Kaiser Permanente study compared two regional anesthesia techniques used during breast cancer surgery
Two pain block techniques are equally effective in reducing opioid use after a mastectomy, new Kaiser Permanente research shows.
The study, published in the Journal of Pain Research, compared two regional anesthesia techniques: a pectoralis nerve (PECS) block and an erector spinae plane (ESP) block. The PECS block is commonly used for breast cancer surgeries; the ESP block is often used in other types of chest and back surgeries but is newer to the breast cancer setting.
The findings should provide reassurance to breast cancer patients who have concerns about optimal pain management.
“There are many factors that go into determining if a pain block will be used during surgery and, if so, what type of block,” said first author Edward Yap, MD, an anesthesiologist with The Permanente Medical Group and a physician researcher at the Kaiser Permanente Division of Research. “There hasn’t been a lot of research comparing the PECS block with the ESP block, and we believed doing this study at Kaiser Permanente could help guide care provided to all breast cancer patients.”
The retrospective study included 517 breast cancer patients who had a mastectomy without reconstruction that included a nerve block between 2017 and 2020 at a Kaiser Permanente Northern California (KPNC) hospital. Within this group, 428 patients had a PECS block and 89 had an ESP block.
A PECS block is injected into the connective tissue near the chest’s pectoral muscles to block pain in the nerves and muscles in the chest wall. The ESP block is injected into connective tissue alongside the spine in the upper thoracic area, where it can control pain in the chest, breast tissue, and middle back.
The study found no significant difference in total opioid use after surgery, average pain scores, or maximum pain scores based on the type of block the patient received. Length of hospital stays, postoperative nausea and vomiting, readmission, and new postmastectomy pain within 6 months of surgery also were about the same in both groups. However, the patients who received the ESP block group did receive more non-opioid options for pain relief after surgery than the patients who had the PECS block.
“Postoperative pain management is a cornerstone of breast cancer care,” said study co-author Elizabeth Linehan, MD, a breast surgical oncologist with The Permanente Medical Group. “Using a nerve block during surgery can decrease the use of opioids to treat pain after surgery, and it’s important to know that both of these options are equally effective in supporting mastectomy patients.”
A common procedure
More than 287,000 people in the U.S. are diagnosed with breast cancer each year, and about 100,000 of these patients will have treatment that includes a mastectomy. Studies have found that a regional pain block helps to control pain after surgery and can reduce both recovery time and a patient’s risk of developing persistent post-mastectomy pain. It also reduces a patient’s risk of becoming dependent on opioids.
Before a mastectomy procedure, the surgeon and the anesthesiologist will discuss whether a block will be used and, if so, what kind. KPNC uses an enhanced recovery pathway for all mastectomy procedures that encourages regional anesthesia. Factors that can determine what type of pain block will be used include the patient’s age and pain history, hospital practices, and expected length of the surgery.
“Our study really underscores the importance of multimodal pain management and multidisciplinary coordination in achieving the best outcomes for our patients,” said Linehan. “Breast cancer treatment is very multidisciplinary outside the operating room, with medical oncologists, radiation oncologists, radiologists, plastic surgeons, pathologists, social workers, navigators, and geneticists working together, and that thread continues into the operating room with our anesthesiologists.”
Added Yap, “Most patients don’t meet the person who will be their anesthesiologist until the day of their surgery. We hope our patients know that before we meet them, we have carefully considered the pain blocks and other anesthesia options available and discussed with the surgeon what we think will be best for them.”
The study was funded by Kaiser Permanente Community Health.
Co-authors include Julia Wei, MPH, of the Division of Research; Curtis Darling, MD, and Kevin P. Ng, MD, of The Permanente Medical Group; and Matthias Behrends, MD, of the University of California, San Francisco.
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About the Kaiser Permanente Division of Research
The Kaiser Permanente Division of Research conducts, publishes, and disseminates epidemiologic and health services research to improve the health and medical care of Kaiser Permanente members and society at large. KPDOR seeks to understand the determinants of illness and well-being and to improve the quality and cost-effectiveness of health care. Currently, DOR’s 720-plus staff, including 73 research and staff scientists, are working on nearly 630 epidemiological and health services research projects. For more information, visit divisionofresearch.kp.org or follow us @KPDOR.
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