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. Author manuscript; available in PMC: 2015 Mar 1.
Published in final edited form as: J Neurogenet. 2014 Jan 7;28(0):122–135. doi: 10.3109/01677063.2013.856430

VARIATIONS IN POTASSIUM CHANNEL GENES ARE ASSOCIATED WITH BREAST PAIN IN WOMEN PRIOR TO BREAST CANCER SURGERY

Dale J Langford 1, Claudia West 1, Charles Elboim 4, Bruce A Cooper 1, Gary Abrams 2, Steven M Paul 1, Brian L Schmidt 5, Jon D Levine 2, John D Merriman 1, Anand Dhruva 2, John Neuhaus 2, Heather Leutwyler 1, Christina Baggott 1, Carmen Ward Sullivan 1, Bradley E Aouizerat 1,3,*, Christine Miaskowski 1,*
PMCID: PMC4035357  NIHMSID: NIHMS587495  PMID: 24392765

Abstract

Preoperative breast pain in women with breast cancer may result from a number of causes. Previous work from our team found that breast pain occurred in 28.2% of women (n=398) who were about to undergo breast cancer surgery. The occurrence of preoperative breast pain was associated with a number of demographic and clinical characteristics, as well as variation in two cytokine genes. Given that ion channels regulate excitability of sensory neurons, we hypothesized that variations in potassium channel genes would be associated with preoperative breast pain in these patients. Therefore, in this study we evaluated for associations between single nucleotide polymorphisms and inferred haplotypes among 10 potassium channel genes and the occurrence of preoperative breast pain in patients scheduled to undergo breast cancer surgery. Multivariable logistic regression analyses were used to identify those genetic variations that were associated with the occurrence of preoperative breast pain while controlling for age and genomic estimates of and self-reported race/ethnicity. Variations in four potassium channel genes: 1) potassium voltage-gated channel, delayed rectifier, subfamily S, member 1 (KCNS1); 2) potassium inwardly-rectifying channel, subfamily J, member 3 (KCNJ3); 3) KCNJ6; and 4) potassium channel, subfamily K, member 9 (KCNK9) were associated with the occurrence of breast pain. Findings from this study warrant replication in an independent sample of women who report breast pain following one or more breast biopsies.

Keywords: breast pain, preoperative pain, potassium channel genes, breast cancer, candidate genes

INTRODUCTION

Breast pain prior to breast cancer surgery was noted by surgeons several decades ago (Corry, 1952; Lane-Claypon, 1926). Prevalence estimates for preoperative breast pain range from 14% to 53% (Corry, 1952; Poleshuck et al., 2006; Tasmuth, von Smitten, & Kalso, 1996). Before the advent of screening mammography and diagnostic biopsies, this localized pain was considered a somewhat reliable indicator of malignant disease (Corry, 1952). This preoperative pain was described as aching or stabbing (Corry, 1952) and reported to interfere with daily activities (Tasmuth, et al., 1996). Aside from these observations, very little information is available on the characteristics of and mechanisms that underlie this clinical condition.

In an attempt to address this gap, our group recently reported on the occurrence of preoperative breast pain as well as its severity, qualities, and impact on function (McCann et al., 2012). Consistent with published reports, 28% of women reported pain in the breast prior to surgery. Average and worst pain scores were 2.2 and 3.6, respectively, using a 0 to 10 numeric rating scale (NRS). This pain significantly interfered with activities of daily living an average of 6.2 hours per day for approximately 3 days a week. Using the Pain Qualities Assessment Scale (PQAS) (Jensen et al., 2006), the qualities with the highest ratings were tender, dull, and aching. In addition, preoperative breast pain interfered with patients’ sleep and mood. Compared to women without preoperative breast pain, women with pain were younger; more likely to be non-white; less likely to be post-menopausal; had lower functional status scores; and more breast biopsies in the past year (McCann et al., 2012). In addition, preoperative breast pain was associated with higher depressive symptom scores and poorer physical well-being (Kyranou et al., 2012). Moreover, women who reported preoperative breast pain were significantly more likely to report persistent pain for six months following breast cancer surgery (Miaskowski et al., 2012b).

We hypothesized that this preoperative breast pain would have an inflammatory component. Consistent with this hypothesis, the rare allele of a single nucleotide polymorphism (SNP) in interleukin (IL) receptor 2 (IL1R2; rs2110726) was associated with decreased risk for preoperative pain and the rare allele of a SNP in IL13 (rs1295686) was associated with increased risk for preoperative pain (McCann et al., 2012). However, given that pain is a complex trait, other genetic factors may contribute to the variability in the occurrence of preoperative breast pain.

This preoperative breast pain may be due to altered neuronal excitability. Potassium channels, the most ubiquitous type of ion channel (Miller, 2000), are distributed centrally and peripherally, and play a key role in the maintenance of resting membrane potential, the regulation of neuronal excitability (Dodson & Forsythe, 2004; Wickenden, 2002), and the transmission of nociceptive information to the central nervous system (Xie, 2007). Variations in a number of potassium channel genes are associated with thermal hyperalgesia (Alloui et al., 2006; Marker, Stoffel, & Wickman, 2004) and inflammatory pain (Marsh et al., 2012) in rodents, analgesic responses in mice and humans (Blednov et al., 2003; Marker et al., 2004; Nishizawa et al., 2009), and a number of chronic pain conditions in humans (Costigan et al., 2010).

Given their involvement in pain and analgesia, we hypothesized that variations in potassium channel genes would be associated with the occurrence of preoperative breast pain in women prior to breast cancer surgery. Specifically, we evaluated for associations between variations in 10 potassium channel genes and the occurrence of preoperative breast pain in a sample of patients scheduled to undergo breast cancer surgery. These candidate genes encode for three classes of potassium channels (KCN): voltage-gated potassium channels (i.e., KCNA1, KCND2, KCNS1), inward-rectifying potassium channels (i.e., KCNJ3, KCNJ5, KCNJ6, KCNJ9), and two-pore domain potassium channels (i.e., KCNK2, KCNK3, KCNK9).

METHODS

Patients and Settings

This analysis is part of a larger study of women undergoing breast cancer surgery (McCann et al., 2012; Miaskowski et al., 2012b; Miaskowski et al., 2013). Patients were recruited from seven breast care centers in the San Francisco Bay Area.

Eligible patients were adult women (>18 years) scheduled to undergo breast cancer surgery on one breast; were able to read, write, and understand English; and gave written informed consent. Exclusion criteria included having breast cancer surgery on both breasts and/or distant metastasis at the time of diagnosis. Of the 516 patients who were approached to participate, 410 were enrolled (response rate 79.4%), and 398 completed the baseline assessment.

