Shivam: My name is Shivam Patel and I’m currently a 3rd year medical student from Western university and today we will be discussing Chronic Pain After Cancer with an emphasis on Improving functionality in cancer survivors and how it overlaps with musculoskeletal dysfunction. We will also talk about the management of pain in outpatient settings as well as the role acute rehab units can play in recovery.

Arreaza: Before getting into specific considerations, let’s start with a framework most clinicians are familiar with, standard, guideline-based management of upper extremity pain.

Typical approach of a patient with shoulder or upper extremity pain

Shivam: The standard approach for any patient coming in with a musculoskeletal issue is stepwise and conservative first. Initial management includes activity modification, NSAIDs or acetaminophen for pain control, and early referral to physical therapy depending on severity and duration. If symptoms persist, we escalate. That may include imaging—usually starting with X-ray, then MRI if indicated, and consideration of corticosteroid injections, particularly for conditions like subacromial impingement or adhesive capsulitis which are commonly seen especially following breast cancer treatment.

Arreaza: Most guidelines emphasize avoiding early imaging unless there are red flags like trauma, neurologic deficits, or suspicion for malignancy or infection. The reason behind this recommendation is that if you image the population of people older than 50 years old, about 40% of people show rotator cuff tears or damage. 

Shivam: When I First heard about this statistic as a medical student, I was shocked and it opened my eyes to the potential downsides of overimaging. We also emphasize maintaining mobility. For example, in adhesive capsulitis, early range-of-motion exercises are key, not immobilization.

Arreaza: Exactly. “Motion is lotion” (Dr. Uy’s mantra).

Shivam: And pharmacologically, we’re moving toward a multimodal approach. NSAIDs are first line when tolerated. Topical agents like diclofenac can be useful. Neuropathic agents like gabapentin or duloxetine are only considered if there’s a neuropathic component.

Arreaza: And a key element is that opioids are not first-line for chronic musculoskeletal pain.

Shivam: Yes, that’s a key point. Current guidelines recommend minimizing opioid use, reserving them for severe, refractory cases, and even then, for short durations with clear treatment goals.

Arreaza: Now, let’s transition this framework into cancer survivors. 

Shivam: The challenge is that many of these patients present with similar complaints. In the upper extremities, for example, they present with shoulder pain, weakness, stiffness, but the underlying causes are more complex.

Particularly in cancer survivors, upper extremity pain is often multifactorial. You still have mechanical issues but layered on top are treatment-related effects such as surgical disruption of anatomy, radiation-induced fibrosis, chemotherapy-induced neuropathy, and generalized deconditioning.

Arreaza: Let’s take an example: THIs a 55-year-old female, s/p left mastectomy and chemoradiation, completed her cancer treatment 1 year ago and now she is presenting with shoulder pain. So, how do we approach this patient?

Shivam: This was a specific case I had the pleasure of familiarizing myself with however it is important to acknowledge just how many patients in America share similar experiences due to the incidence of breast cancer. If we approach this as a typical rotator cuff issue, we might miss key contributors that have been seen in cancer survivors like pectoralis tightness from radiation, scapular dyskinesis from surgery, or even early lymphedema.

Arreaza: Right, and that changes management. Because if you don’t address those underlying contributors, standard treatments may only provide partial or temporary relief.

Shivam: Exactly. And this is where we start to see the limitations of a purely symptom-based approach. Let’s zoom out again. There are nearly 19 million cancer survivors in the U.S., and that number is increasing due to rapidly improving cancer treatment options. With that, we’re seeing more long-term sequelae—especially involving the musculoskeletal system.

Arreaza: Some symptoms in cancer survivors are reduced mobility, persistent fatigue, weakness, and impaired return to activities of daily living. And this may lead to chronic pain and reduced quality of life. 

Shivam: As a side note, we can also acknowledge the impact of mental and psychological aspects on patients who have cancer or any other chronic condition. If they are depressed or less motivated to be active, participate in therapy, the deconditioning effect can be exacerbated in these patients. 

Arreaza: Great point, and also, this is a population that is often under-referred to rehabilitation services. We hope we can increase awareness today.

Shivam: Yes, some sources state that only around 30% of those that qualify for acute rehab are referred to it. Which is surprising, because rehabilitation directly addresses many of these issues that cancer patients experience—strength deficits, mobility limitations, and functional decline.

Arreaza: Let’s talk about pathophysiology for a moment. Why do these patients develop chronic pain?

Shivam: A major factor is deconditioning. During cancer treatment, patients often reduce their activity levels significantly. That leads to loss of muscle mass, decreased endurance, and altered biomechanics.

Arreaza: I see, sarcopenia plays a role in the development of pain in these patients. 

Shivam: And once pain develops, it further limits activity, reinforcing that cycle—pain → inactivity → deconditioning → more pain. On top of that, structural changes, often caused by fibrosis from radiation, reduce tissue elasticity, limit range of motion, and contribute to stiffness and pain.

Arreaza: And neuropathic pain from chemotherapy adds another layer—burning, tingling, or hypersensitivity—which requires a different treatment approach. So, given this complexity, how should we as clinicians adjust our assessment of pain in these patients?

Shivam: I think it’s very important to start with a thorough history to ensure we don’t miss any past history of chronic conditions or intensive treatment for prior medical diagnoses. First, we need to broaden the differential. Don’t assume it’s a single pathology. Second, incorporate function into our assessment. Ask the patient: What can you do? What can’t you do?  Additionally, I think it’s very important to ask what your patient’s goals are for themselves and what they would like to accomplish. 

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