The Fascinating New Treatment for Mastectomy Pain Relief: ‘Nerve Freezing’ Could Be Life-Changing for Breast Cancer Survivors

"It's usually challenging to treat the pain," Dr. Shrif Costandi, a pain management specialist for Cleveland Clinic, said in an interview with SurvivorNet."Usually patients start to use some medications, some topicals. I would say the majority usually get better with that, but then there’s always a percentage of patients that end up having this refractory pain."

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Treatment for PMPS looks different from person to person. But Dr. Costandi says that he starts with a "thorough examination of the nerves" to determine the extent of any existing nerve damage. From there, a first line of treatment might be anti-inflammatories like ibuprofen or acetaminophen. From there, there's a "wide array" of neuropathic pain medications that can be explored such as gabapentin and pregavlin.

"Then another important class of medications that we use are the neuropathic pain medications or just nerve pain medications, for simplicity, and that class includes medications like gabapentin and pregavlin," Dr. Costandi explained. "We usually try those medications and then, if they're ineffective, we add another medication.

"As for the gabapentin and pregabalin, we usually start with a lower dose and then see how patients respond to that. If patients are responding well we stop there, if patients are not responding well, then we try to titrate up (gradually increase) the medication until we get a good therapeutic effect."

Topical treatments like lidoderm or lidocaine patches, creams or gels are also an option. But if patients aren't responding to these treatments over time, Dr. Costandi uses cryoablation.

"So, usually when patients do not respond to the conservative measures and it’s been more than six to eight weeks after surgery, that’s when I consider using the cryoablation," Dr. Costandi said. "I would say 70-80% would respond to conservative measures, but you’d still have around 20% that will need an intervention to kind of help to fix the pain."

What Is Cryoablation for Post-Mastectomy Pain Syndrome?

Cryoablation, in general, is a procedure that uses extremely cold gas to freeze and destroy abnormal cells or diseased tissue. It has been used within the cancer world for more than a decade, but Dr. Costandi says this specific application for breast cancer patients only started being used "within the past five years."

"The therapy itself is old, but there are new applications now that are kind of starting to become more common," he said. "And I think the main reason is because the imaging guidance has improved a lot."

When Should You Consider a Mastectomy?

But how does it work? First, a nerve block is performed. According to Dr. Costandi, the nerve block helps him:

• Confirm the nature of the pain the breast cancer survivor is experiencing.
• Confirm the location of the pain and understand which nerves are being affected.

"So the nerve block has diagnostic, and, at the same time, what we call prognostic value," Dr. Costandi said. "Meaning that it helps you to know where the problem is coming from and would the patient receive any benefit if I do cryoablation or not."

If he determines that the breast cancer survivor would, in fact, benefit from cryoablation, then the 'freezing' begins via a probe being guided with the help of imaging such as an ultrasound or an X-ray.

"So, the nerves have multiple layers and covering around them just like any electrical cable that has an insulating layer from outside, and then the nerve signals kind of travel from within the nerve," Dr. Costandi said. "We freeze the nerves to a temperature of minus 60 and that kind of freezes the cells within the nerves and that causes an interruption of the pain signals going to the brain."

Most often, the nerve that is being treated during cryoablation for post-mastectomy pain syndrome is the intercostobrachial nerve.

"[The intercostobrachial nerve] is the most common nerve to be severed or injured during a mastectomy and it's not just because of the surgery, sometimes the cancer cells are enveloping that nerve," Dr. Costandi explained. "So, sometimes to peel off some of the cancer cells then some of the nerve gets damaged through that process. I would say there are other ones that could potentially cause the problem, but I would say this is by far the most common one."

Which Breast Cancer Survivors Are Having This Procedure?

While PMPS can affect breast cancer survivors who've undergone either a lumpectomy or a mastectomy, Dr. Costandi says he's generally using cryoablation on breast cancer survivors who've undergone mastectomies or lymph node removals in the axillary region an anatomical region under the shoulder joint where the arm connects to the shoulder.

"Most of the time, the intercostobrachial is affected with mastectomies, or with the lymph node removals in the axillary region or the armpit so it's unlikely to be injured with a lumpectomy," Dr. Costandi said.

Dr. Costandi clarified that cryoablation of the intercostobrachial nerve for PMPS could "theoretically" be appropriate for a survivor who's undergone a lumpectomy if the lumpectomy was "done closer toward the nerve runs," but he doesn't really come across this usage and the cryoablation is most often performed on patients who've had a mastectomy.

This then begs the question on whether or not a breast cancer warrior should get a mastectomy or a lumpectomy in the first place. In an interview with SurvivorNet, Dr. Sarah Cate, a breast surgeon at Mount Sinai Health System, said mastectomies are performed under "very specific indications."

Should I Have a Lumpectomy or Mastectomy?

"Some of the things that would predicate a mastectomy are things like a large tumor size to breast ratio, or having cancer in more than one area of the breast, or things like a genetic mutation," Dr. Cate explained. "So really, at Mount Sinai, we’re not doing a lot of mastectomies unless we’re following those very strict guidelines."

In addition, some of the things that would make a breast cancer survivor not a candidate for cryoablation include the following, according to Dr. Costandi:

• Having an anatomical distortion that makes the nerves impossible to reach or unsafe to do the nerve block
• If there is a cancer regrowth or recurrence.

What Are The Benefits and Risks for Breast Cancer Survivors?

For eligible patients, cryoablation may be the right choice for PMPS treatment if previous conservative measures have tried and failed. One of the benefits to this therapy is that it can address existing pain while also allowing the nerves to regenerate again since it freezes the nerves from within and preserve its outer layers.

"The benefit of the cryoablation is it does not disrupt the outer layers and that gives the nerves the time or the ability to heal again," Dr. Costandi said.

But complications including the following can occur:

• Potential nerve injury
• Bleeding
• Infection

"I would say the most concerning one is another potential nerve injury," Dr. Costandi said of potential complications from the procedure. "Just because, again, we’re working in an area that's loaded with nerves, so it can cause another nerve injury.

"Now, how common are those potential complications? I would say less than 1%."

After the procedure, Dr. Costandi says "patients are doing very well" within a few days.

"I would definitely recommend [cryoablation of the intercostobrachial nerve] if they fail conservative measures and it’s been more than three months after the surgery," Dr. Costandi said.

What Questions Should You Ask Your Doctor?

If you are a breast cancer survivor struggling with post-mastectomy pain syndrome, consider asking your doctor the following questions if you'd like to weigh treatment options:

1. What is causing my PMPS? Are there any other underlying issues that could be contributing to my nerve pain?
2. Have all my options for pain management been explored?
3. Am I a candidate for cryoablation?
4. Does my hospital care team perform cryoablations to treat PMPS?

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