Instruments

A demographic questionnaire obtained information on age, marital status, education, ethnicity, employment status, and living arrangements. The Karnofsky Performance Status (KPS) scale was used to evaluate functional status (Karnofsky et al., 1948). For this study, the KPS scale ranged from 30 (I feel severely disabled and need to be hospitalized) to 100 (I feel normal; I have no complaints or symptoms). The KPS scale has well established validity and reliability (Karnofsky, 1977).

The Self-Administered Comorbidity Questionnaire (SCQ) was used to measure the occurrence, severity, and functional limitations of 13 common medical conditions (Sangha et al., 2003). The SCQ has well-established validity and reliability and has been used in studies of patients with a variety of chronic conditions (Brunner et al., 2008; Sangha et al., 2003).

At the time of enrollment, patients were asked whether they currently had pain in their affected breast (yes/no). Responses to this question were used to dichotomize the sample into patients with (n=110) and without (n=280) breast pain prior to surgery.

Study Procedures

The study was approved by the Committee on Human Research at the University of California, San Francisco and by the Institutional Review Boards at each of the study sites. During the patient’s preoperative visit, a clinician explained the study and determined the patient’s willingness to participate. Women who were willing to participate met with the research nurse who determined eligibility and obtained written informed consent prior to surgery. Patients completed the enrollment questionnaires on average four days prior to surgery. Medical records were reviewed for disease and treatment information.

Genomic Analyses

Gene selection

Candidate genes were selected based on evidence in the literature of an association between the gene and various pain outcomes (e.g., pain severity). In addition to a literature search of potassium channel genes and pain in humans, the Pain Genes Database (Lacroix-Fralish, Ledoux, & Mogil, 2007) was used to identify potassium channel genes. In total, 10 potassium channel genes were selected. Three of the selected genes encode for voltage-gated potassium channels (i.e., KCNA1, KCND2, KCNS1); four encode for inward-rectifying potassium channels (i.e., KCNJ3, KCNJ5, KCNJ6, KCNJ9); and three encode for two-pore domain potassium channels (i.e., KCNK2, KCNK3, KCNK9).

Blood collection and genotyping

Of the 398 patients who completed the baseline questionnaires, 302 provided a blood sample. Genomic DNA was extracted from PBMCs using the PUREGene DNA Isolation System (Invitrogen, Carlsbad, CA). Samples were genotyped using the Golden Gate genotyping platform (Illumina, San Diego, CA) and processed using GenomeStudio (Illumina, San Diego, CA). Genotyping was performed blinded to pain group status and positive and negative controls were included.

SNP Selection

A combination of tag-SNPs and literature driven SNPs were selected for analysis. Tag-SNPs were common (minor allele frequency ≥0.05) in public databases. SNPs with call rates <95% or Hardy-Weinberg p<.001 were excluded. As shown in Table 1, a total of 155 SNPs among the 10 candidate genes (KCNA1: 1 SNP; KCND2: 9 SNPs; KCNS1: 4 SNPs; KCNJ3: 28 SNPs; KCNJ5: 8 SNPs; KCNJ6: 58 SNPs; KCNJ9: 2 SNPs; KCNK2: 22 SNPs, KCNK3: 6 SNPs; KCNK9: 17 SNPs) passed all quality control filters and were included in the genetic association analyses. Potential functional roles for SNPs associated with preoperative breast pain were examined using PUPASuite 3.1 (Conde et al., 2006).

Table 1.

Summary of Potassium Channel Gene Single Nucleotide Polymorphisms (SNPs) and Haplotypes Analyzed for Pain Versus No Pain in Women Prior to Breast Cancer Surgery

