Breast cancer is the most common cancer in women over 65. For many, a modified radical mastectomy (MRM), removal of the breast and underarm lymph nodes, is essential. Yet the operation often brings long-term challenges, such as shoulder immobility, painful arm swelling (lymphoedema), and emotional burden.
Dr. Merve Tokocin and her team at Istanbul Bagcilar Training and Research Hospital followed 89 elderly women (median age 72) for a full 60 months. Their findings, published in BMC Geriatrics, suggest that the strongest predictor of persistent physical problems was not the surgery or radiotherapy itself, but how patients thought about their pain.
What is pain catastrophising?
Pain catastrophising is not ordinary worry. It is a specific pattern involving rumination (“This pain will never stop”), magnification (“This is unbearable”), and helplessness (“Nothing can help”). It is measured with the Pain Catastrophizing Scale (PCS). Women scoring ≥25 were classified as high catastrophisers.
This thinking style is common after major surgery, especially in older adults, and it can become a self-fulfilling prophecy.
Five years of follow-up, one striking pattern
The team assessed the women at nine time points: before surgery, 1 month, 3 months, after radiotherapy, and then yearly up to 60 months. They measured depression, pain interference in daily life, shoulder range of motion, and arm volume (lymphoedema).
Results showed that women with high baseline PCS scores had significantly worse outcomes at every time point:
- Far higher depression and pain interference
- Much greater shoulder movement limitation
- Dramatically higher lymphoedema rates: 72.7% in the high group vs 17.8% in the low group at 5 years
The statistical correlation between catastrophising and pain interference at 12 months reached 0.994, which is almost perfect. Shoulder restriction and lymphoedema associations also strengthened over time, remaining powerful even at 60 months.
Mind-body relationship
The mind-body relationship was consistent over 5 years and across multiple objective measures. While correlation does not prove causation, the persistence and strength of the findings suggest a powerful vicious cycle: catastrophising → less arm movement → more stiffness and swelling → more pain and worry.
A five-year study of elderly breast cancer survivors shows that “pain catastrophising” – constantly worrying that the pain will never end – strongly predicts long-term shoulder stiffness and arm swelling (lymphoedema). Early mental support could change everything.
—Merve Tokocin
Why are elderly patients particularly vulnerable?
The participants had typical geriatric challenges: a median Charlson Comorbidity Index of 3, 67% polypharmacy, and 46% at risk of sarcopenia. These factors make recovery harder. When psychological distress leads to reduced arm use, muscle wasting and fluid accumulation accelerate.
This may explain why the associations in this study were stronger and longer-lasting than those seen in younger breast cancer survivors. The researchers recommend routine PCS screening at 1–3 months post-surgery. For high-scoring patients:
- Prompt cognitive behavioural therapy (CBT)
- Intensive physiotherapy with lymphatic drainage
- Closer lymphoedema surveillance from month 3
These are practical, relatively low-cost steps that could significantly improve quality of life.
In elderly breast cancer survivors, integrating psychological support from the very beginning may be one of the most powerful things we can do to improve long-term physical outcomes. By treating the mind and body together, we give older survivors the best chance not just to live, but to live well.
Reference
Tokocin, M., Pehlivan, T. & Celik, A. Pain catastrophizing as a longitudinal correlate of shoulder dysfunction and lymphedema in geriatric breast cancer survivors. BMC Geriatr 26, 10 (2026). https://doi.org/10.1186/s12877-025-06813-9
