasive in nature, and thus, more likely to have produced these sorts of side effects. If you also had radiation, this too can restrict the movement capacity of the tissue of the chest and armpit areas, which can contribute to nerve irritation as well. I would recommend you seeing a physiotherapist or massage therapist who is experienced in cancer rehab/lymphedema, since many of us are very accustomed to treating these types of conditions, and I’m happy to say, there doesn’t tend to be a limit of how long after surgery/radiation we can see symptom improvement with the release of restricted tissue. I hope this helps Heather, and hope you can find someone in your area to assess and release any restrictions they find in the chest/armpit areas, which should help the nerve irritation and symptoms you’re experiencing. Best wishes, Lindsay Davey