Gene SNP Position Chr MAF Alleles Chi
Square		 p-value Model
VOLTAGE-GATED POTASSIUM CHANNELS
KCNA1 rs4766311 4892699 1 0.466 C>T 3.16 0.206 A
KCND2 rs17376373 119787721 7 0.197 T>G 4.36 0.113 A
KCND2 rs702414 119924204 7 0.249 G>C 3.52 0.172 A
KCND2 rs802340 119975021 7 0.293 G>T 1.87 0.393 A
KCND2 rs12706292 120012310 7 0.346 A>G 0.08 0.963 A
KCND2 rs4730967 120060462 7 0.320 T>C 4.52 0.104 A
KCND2 rs1072198 120114585 7 0.304 A>G 0.63 0.730 A
KCND2 rs11489533 120117902 7 0.268 A>G 0.70 0.704 A
KCND2 rs4727914 120122574 7 0.343 A>G 4.40 0.111 A
KCND2 rs12673992 120160059 7 0.319 A>G 0.01 0.996 A
KCND2 HapA1 0.77 0.682
KCND2 HapA3 4.40 0.111
KCNS1 rs4499491 43154833 20 0.432 C>A FE 0.001 R
KCNS1 rs6124684 43154907 20 0.223 C>T FE 0.025 D
KCNS1 rs734784 43157041 20 0.447 A>G 4.31 0.116 A
KCNS1 rs6073643 43161484 20 0.274 T>C 1.31 0.520 A
KCNS1 HapA1 12.71 0.002
KCNS1 HapA2 3.96 0.138
KCNS1 HapA3 5.36 0.069
KCNS1 HapB1 4.31 0.116
KCNS1 HapB2 5.43 0.066
KCNS1 HapB3 1.38 0.501
INWARD-RECTIFYING POTASSIUM CHANNELS
KCNJ3 rs6435329 155265893 2 0.445 G>T FE 0.014 D
KCNJ3 rs3111020 155275635 2 0.450 T>C FE 0.025 D
KCNJ3 rs11895478 155279369 2 0.246 C>T FE 0.027 D
KCNJ3 rs3106653 155283806 2 0.262 A>C FE 0.014 D
KCNJ3 rs3111003 155300413 2 0.465 C>T 2.45 0.294 A
KCNJ3 rs3111006 155302345 2 0.375 C>T 4.59 0.101 A
KCNJ3 rs12471193 155304383 2 0.343 A>G 4.83 0.089 A
KCNJ3 rs6711727 155304684 2 0.485 G>A 1.29 0.524 A
KCNJ3 rs2652443 155313983 2 0.395 G>A 5.49 0.064 A
KCNJ3 rs7574878 155315394 2 0.429 T>G FE <.0001 D
KCNJ3 rs2121085 155315711 2 0.447 A>G 9.04 0.011 A
KCNJ3 rs2121089 155317633 2 0.479 C>A FE 0.041 D
KCNJ3 rs2961959 155326068 2 0.432 C>G FE 0.045 R
KCNJ3 rs2591168 155326179 2 0.316 A>G 2.37 0.306 A
KCNJ3 rs2591172 155330423 2 0.333 T>G 9.29 0.010 A
KCNJ3 rs12995382 155340539 2 0.290 T>C 1.40 0.498 A
KCNJ3 rs13398937 155348593 2 0.362 C>G 2.16 0.339 A
KCNJ3 rs13390038 155351011 2 0.403 G>A 2.96 0.228 A
KCNJ3 rs12616121 155353928 2 0.469 A>G 2.00 0.367 A
KCNJ3 rs2591158 155355912 2 0.280 A>C 1.42 0.491 A
KCNJ3 rs2591157 155356612 2 0.330 A>G 1.25 0.536 A
KCNJ3 rs717175 155356841 2 0.332 C>T 5.27 0.072 A
KCNJ3 rs1037091 155360603 2 0.375 G>A 2.63 0.269 A
KCNJ3 rs17641121 155373998 2 0.259 T>C 0.39 0.824 A
KCNJ3 rs2591173 155395322 2 0.477 C>A 2.53 0.283 A
KCNJ3 rs2971902 155400624 2 0.220 G>T 0.87 0.649 A
KCNJ3 rs2937600 155411014 2 0.299 A>G 0.34 0.843 A
KCNJ3 rs4467223 155414657 2 0.479 T>A 0.28 0.871 A
KCNJ3 HapA1 0.20 0.907
KCNJ3 HapA2 5.64 0.060
KCNJ3 HapA3 6.08 0.048
KCNJ3 HapB1 6.43 0.040
KCNJ3 HapB4 5.75 0.056
KCNJ3 HapC3 5.46 0.065
KCNJ3 HapC5 5.87 0.053
KCNJ3 HapD1 5.95 0.051
KCNJ3 HapD4 5.69 0.058
KCNJ3 HapE1 10.55 0.005
KCNJ3 HapE2 3.69 0.158
KCNJ3 HapE4 2.06 0.358
KCNJ3 HapF1 1.49 0.475
KCNJ3 HapF2 0.31 0.858
KCNJ3 HapF4 1.35 0.509
KCNJ3 HapG1 0.89 0.642
KCNJ3 HapG3 0.87 0.649
KCNJ3 HapG4 2.46 0.293
KCNJ5 rs7941582 128266885 11 0.408 A>G 1.87 0.393 A
KCNJ5 rs2846700 128274148 11 0.172 A>G 1.51 0.469 A
KCNJ5 rs4937384 128285012 11 0.223 T>C 2.47 0.290 A
KCNJ5 rs11221503 128277662 11 0.184 C>T 0.45 0.800 A
KCNJ5 rs2604212 128278165 11 0.459 C>G 0.17 0.920 A
KCNJ5 rs4937387 128278623 11 0.257 T>C 0.29 0.865 A
KCNJ5 rs11221510 128285907 11 0.241 A>T 0.27 0.876 A
KCNJ5 rs6590357 128286549 11 0.163 C>T 0.03 0.987 A
KCNJ5 HapA1 0.38 0.826
KCNJ5 HapA2 0.17 0.920
KCNJ5 HapA5 0.33 0.846
KCNJ6 rs860795 37937160 21 0.208 G>C 0.25 0.884 A
KCNJ6 rs1709838 37941983 21 0.431 C>A 0.68 0.710 A
KCNJ6 rs10483038 37946641 21 0.279 T>C 0.36 0.835 A
KCNJ6 rs857967 37954006 21 0.197 T>A 3.41 0.182 A
KCNJ6 rs2835885 37961436 21 0.432 T>G 0.67 0.714 A
KCNJ6 rs858010 37987109 21 0.166 G>A 0.03 0.983 A
KCNJ6 rs1005546 37990742 21 0.450 C>T 0.51 0.777 A
KCNJ6 rs858003 37994854 21 0.197 C>T 1.76 0.416 A
KCNJ6 rs1709816 37999129 21 0.390 G>T 1.20 0.548 A
KCNJ6 rs13049947 38002710 21 0.403 C>T 0.26 0.877 A
KCNJ6 rs2835914 38020720 21 0.347 G>C FE 0.027 D
KCNJ6 rs858035 38021061 21 0.344 T>C FE 0.010 D
KCNJ6 rs13048511 38037731 21 0.468 A>G 1.82 0.403 A
KCNJ6 rs2835925 38041173 21 0.176 A>G 1.40 0.497 A
KCNJ6 rs857989 38042001 21 0.115 G>C 0.20 0.906 A
KCNJ6 rs2835931 38043518 21 0.282 C>T 1.51 0.469 A
KCNJ6 rs1399596 38045382 21 0.260 T>C 2.44 0.295 A
KCNJ6 rs2835942 38052778 21 0.303 C>T 3.44 0.179 A
KCNJ6 rs2835945 38057170 21 0.398 G>A 2.43 0.297 A
KCNJ6 rs1160350 38065897 21 0.494 G>C 4.31 0.116 A
KCNJ6 rs762145 38068188 21 0.366 C>T 1.14 0.566 A
KCNJ6 rs2226356 38075902 21 0.427 C>T 1.25 0.535 A
KCNJ6 rs1787337 38077824 21 0.494 A>G 2.59 0.274 A
KCNJ6 rs2835961 38083028 21 0.482 G>A 2.62 0.269 A
KCNJ6 rs2835976 38103779 21 0.385 C>T 0.47 0.790 A
KCNJ6 rs2835977 38104067 21 0.224 G>A 0.07 0.967 A
KCNJ6 rs2211842 38105403 21 0.376 C>A 0.33 0.846 A
KCNJ6 rs2211843 38106055 21 0.234 G>T 1.78 0.410 A
KCNJ6 rs2211845 38106371 21 0.447 T>C 1.20 0.549 A
KCNJ6 rs2835982 38110247 21 0.368 C>A 0.84 0.658 A
KCNJ6 rs2835983 38110476 21 0.304 G>A 1.30 0.521 A
KCNJ6 rs2835984 38110657 21 0.497 A>T 0.40 0.818 A
KCNJ6 rs3787835 38111440 21 0.455 C>T 1.28 0.527 A
KCNJ6 rs6517435 38117092 21 0.422 G>A 0.30 0.859 A
KCNJ6 rs2154556 38120757 21 0.344 T>C 1.55 0.462 A
KCNJ6 rs4817896 38123831 21 0.248 C>T 0.23 0.892 A
KCNJ6 rs3787840 38124263 21 0.139 C>T 1.17 0.558 A
KCNJ6 rs991985 38128024 21 0.286 C>A 0.04 0.979 A
KCNJ6 rs2836007 38128761 21 0.194 C>T 0.11 0.947 A
KCNJ6 rs2836013 38132582 21 0.292 C>T 0.39 0.823 A
KCNJ6 rs2836016 38134890 21 0.411 A>G 0.49 0.785 A
KCNJ6 rs2836019 38136864 21 0.327 C>T 2.04 0.360 A
