Study: Doctors Underreport Side Effects of Breast Irradiation

Sara Freeman

December 29, 2020

There is a substantial mismatch between patient and physician reports of toxicity during radiotherapy for breast cancer, according to an analysis of nearly 10,000 U.S. patients.

Researchers assessed physician underrecognition of four key symptoms – pain, pruritus, edema, and fatigue – during radiotherapy. Physicians underrecognized one of these four symptoms at least once in 53.2% of patients who reported having at least one substantial symptom.

"Understanding whether physicians detect when their patients are experiencing substantial toxicity is important, not only because recognition of symptoms is necessary for appropriate supportive care, but also because it influences what techniques and treatments we adopt," said Reshma Jagsi, MD, DPhil, of the University of Michigan, Ann Arbor.

Jagsi presented the study results at the 2020 San Antonio Breast Cancer Symposium.

The underrecognition of symptoms during radiotherapy may reflect differences in physician or patient behaviors, according to Jagsi. "It's absolutely something we need to understand better."

Ian E. Krop, MD, PhD, of the Dana-Farber Cancer Institute in Boston, moderated the session where this research was presented and called the work "striking," noting that it "clearly identifies an important area that needs improvement."

"We need to do a better job. We as physicians need to listen more to our patients," said Virginia Kaklamani, MD, of the University of Texas Health Science Center, San Antonio, and codirector of the SABCS 2020 meeting.

Comparing Patient and Physician Reports

Jagsi and colleagues analyzed data on patients who had received radiotherapy after lumpectomy for breast cancer and had completed patient-reported outcome measures (PROs) as part of the Michigan Radiation Oncology Quality Consortium (MROQC). The MROQC registry collects data on patients receiving radiation for breast, lung, and prostate cancers, as well as for bone metastases.

Results of the PROs were compared with physician reports of toxicity as assessed using the Common Terminology Criteria for Adverse Events (CTCAE) system.

The researchers could evaluate underrecognition of toxicity in 9,868 patients by comparing 37,593 independent paired observations from patients and their doctors. Patient and physician reports were made on the same day (n = 35,797) or within 3 days of each other (n = 1,796).

The comparison showed underrecognition of all four symptoms assessed – pain, pruritus, edema, and fatigue.

Underrecognition of pain was defined as patients reporting moderate pain while physicians graded pain as absent or as patients reporting severe pain while physicians rated pain as grade 1 or lower. Underrecognition of fatigue, bother from pruritus, or bother from edema were defined as physicians grading these symptoms as absent when patients reported fatigue or bother from pruritus/edema often or all of the time.

The percentage of observations with underrecognized symptoms was 30.9% for moderate to severe pain, 36.7% for frequent bother from pruritus, 51.4% for frequent bother from edema, and 18.8% for severe fatigue.

Factors independently associated with symptom underrecognition were younger age (odds ratio, 1.4 for <50 years and 1.2 for 50-59 years), Black or other non-White race (OR, 1.9 and 1.8, respectively), conventional fractionation (OR, 1.2), not having a supraclavicular field (OR, 1.3), and being treated at an academic center (OR, 1.1).

Underreporting Worse in the Time of COVID?

Data collection for this study ended before the start of the COVID-19 pandemic, but Jagsi expressed concern that the pandemic could lead to underrecognition of toxicity as well.

"We are doing more virtual visits, and I think the relationships between physicians and patients are a bit more strained," Jagsi said. While virtual visits mean that patients can be seen safely, they are "not the same as being in the same room as one another."

On the other hand, in-person visits during the pandemic may pose challenges as well. The need to wear masks during in-person consultations could lead to a lot of nonverbal communication being missed.

"I wouldn't be surprised at all if underrecognition were worse in this context," Jagsi said.

Encourage Patients to Speak Up, Use PROs

"I think we need to encourage patients that when we've told them that certain side effects are expected, it doesn't mean that they shouldn't tell us if they're bothered by those side effects," Jagsi said. "They're not bothering us. They're not troubling us to bring those symptoms to our attention, because there actually are things that we can do to help support them through the experience."

Jagsi also said PROs should be included in clinical trials. Trials tend to rely on physician assessment of possible toxicity using the CTCAE system, but this can miss important symptoms that patients experience during radiotherapy.

The current study and MROQC were sponsored by Blue Cross Blue Shield of Michigan and the Blue Care Network as part of the BCBSM Value Partnership program. Jagsi disclosed financial relationships with Amgen, Equity Quotient, Genentech, Vizient, law firms, various foundations, the National Institutes of Health, and BCBSM for the MROQC. Kaklamani and Krop disclosed relationships with many pharmaceutical companies.

SOURCE: Jagsi R J et al. SABCS 2020, Abstract GS3-07.

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