Symptoms Under-Recognized in Patients Who Receive Radiotherapy After Lumpectomy

Reshma Jagsi, MD, DPhil

Oncologists widely under-recognize substantial symptoms in patients with breast cancer receiving radiotherapy (RT) after undergoing a lumpectomy, highlighting a need to improve symptom detection, according to data from a 29-practice consortium presented at the 2020 San Antonio Breast Cancer Symposium.¹

“Understanding whether physicians detect whether patients are experiencing substantial toxicity is important, both because recognition of symptoms is necessary for appropriate supportive care and because clinical trials investigating new treatment options often rely on physician assessments using common toxicity criteria for adverse events,” Reshma Jagsi, MD, DPhil, deputy chair of the Department of Radiation Oncology at University of Michigan, said during a virtual presentation of the data.

Using a large multicenter consortium of 29 practices in Michigan, Jagsi and colleagues aimed to compare physician and patient reports of acute toxicity during breast RT, and specifically analyze if under-recognition of toxicities were pronounced in certain subgroups.

Between January 2012 and March 2020, 13,725 patients completed RT at one of the practices included in the Michigan Radiation Oncology Quality Consortium. Among those who completed RT, 9,941 completed at least one patient-reported outcome (PRO) questionnaire while receiving RT.

Where physician assessments via Common Terminology Criteria for Adverse Events (CTCAE) reporting of patient toxicity were available within 3 days of PRO evaluations, Jagsi and colleagues compared the difference in ratings on four symptoms: pain, pruritis, edema and fatigue. The main symptom the researchers wanted to evaluate was pain, which was defined using the Brief Pain Inventory rating pain within the past 24 hours as worst, least, average and “right now.” If patients reported their pain as a 4 to 6 on a 10-point scale, they were considered to have under-recognized pain if the physician graded it as absent or 0.

For patients who reported severe pain as a score of 7 or more, they were deemed to have under-recognized pain if the physician graded it as less than or equal to grade 1 mild pain.

In measuring the frequency of bother from pruritis and edema, symptoms were considered under-recognized if physicians graded those symptoms as absent when patients graded them as bothered often or all the time.

As for fatigue, a patient’s symptoms were deemed under-recognized if they reported experiencing fatigue most of the time and their physician said the condition was absent.

Approximately 1/3 of patients reported moderate or severe pain (34.5%; 3,433 of 9,940) and frequent both from pruritis (30.6%; 3,039 of 9,923). Less than 1/4 of patients reported frequent bother from edema (23.9%; 2,363 of 9,906) or severe fatigue (24.9%; 2,209 of 8,860).

Under-recognition of at least 1 of the 4 symptoms occurred at least once during in the treatment course of 53.2% of patients who reported at least 1 substantial symptom while receiving RT.

Patients aged under 50 years (OR = 1.35; 95% CI, 1.15-1.58; P < .001), as well as 50 to 59 years (OR = 1.21; 95% CI, 1.06-1.39; P = .006) were more likely to be under-recognized versus patients aged 60 to 69 years. Moreover, Black (OR = 1.92; 95% CI, 1.65-2.23; P < .001) or other race (OR = 1.82; 95% CI, 1.24-2.66; P = .002) were also associated with under-recognition of symptoms.

“We concluded that patient-reported outcome collection is essential for trials, because relying on the common toxicity criteria for adverse events to detect adverse events based on physician record will miss important symptoms. And prior work has actually suggested this for acute gastrointestinal symptoms associated with radiation treatment, and this work shows that it's also true for the acute symptoms associated with breast radiotherapy,” Jagsi concluded. “Moreover, this work reveals that physicians systematically miss substantial symptoms in certain patients, including patients who are younger, or who have Black or other race, and therefore, improving symptom detection may actually be a targetable mechanism to reduce disparities in radiation therapy, experiences and outcomes.”

Following the presentation of the data, SABCS Co-Director Virginia Kaklamani, MD, DSc, said it was surprising to see that 30% of cases of what patients were reporting as issues associated with their radiation therapy were underrecognized by physicians. Moreover, she said, it was surprising to see those cases higher in young women and racial minorities.

“We need to do a better job,” said Kaklamani, leader of the Breast Oncology Program at the University of Texas Health San Antonio’s MD Anderson Cancer Center. “That's really what it is, we need to conduct studies where patient-reported outcomes are being reported, and we as physicians need to listen more to our patients.”

Reference

Jagsi R, Griffith KA, Vicin F, et al. Identifying patients whose symptoms are under-recognized during breast radiotherapy: Comparison of patient and physician reports of toxicity in a multicenter cohort. Presented at: 2020 San Antonio Breast Cancer Symposium; December 8-11, 2020; Virtual. Abstract GS3-07