KCNJ6 rs915800 38138203 21 0.455 C>T 1.18 0.554 A
KCNJ6 rs2226741 38146803 21 0.147 A>G 1.40 0.496 A
KCNJ6 rs7276928 38147607 21 0.288 G>A 2.00 0.368 A
KCNJ6 rs3827199 38149472 21 0.408 G>A 3.27 0.195 A
KCNJ6 rs4816585 38151120 21 0.495 G>A 1.26 0.533 A
KCNJ6 rs9305628 38166861 21 0.227 A>G FE 0.036 D
KCNJ6 rs9974219 38168568 21 0.277 A>T 4.10 0.129 A
KCNJ6 rs7277957 38168770 21 0.492 A>G 1.50 0.473 A
KCNJ6 rs1892682 38169935 21 0.265 G>A 0.61 0.738 A
KCNJ6 rs928765 38173472 21 0.292 C>T 1.77 0.413 A
KCNJ6 rs3787862 38174571 21 0.197 G>A 0.74 0.692 A
KCNJ6 rs10775660 38175388 21 0.415 C>T 0.90 0.637 A
KCNJ6 rs8129919 38176410 21 0.471 G>A 10.69 0.005 A
KCNJ6 rs2836039 38188930 21 0.195 G>A n/a n/a n/a
KCNJ6 rs2836048 38206168 21 0.321 G>A 3.04 0.218 A
KCNJ6 rs2836050 38206705 21 0.227 C>T FE 0.044 R
KCNJ6 rs3787870 38207323 21 0.463 A>G 0.07 0.966 A
KCNJ6 HapA1 0.25 0.882
KCNJ6 HapA2 0.58 0.749
KCNJ6 HapA3 0.22 0.895
KCNJ6 HapB1 0.55 0.761
KCNJ6 HapB2 3.41 0.182
KCNJ6 HapB3 0.36 0.835
KCNJ6 HapC1 0.51 0.777
KCNJ6 HapC2 0.21 0.902
KCNJ6 HapC3 0.03 0.983
KCNJ6 HapD1 0.23 0.892
KCNJ6 HapD4 1.27 0.529
KCNJ6 HapD6 1.41 0.493
KCNJ6 HapE1 2.47 0.290
KCNJ6 HapE2 3.42 0.181
KCNJ6 HapE5 1.77 0.413
KCNJ6 HapE7 1.40 0.496
KCNJ6 HapF1 2.77 0.251
KCNJ6 HapF2 0.01 0.993
KCNJ6 HapF4 3.04 0.219
KCNJ6 HapG1 1.64 0.441
KCNJ6 HapG5 0.98 0.613
KCNJ6 HapG6 0.08 0.962
KCNJ6 HapH1 0.68 0.713
KCNJ6 HapH3 1.18 0.556
KCNJ6 HapH5 1.74 0.418
KCNJ6 HapI1 0.14 0.932
KCNJ6 HapI5 0.28 0.869
KCNJ6 HapJ1 1.01 0.605
KCNJ6 HapJ2 0.39 0.823
KCNJ6 HapJ3 0.09 0.955
KCNJ6 HapK1 1.18 0.554
KCNJ6 HapK4 2.05 0.358
KCNJ6 HapL1 1.80 0.407
KCNJ6 HapL4 3.15 0.207
KCNJ6 HapL5 5.77 0.056
KCNJ6 HapM1 0.71 0.702
KCNJ6 HapM4 1.59 0.451
KCNJ6 HapM6 1.73 0.421
KCNJ6 HapN2 3.44 0.179
KCNJ6 HapN3 4.66 0.097
KCNJ9 rs6677510 158318743 1 0.442 A>G 0.93 0.629 A
KCNJ9 rs2753268 158324876 1 0.260 C>T 3.82 0.148 A
TWO-PORE POTASSIUM CHANNELS
KCNK2 rs2601640 213253979 1 0.492 A>G 0.92 0.630 A
KCNK2 rs12141327 213273537 1 0.335 G>A 0.44 0.802 A
KCNK2 rs1452619 213280153 1 0.120 A>G 0.64 0.725 A
KCNK2 rs10494991 213287222 1 0.331 T>C 1.57 0.456 A
KCNK2 rs1584759 213289445 1 0.453 A>C 0.75 0.687 A
KCNK2 rs12064317 213293664 1 0.136 G>T 0.26 0.880 A
KCNK2 rs6665177 213298091 1 0.155 G>A 0.14 0.933 A
KCNK2 rs12028008 213298169 1 0.497 A>G 0.34 0.842 A
KCNK2 rs12038094 213302819 1 0.291 C>T 1.96 0.375 A
KCNK2 rs17024179 213304166 1 0.163 T>C 2.06 0.358 A
KCNK2 rs7528988 213315040 1 0.259 C>T 3.01 0.222 A
KCNK2 rs2363561 213321930 1 0.395 C>T 0.41 0.815 A
KCNK2 rs12133857 213331109 1 0.128 G>T 0.34 0.843 A
KCNK2 rs4411107 213355542 1 0.375 T>C 1.08 0.584 A
KCNK2 rs4303048 213385781 1 0.236 G>A 2.10 0.349 A
KCNK2 rs12757222 213391641 1 0.233 A>G 2.81 0.246 A
KCNK2 rs1556905 213428215 1 0.411 C>A 0.21 0.899 A
KCNK2 rs10494994 213428830 1 0.207 G>A 0.53 0.767 A
KCNK2 rs12038695 213444580 1 0.494 A>C 1.16 0.559 A
KCNK2 rs2027320 213446566 1 0.385 G>A 0.37 0.833 A
KCNK2 rs12143625 213458463 1 0.235 T>C 0.61 0.739 A
KCNK2 rs12080135 213463166 1 0.252 T>G 0.20 0.905 A
KCNK2 HapA1 0.44 0.802
KCNK2 HapA4 0.92 0.630
KCNK2 HapB1 1.45 0.485
KCNK2 HapB4 0.97 0.615
KCNK2 HapC1 0.45 0.799
KCNK2 HapC4 1.59 0.451
KCNK2 HapC5 0.34 0.842
KCNK2 HapD1 0.01 0.994
KCNK2 HapD3 0.41 0.815
KCNK2 HapE1 0.14 0.935
KCNK2 HapE3 1.18 0.554
KCNK2 HapE4 0.62 0.733
KCNK2 HapF2 0.37 0.833
KCNK2 HapF3 1.16 0.559
KCNK3 rs1275982 26772593 2 0.497 C>T 4.75 0.093 A
KCNK3 rs1275977 26776359 2 0.414 A>G 4.79 0.091 A
KCNK3 rs11126666 26782315 2 0.330 G>A 4.00 0.135 A
KCNK3 rs1662987 26791686 2 0.243 A>G 4.80 0.091 A
KCNK3 rs1662988 26793738 2 0.290 C>T 0.72 0.699 A
KCNK3 rs7584568 26798797 2 0.471 G>A 1.80 0.407 A
KCNK3 HapA1 4.00 0.135
KCNK3 HapA4 4.75 0.093
KCNK3 HapB1 1.51 0.470
KCNK3 HapB2 4.22 0.121
KCNK3 HapB4 0.50 0.780
KCNK9 rs2542424 140701683 8 0.362 A>G 4.75 0.093 A
KCNK9 rs2542422 140706306 8 0.328 C>A 0.08 0.961 A
KCNK9 rs2014712 140709816 8 0.235 C>T 1.01 0.604 A
KCNK9 rs2545462 140714686 8 0.343 C>A 0.24 0.887 A
KCNK9 rs2542420 140714883 8 0.419 C>G 0.21 0.902 A
KCNK9 rs2545461 140717431 8 0.257 A>G n/a n/a n/a
KCNK9 rs3780051 140727983 8 0.471 A>G 0.12 0.943 A
KCNK9 rs2545457 140730467 8 0.350 T>C 1.43 0.489 A
KCNK9 rs2005895 140738217 8 0.256 T>C 0.34 0.842 A
KCNK9 rs888349 140738927 8 0.197 A>C 0.45 0.801 A
KCNK9 rs759656 140739149 8 0.320 T>C n/a n/a n/a
KCNK9 rs13277242 140739269 8 0.495 G>A 3.84 0.147 A
KCNK9 rs885724 140740112 8 0.380 A>C FE 0.048 D
KCNK9 rs3780039 140745846 8 0.372 T>G FE 0.003 D
KCNK9 rs10110946 140754803 8 0.333 T>C 1.08 0.583 A
KCNK9 rs7828107 140756023 8 0.409 C>A 4.05 0.132 A
KCNK9 rs983740 140762922 8 0.472 T>G 3.72 0.156 A
KCNK9 rs11166921 140776937 8 0.395 C>A FE 0.020 R
KCNK9 rs13278664 140779544 8 0.455 A>G 3.52 0.173 A
KCNK9 HapA1 0.16 0.925
KCNK9 HapA2 0.13 0.938
KCNK9 HapA3 4.28 0.118
KCNK9 HapB1 0.09 0.957
KCNK9 HapB4 0.13 0.939
KCNK9 HapC1 1.13 0.568
KCNK9 HapC3 1.54 0.464
KCNK9 HapC4 3.85 0.146
KCNK9 HapD1 0.42 0.812
KCNK9 HapD2 3.18 0.204
KCNK9 HapD3 6.60 0.037
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Abbreviations: A = additive model, Chr = chromosome, D = dominant model, Hap = haplotype, KCNA = voltage-sensitive potassium channel, KCND = voltage-gated potassium channel, KCNJ = potassium inward-rectifying channel, KCNK = potassium channel, subfamily K, MAF = minor allele frequency, n/a = not assayed because SNP violated Hardy-Weinberg expectations (p<.001) or because MAF was <.05, R = recessive model, SNP= single nucleotide polymorphism

