Physicians May Underestimate the Severity of Radiation-Associated Symptoms in Some Patients with Breast Cancer

TON - April 2021 Vol 14, No 2

Physicians often fail to perceive radiation-associated symptoms and the severity of those symptoms, according to the results of a large observational study that compared the reports of patients with breast cancer with physicians’ assessments of 4 common radiation-associated symptoms. Physicians were also more likely to underrecognize the severity of these symptoms in younger women and black women with breast cancer.

“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,” said lead investigator Reshma Jagsi, MD, DPhil, Deputy Chair, Radiation Oncology, and Director, Center for Bioethics and Social Sciences, University Hospital, University of Michigan, Ann Arbor, at the virtual 2020 San Antonio Breast Cancer Symposium.

Study Details

The large, observational study included 9868 patients who were treated with radiotherapy after a lumpectomy. Patients received care in 29 practices that were enrolled in the Michigan Radiation Oncology Quality Consortium. Participants who completed at least 1 patient-reported outcome questionnaire during radiation therapy had to have physician assessments performed within 3 days of completing the questionnaire. Physicians’ assessment of symptom severity was compared with patient-reported outcomes for 4 common radiation-associated symptoms: pain, pruritus, edema, and fatigue. The investigators focused on 37,593 paired observations from physicians and patients.

Using the 5-point Common Terminology Criteria for Adverse Events (CTCAE) scoring, where a “0” score indicates no symptoms and a “5” refers to a death-related symptom, the investigators determined that patients had substantial symptoms if they reported moderate-to-severe pain, frequent-to-constant itching or swelling, and near constant-to-constant fatigue. In that context, if physicians gave these patients either a “0” or “1” score for any of these symptoms, their response was labeled as an underrecognition.

Pain was rated according to the Brief Pain Inventory (BPI), a scale from 0 = no pain to 10 = most severe pain. Discordance between patient-reported outcomes and physicians’ assessments of pain that reflected underrecognition of symptom severity occurred when physicians reported no pain (BPI 0), when patients reported moderate pain (BPI 4-6), or when patients reported severe pain (BPI ≥7) that physicians graded as ≤1. Similarly, for pruritus, edema, and fatigue, physicians were categorized as underrecognizing any of these symptoms if they reported the symptom as grade 0 when patients reported being bothered by that symptom often, most of the time, or all of the time.


Among patients with substantial symptoms, physicians’ underrecognition of moderate-to-severe pain was observed in 30.9%, underrecognition of frequent pruritus in 36.7%, underrecognition of frequent edema in 51.4%, and underrecognition of severe fatigue in 18.8%.

Among 5510 patients who reported ≥1 substantial symptoms during radiotherapy, 53.2% had underrecognition by physicians of at least 1 of the 4 symptoms.

According to a multivariate analysis, younger age and black or other race were strongly associated with the likelihood of underrecognition of symptom severity. Patients aged <50 years were 35% more likely to experience underrecognition compared with patients aged 60 to 69 years and 21% more likely compared with those aged 50 to 59 years. Compared with white patients, black patients were at 92% greater odds of symptom underrecognition, and patients of “other” races (not black or Asian) were at 82% greater odds.

No treatment of a supraclavicular field, treatment with conventional fractionation compared with hypofractionation, and not being treated at an academic center were all associated with a greater likelihood of physician underrecognition of symptom severity.

“It is essential to collect patient-reported outcomes, because relying on CTCAE [physicians’ assessments] to detect adverse events misses important symptoms. Prior research suggests this is true for acute radiation therapy-related gastrointestinal symptoms. This research shows it is also true for breast radiation therapy,” Dr Jagsi noted.

It is becoming more common to include patient-reported outcomes in clinical trials. “All NRG Oncology trials where I have been involved now gather patient-reported outcomes. In the end, patients’ perceptions of side effects and quality of life are what really matter in their decision-making,” Dr Jagsi stated.

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