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4% lidocaine gel applied to the breasts
before screening mammography reduced
Lambertz CK, Johnson CJ, Montgomery PG, Maxwell JR.
Premedication to reduce discomfort during screening mammography.
Clinical impact ratings:
In women who expect a high degree of discomfort from screening
mammography, does premedication with acetaminophen, ibupro-
fen, or 4% lidocaine gel decrease discomfort?
Design: Randomized, placebo-controlled trial.
Blinding: Blinded (participants, nurses, technologists, and
Follow-up period: Immediately after mammography.
Setting: Screening mammography center in Boise, Idaho, USA.
Participants: 418 women (median age 50 to 59 y) who were having
screening mammography and expected discomfort ≥ 40 on a scale
of 0 to 100 (worst).Women who were sensitive to the study
medications or had liver or kidney dysfunction were excluded.
Intervention: Women were instructed not to take any pain
medication for 24 hours before mammography and to arrive at
the center ≥ 60 min before their appointment, at which time they
received 1 of 12 treatments:oral acetaminophen,1000 mg (n = 38),
oral ibuprofen, 800 mg (n = 29), oral placebo (n = 35), 1 oz of 4%
lidocaine gel (n = 32), placebo gel (n = 42), acetaminophen plus
lidocaine gel (n = 36), acetaminophen plus placebo gel (n = 31),
ibuprofen plus lidocaine gel (n = 39), ibuprofen plus placebo gel
(n = 35), oral placebo plus lidocaine gel (n = 33), oral placebo plus
placebo gel (n = 36), or no medication (n = 32).The gels were
applied to the skin of the woman’s breasts and chest wall by a
nurse and covered with plastic wrap.The gel was removed 30 to
65 minutes before the mammogram and was on the woman’s skin
for 30 to 75 minutes (median 48 min). Oral medications were
taken 36 to 129 minutes (median 80 min) before the procedure.
Outcomes: Discomfort of mammography (assessed on a visual
analogue scale, range 1 to 100 [worst]).
Patient follow-up: 100% (intention-to-treat analysis).
Mean expected discomfort level was 58. Actual mean discomfort
levels ranged from 24 with acetaminophen and lidocaine gel to 38
with placebo gel (Table). Lidocaine gel resulted in less discomfort
during mammography than placebo gel or no gel (P = 0.01);
discomfort did not vary by type of oral medication (P = 0.35). No
evidence of interaction between gel and type of oral medication
was found (P = 0.84).
4% lidocaine gel applied to the skin of the breasts and chest wall
about 1 hour before screening mammography reduced discomfort
in women who expected a high degree of discomfort. Oral med-
ications did not reduce discomfort.
Source of funding:ESBA Laboratories provided the lidocaine gel.
For correspondence:Ms.C.K.Lambertz,St.Luke’s Mountain States
Tumor Institute,Boise,ID,USA.E-mail email@example.com. ■
Breast cancer is the most common major cancer affecting women.
Many women have mammography to reduce the chance of dying
from breast cancer,attracted by the approximate 15% relative risk
reduction afforded by repeated screening over 10 years,as reported
in a Cochrane review (1).Some researchers question the potential
for bias among the included randomized trials,the small increase of
about 1 in 2000 women whose lives are thereby prolonged,and the
harm caused by screening (1).Nevertheless,many industrialized
countries fund mammography screening and encourage women to
engage in it.
However,mammography involves breast compression that inflicts
sufficient pain and discomfort to deflect many women from return-
ing for repeated screening (2).For reducing the discomfort of
mammography,another Cochrane review found no benefit from
acetaminophen but some evidence of effectiveness for special
radiolucent cushions;subject control over compression;reduced
compression (by the technician);and careful explanation of the
procedure first,with reflection (3).
The randomized trial by Lambertz and colleagues,which enlarged
on a previous smaller trial of oral analgesics by including groups
treated with topical lidocaine 4% gel,provided more optimistic
results.The benefits of the gel were modest (about 20% reduction
from an average pain score of 35 on a 100-point visual analogue scale
without lidocaine gel) among women who anticipated a pain-dis-
comfort score ≥ 40/100.Nevertheless,because pain was a predictor
of intention to return the following year for mammography screen-
ing,use of lidocaine gel might result in a useful increase in adherence.
Chris Del Mar, MD
Gold Coast, Queensland, Australia
1. Gøtzsche PC,Nielsen M. Screening for breast cancer with mammography.
Cochrane Database Syst Rev. 2006;(4):CD001877.
2. Schonberg MA,McCarthy EP,York M,Davis RB,Marcantonio ER.
Factors influencing elderly women’s mammography screening decisions:
implications for counseling. BMC Geriatr. 2007;7:26.
3. Miller D,Livingstone V,Herbison P. Interventions for relieving the pain
and discomfort of screening mammography. Cochrane Database Syst Rev.
Combinations of topical 4% lidocaine gel, oral acetaminophen,
oral ibuprofen, and placebo to reduce discomfort of mammography
†Assessed on a visual analogue scale (range 0 to 100 [worst]), adjusted for expected discom-
fort, age, breast density, mammography history, technologist, and mammography machine.
18 November 2008 | ACP Journal Club | Volume 149 • Number 5
© 2008 American College of Physicians
Mean discomfort scores†