Statistical Analyses for the Phenotypic Data

Data were analyzed using SPSS version 19 (SPSS, 2010) and STATA Version 12 (StataCorp, 2005). Independent samples t-tests, Mann-Whitney U tests, and Chi-square analyses were used to evaluate for differences in demographic and clinical characteristics between the pain and no pain groups. All calculations used actual values. Adjustments were not made for missing data.

Statistical Analyses for the Genetic Data

Allele and genotype frequencies were determined by gene counting. Hardy-Weinberg equilibrium was assessed by the Chi-square or Fisher Exact tests. Measures of linkage disequilibrium ((LD); i.e., D’ and r2) were computed from the patients’ genotypes using Haploview 4.2. LD-based haplotype block definition was based on D’ confidence interval (Gabriel et al., 2002).

Haplotype analyses were conducted in order to localize the association signal within each gene and to determine if haplotypes improved the strength of the association with the phenotype. Haplotypes were constructed using the PHASE version 2.1 (Stephens, Smith, & Donnelly, 2001). Only haplotypes that were inferred with probability estimates of >.85, across five iterations, were retained for subsequent analyses.

One hundred and six ancestry informative markers (AIMs) were used to control for population stratification (i.e., race/ethnicity) (Halder et al., 2008; Hoggart et al., 2003; Tian, Gregersen, & Seldin, 2008). Using Helix Tree (Golden Helix, Bozeman, MT), homogeneity in ancestry among patients was verified by principal component (PC) analysis (Price et al., 2006) (data not shown). The first three PCs were selected to adjust for potential confounding due to population substructure by including the three covariates in all regression models.

For association tests, additive, dominant, and recessive genetic models were assessed for each SNP. Barring small improvements from the additive model (i.e., delta <10%), the model that best fit the data (by maximizing the significance of the p-value) was selected for each SNP. Logistic regression analysis that controlled for significant covariates, genomic estimates of and self-reported race/ethnicity, and variation in other SNPs/haplotypes within the same gene, was used to evaluate the association between genotype and pain group membership. A backwards stepwise approach was used to create a parsimonious model. Genetic model fit and covariate-adjusted odds ratios were estimated using STATA version 12.

As done previously (Dunn et al., 2013; Illi et al., 2012; McCann et al., 2012; Miaskowski et al., 2012a), based on recommendations in the literature (Hattersley & McCarthy, 2005; Rothman, 1990) as well as the implementation of rigorous quality controls, the non-independence of genetic markers in LD, and the exploratory nature of the analyses, adjustments were not made for multiple testing. Moreover, significant SNPs identified in the bivariate analyses were evaluated using regression analyses that controlled for differences in phenotypic characteristics, potential confounding due to population stratification, and variation in other SNPs/haplotypes within the same gene. Only those SNPs that remained statistically significant in the multivariable analyses were included in the final presentation of the results. Therefore, the identified significant genetic associations are unlikely to be due solely to chance. Unadjusted associations are reported for all SNPs passing quality control criteria in Table 1 to allow for subsequent comparisons and meta-analyses.

RESULTS

Differences in Demographic and Clinical Characteristics

A detailed description of the differences in demographic and clinical characteristics between our patients with and without preoperative breast pain is available elsewhere (McCann et al., 2012). Table 2 summarizes only those characteristics that differed significantly between the two groups. The characteristics associated with the occurrence of preoperative breast pain were younger age, lower functional status, being non-white, being pre-menopausal, and having more biopsies in the past year.

Table 2.

Significant Differences in Demographic and Clinical Characteristics Between Patients With (n = 110) and Without (n = 280) Preoperative Breast Pain*

Characteristic NO PAIN
Mean (SD)		 PAIN
Mean (SD)		 Statistic and
p-value
Age (years) 56.5 (11.8) 50.9 (9.8) t=4.81; p<0.001
Karnofsky Performance Status score 94.0 (10.3) 90.9 (10.1) t=2.66; p= 0.008
Number of biopsies in past year 1.5 (0.8) 1.6 (0.8) U=12887.0, p<0.01
% (N) % (N)
Non-white race/ethnicity 31.9 (89) 45.0 (49) FE; p=0.018
Post-menopausal 67.9 (186) 53.8 (57) FE; p=0.012
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Abbreviations: FE = Fisher’s Exact, SD = standard deviation

*

Modified from McCann, B., Miaskowski, C., Koetters, T., Baggott, C., West, C., Levine, J. D., et al. (2012). Associations between pro- and anti-inflammatory cytokine genes and breast pain in women prior to breast cancer surgery. J Pain, 13, 425-437.

Regression Analyses for KCNJ3, KCNJ6, KCNK9, and KCNS1 Genotypes and Haplotypes

In order to better estimate the magnitude (i.e., odds ratio, OR) and precision (95% confidence interval [CI]) of genotype on the odds of reporting preoperative breast pain, multivariate logistic regression models were fit. Using a backwards stepwise approach, age was the only phenotypic characteristic listed in Table 2 that remained significant in this initial logistic regression model. Age was included as a covariate in subsequent models that evaluated genotypic predictors. Each 5-year increase in age was associated with a 23% reduction in odds of reporting preoperative breast pain (OR: 0.77; 95% CI: 0.682, 0.878).

After controlling for age and genomic estimates of and self-reported race/ethnicity, and variation in other SNPs/haplotypes within the same gene, eight genetic associations (7 SNPs, 1 haplotype) among four candidate genes were associated with pain group membership: KCNS1 (rs4499491); KCNJ3 (rs7574878) and haplotype E1 (composed of rs2591168 and rs2591172); KCNJ6 (rs2835914, rs8129919, rs2836050); and KCNK9 (rs3780039, rs11166921; see Table 3).

Table 3.

Multiple Logistic Regression Analyses for Single Nucleotide Polymorphisms in KCNS1, KCNJ3, KCNJ6, and KCNK9 and the Occurrence of Preoperative Breast Pain (N=302)

Pain Group
Comparison		 Predictor Odds
Ratio		 Standard Error 95% CI Z p-value
No pain (n=218)
versus
Pain (n=84)		 KCNS1 rs4499491 3.01 1.004 1.561, 5.785 3.29 0.001
Age 0.77 0.051 0.677, 0.878 −3.92 <0.001
Overall model fit: χ2 = 34.94, p <.0001; R2 = 0.0989
No pain (n=218)
versus
Pain (n=84)		 KCNJ3 rs7574878 0.52 0.165 0.276, 0.966 −2.07 0.038
KCNJ3 Hap E1 1.69 0.408 1.049, 2.710 2.16 0.031
Age 0.76 0.051 0.664, 0.863 −4.16 <0.001
Overall model fit: χ2 = 40.74, p <.0001; R2 = 0.1154
No pain (n=218)
versus
Pain (n=84)		 KCNJ6 rs2835914 0.48 0.140 0.274, 0.850 −2.52 0.012
KCNJ6 rs8129919 2.10 0.459 1.367, 3.220 3.39 0.001
KCNJ6 rs2836050 3.58 2.001 1.199, 10.708 2.29 0.022
Age 0.74 0.052 0.648, 0.854 −4.20 <0.001
Overall model fit: χ2 = 46.71, p <.0001; R2 = 0.1322
No pain (n=218)
versus
Pain (n=84)		 KCNK9 rs3780039 1.90 0.594 1.027, 3.506 2.05 0.041
KCNK9 rs11166921 2.40 0.830 1.218, 4.726 2.53 0.011
Age 0.77 0.051 0.678, 0.878 −3.92 <0.001
Overall model fit: χ2 = 35.59, p <.0001; R2 = 0.1008
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Multiple logistic regression analyses of candidate gene associations with no pain versus pain. The first three principal components identified from the analysis of ancestry informative markers as well as self-reported race/ethnicity were retained in all models to adjust for potential confounding due to population substructure (data not shown). Predictors evaluated in each model included genotype (KCNS1 rs4499491: CC+CA (no pain (n=189), pain (n=58)) versus AA (no pain (n=29), pain (n=26)); KCNJ3 rs7574878: TT (no pain (n=61), pain (n=42)) versus TG+GG (no pain (n=157), pain (n=42)); KCNJ3 haplotype E1 composed of rs2591168-rs2591172: zero, one, or two doses of the A-G haplotype; KCNJ6 rs2835914: GG (no pain (n=85), pain (n=45)) versus GC+CC (no pain (n=133), pain (n=39)); KCNJ6 rs8129919: GG (no pain (n=65), pain (n=15)) versus GA (no pain (n=121), pain (n=44)) versus AA (no pain (n=32), pain (n=25)); KCNJ6 rs2836050: CC+CT (no pain (n=207), pain (n=74)) versus TT (no pain (n=11), pain (n=10)); KCNK9 rs3780039: TT (no pain (n=103), pain (n=24)) versus TG+GG (no pain (n=114), pain (n=60)); KCNK9 rs11166921: CC+CA (no pain (n=185), pain (n=61)) versus AA (no pain (n=33), pain (n=23))), and age (in 5 year increments).

Abbreviations: CI =confidence interval; Hap = haplotype; KCNJ3 = potassium inwardly-rectifying channel, subfamily J, member 3; KCNJ6 = potassium inwardly-rectifying channel, subfamily J, member 6; KCNK9 = potassium channel subfamily K, member 9; KCNS1 = potassium voltagegated channel, delayed-rectifier, subfamily S, member 1.

For KCNS1 rs4499491, individuals homozygous for the rare A allele (CC+CA versus AA) had a 3.0-fold increase in the odds of reporting preoperative breast pain.

For KCNJ3 rs7574878, individuals who were heterozygous or homozygous for the rare G allele (TT versus TG+GG) had a 48% reduction in the odds of reporting preoperative breast pain. In addition, each dose of the KCNJ3 haplotype E1 (composed of the common A allele at rs2591168 and the rare G allele at rs2591172; Figure 1) was associated with a 1.7-fold increase in the odds of reporting preoperative breast pain.

Figure 1.

Figure 1

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KCNJ3 linkage disequilibrium-based heatmap and haplotype analysis. An ideogram of potassium inwardly-rectifying channel, subfamily J, member 3 (KCNJ3, GIRK1, Kir3.1) is presented above the white bar that represents the physical distance along human (chromosome 2 position 155555093 to 155714864; genome build 37.10, NC_000002.11). Exons are represented as boxes. Gray lines connecting the exons represent introns. The direction of transcription is from left to right. Reference sequence identifiers (rsID) for each single nucleotide polymorphism (SNP) are plotted both in terms of their physical distance (i.e., the white bar at the top of the figure) and equidistantly in order to render the pairwise linkage disequilibrium (LD) estimates that were calculated and visualized with Haploview 4.2. The gene structure for KCNJ3 (i.e., hg18 NM_002239) was rendered with FancyGene 1.4. The correlation statistics (r2 and D’) are provided in the heatmap. LD-based haplotype block definition was based on D’ confidence interval (Conde et al., 2006a). The haploblock is outlined in a bolded triangle and its component SNPs are rendered in bold font. Pairwise D’ values (range: 0-1, inclusive) were rendered in greyscale, with dark grey diamonds representing D’ values approaching 1.0. When the r2 values (range of 0-100, inclusive) are not equal to 0 or 100, they are provided in a given diamond. The haplotypes i.e., HapE1-HapE4) observed in the haploblock 5 (i.e., “Block 5” indicated by the vertical black arrow in the figure) are listed in each row, starting with the nucleotide composition across the two SNPs that compose the haplotype (i.e., rs2591168, rs2591172) and the count frequency (%) of each haplotype observed in the no preoperative breast pain and preoperative breast pain groups.

#The haplotype E1, composed of the “A” common allele at rs2591168 and the “G” rare allele at rs2591172, identified in the bivariate analyses (Table 1) remained significant after controlling for relevant covariates.

For KCNJ6, three SNPs (i.e., rs2835914, rs8129919, rs2836050) were associated with the occurrence of preoperative breast pain. For KCNJ6 rs2835914, individuals who were heterozygous or homozygous for the rare C allele (GG versus GC+CC) had a 52% reduction in the odds of reporting preoperative breast pain. For KCNJ6 rs8129919, each dose of the rare A allele (GG versus GA versus AA) was associated with a 2.1-fold increase in the odds of reporting preoperative breast pain. For KCNJ6 rs2836050, individuals homozygous for the rare T allele (CC+CT versus TT) had a 3.6-fold increase in the odds of reporting preoperative breast pain.

For KCNK9, two SNPs (i.e., rs3780039, rs11166921) were associated with the occurrence of preoperative breast pain. For KCNK9 rs3780039, individuals who were heterozygous or homozygous for the rare G allele (TT versus TG+GG) had a 1.9-fold increase in the odds of reporting preoperative breast pain. For KCNK9 rs11166921, individuals homozygous for the rare A allele (CC+CA versus AA) had a 2.4-fold increase in the odds of reporting preoperative breast pain.

DISCUSSION

This study provides new evidence of associations between four potassium channel genes and the occurrence of breast pain prior to breast cancer surgery. These findings build on our previous work that identified associations between cytokine gene variations and preoperative breast pain (McCann et al., 2012). While our initial phenotypic and genotypic findings suggested that preoperative breast pain has an inflammatory component, the current findings suggest that potassium channel activity also contributes to preoperative breast pain. These findings are not discrepant, because interplay may exist between potassium channels and cytokines that presents an interesting avenue for future research.

Differences in demographic and clinical characteristics between women with and without breast pain prior to breast cancer surgery are discussed in detail elsewhere (McCann et al., 2012). However, it is interesting to note that age was the only phenotypic characteristic that remained significant in the final phenotypic regression model. Each 5-year increase in age was associated with a 23% reduction in the odds of reporting breast pain. This finding is consistent with previous reports of age-related differences in the occurrence of cancer pain (Gibson & Helme, 2001). In addition, it is consistent with work from our research group that found decreases in the occurrence rates for a number of common symptoms (e.g., depressive symptoms, fatigue, sleep disturbance) in older oncology patients (Dunn et al., 2012; Dunn et al., 2013; Illi et al., 2012; Linden et al., 2012). The effect of age on the occurrence of preoperative breast pain warrants additional investigation, as some reviews noted that a number of persistent pain conditions increase with age (Fillingim, 2005; Gibson & Helme, 2001).

Of the three voltage-gated potassium channel genes that were evaluated, only KCNS1, which encodes for the potassium channel, Kv9.1, demonstrated an association with the occurrence of preoperative breast pain. In this sample, patients who were homozygous for the rare “A” allele for KCNS1 rs4499491, located in the 3′ untranslated region of KCNS1, had a 3-fold increase in the odds of reporting preoperative breast pain. While no functional data are reported for this SNP, it is located in a conserved region of the gene. Therefore, it may be functional or may be in LD with an unmeasured functional SNPs. Interestingly, the minor allele of a nearby functional SNP rs734784 (isoleucine to valine missense mutation) was associated with an increased risk for a number of persistent pain conditions (Costigan et al., 2010). However, rs734784 was not associated with ratings of average pain in women at least one year after surgery for breast cancer (Costigan et al.). The estimates of LD between rs4499491 and rs734784 (D’ = 0.416, r2 = 0.106) in our study suggest that the association observed between rs4199491 and preoperative pain is not likely to be attributable to its LD with rs734784. Moreover, no association was found between KCNS1 rs734784 and preoperative pain in our study.

Located on sensory neurons, voltage-gated potassium channels play a key role in modulating resting membrane potentials as well as the shape and magnitude of action potentials (Takeda et al., 2011; Tsantoulas et al., 2012). Although non-functional on its own, Kv9.1 modifies the activity of co-expressed functional voltage-gated potassium channels. (Richardson & Kaczmarek, 2000). Taken together, these findings suggest that KCNS1 may play a role in the pathophysiology of pain. The specific SNP identified in this study (i.e., rs4499491) warrants additional investigation in terms of its role in preoperative pain as well as persistent postsurgical pain.

Four genes that encode for G-protein-gated inwardly-rectifying potassium (GIRK) channels were evaluated in our study. Only KCNJ3 (GIRK1) and KCNJ6 (GIRK2) were associated with the occurrence of preoperative breast pain. All four of the polymorphisms identified are intronic. However, with the exception of one SNP in haplotype E1, they are located in conserved regions of the gene. Therefore, they may be functional or in LD with nearby functional SNPs.

GIRK channels are involved in postsynaptic inhibition in response to a number of neurotransmitters (Luscher & Slesinger, 2010), including those implicated in pain transmission (e.g., dopamine, serotonin, gamma-aminobutyric acid, opioids) (Fields, Heinricher, & Mason, 1991; Luscher & Slesinger, 2010). In addition, GIRK1 and GIRK2 channels closely interact with opioid receptors to modulate neuronal transmission (Ulens, Daenens, & Tytgat, 1999). Evidence from animal models suggests that GIRK1 (KCNJ3) and GIRK2 (KCNJ6), but not GIRK3 (KCNJ9), subunits are expressed in the superficial layers of the dorsal horn; play a role in thermal nociception and analgesic responses to morphine; and are highly interactive (Marker et al., 2004). Consistent with findings of altered thermal nociception in transgenic mice (Marker et al., 2004), only variations in KCNJ3 and KCNJ6, but not KCNJ9, were associated with the occurrence of preoperative breast pain in our sample. Given the substantial evidence for the role of these channels in the modulation of nociceptive transmission, additional investigations are warranted on the role of GIRK channels in preoperative breast pain.

Of the three two-pore domain potassium leak channel genes evaluated in this study, only variations in KCNK9 (TWIK-related acid sensing potassium channel-3; TASK3) were associated with an increased risk for the occurrence of preoperative breast pain. While these two intronic SNPs have no known function, they are located in a conserved region of KCNK9 and may be in LD with an unmeasured functional SNPs.

Two-pore domain potassium leak channels establish resting membrane potentials, play a key role in the modulation of neuronal excitability (Lesage, 2003; Talley et al., 2003), and are expressed in sensory neurons of rat DRG (Rau, Cooper, & Johnson, 2006). Like GIRK channels, TASK channels are inhibited by several neurotransmitters (Talley et al., 2000). Recently, in a rodent model of cutaneous inflammation, TASK3 mRNA expression in DRG neurons was reduced bilaterally four days after unilateral inflammation compared to one day after inflammation (Marsh et al., 2012). In addition, reduced mRNA expression was associated with reduced ipsilateral spontaneous pain behavior (i.e., foot lifting) (Marsh, et al., 2012). Further investigation of KCNK9, including an evaluation of whether genetic variations (e.g., rs3780039, rs11166921) are associated with TASK3 expression levels, is warranted.

In light of our previous findings (McCann et al., 2012), which suggested that preoperative breast pain has an inflammatory component, it is possible that gene × gene interactions between cytokine and potassium channel genes may occur and result in a higher risk for preoperative breast pain. This hypothesis is supported by work that demonstrates that potassium channel activity can impact cytokine production in lymphocytes (Feske, Skolnik, & Prakriya, 2012) and THP-1 cells through toll-like receptor 4 inhibition (Jo et al., 2011). Larger samples are needed to test for such potential epistatic interactions in patients with preoperative breast pain.

Some study limitations should be noted. Firstly, in this study, preoperative breast pain was operationalized as pain occurring in the affected breast prior to breast cancer surgery. Because the timeframe of occurrence was not evaluated, it is not clear whether this preoperative breast pain was acute or chronic in nature. Secondly, as with any association study, it is important to note that the genetic associations identified herein are not necessarily causal. Replication in independent samples, followed by functional studies and/or deep sequencing may be required before a causal relationship between these SNPs and the occurrence of preoperative breast pain is established. Thirdly, with an increased sample size, additional genetic associations may be identified. Likewise, regression models would have sufficient power to fit interaction terms (e.g., gene × environment interactions). Finally, although our sample size of 302 is substantial, it is possible that these associations may not be replicated in an independent sample (Ioannidis et al., 2001).

In summary, this study identified eight genetic variations among four potassium channel genes (i.e., KCNS1, KCNJ3, KCNJ6, KCNK9) that were significantly associated with the occurrence of preoperative breast pain. Variation among these genes may constitute important risk factors for the occurrence of preoperative breast pain. Moreover, in our work preoperative breast pain was associated with more severe postoperative pain data in preparation), as well as with the development of persistent breast pain after breast cancer surgery (Miaskowski et al., 2012b). An evaluation of genetic associations may help to identify the underlying mechanisms for preoperative, postoperative, and persistent pain in patients who undergo breast cancer surgery.

Acknowledgements

This study was funded by grants from the National Cancer Institute (CA107091 and CA118658). Dr. Miaskowski is an American Cancer Society (ACS) Clinical Research Professor. Dr. Dhruva is funded through NIH Mentored Patient-Oriented Research Career Development Award (K23 AT005340). Dr. Langford is supported by a Department of Defense Breast Cancer Research Program Postdoctoral Fellowship. Dr. Merriman was supported by an NINR fellowship (F31 NR012604), an ACS Doctoral Degree Scholarship (DSCN-10-087), an Oncology Nursing Society Doctoral Scholarship, and a UCSF Nursing Alumni Association Scholarship. Dr. Baggott is funded by an American Cancer Society Mentored Research Scholar Award (MRSG 12-01-PCSM). Dr. Leutwyler is funded by the KL2 Program (RR624130). Ms. Ward Sullivan is supported by an NINR T32. This project is supported by NIH/NCRR UCSF-CTSI Grant Number UL1 RR024131. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH.

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