Severity of Patients’ Symptoms May Be Underrecognized During and After Breast Radiotherapy

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Physicians may commonly underrecognize radiation-associated symptoms and their severity compared with self-reports of patients with breast cancer, according to a large study comparing patient-­reported outcomes with physician assessments of four common radiation-associated symptoms: pain, pruritus, edema, and fatigue. Underrecognition of symptom severity was more common in younger and Black patients. The study was presented at the 2020 San Antonio Breast Cancer Symposium.1

“Recognizing side effects is necessary for physicians to provide supportive care to help patients manage their symptoms and improve quality of life,” said lead author Reshma Jagsi, MD, DPhil, the Newman Family Professor and Deputy Chair of the Department of Radiation Oncology and Director of the Center for Bioethics and Social Science in Medicine, University of Michigan.

Reshma Jagsi, MD, DPhi

Reshma Jagsi, MD, DPhi

Study Details

The study included 9,868 patients with breast cancer treated with lumpectomy followed by radiation therapy at 29 practices across Michigan who are enrolled in the Michigan Radiation Oncology Quality Consortium initiative. Participants who completed at least one 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 four symptoms: pain, pruritus, edema, and fatigue. The investigators focused on 37,593 paired observations from physicians and patients.

For nearly 3,000 patients, physicians’ underrecognition of symptoms occurred at least once. Physicians used Common Terminology Criteria for Adverse Events (CTCAE) assessments for these four symptoms. Patients were considered to have substantial symptoms if they reported moderate or severe pain, bother from occasional or constant itching or swelling, or significant fatigue most of the time or always.

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’ assessment of pain that signaled underrecognition of symptom severity occurred when physicians reported no pain (BPI score of 0) but patients reported moderate pain (BPI scores of 4–6) or when patients reported severe pain (BPI of 7 or higher) but physicians graded as up to grade 1. Similarly, for pruritus, edema, and fatigue, physicians were categorized as underrecognizing these symptoms if they reported the symptom as grade 0 when patients reported it as bothersome sometimes, 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% of paired observations; underrecognition of frequent pruritus, in 36.7%; underrecognition of frequent edema, in 51.4%; and underrecognition of severe fatigue, in 18.8%. Among 5,510 patients who reported at least one of four substantial symptoms during radiotherapy, 53.2% of them had at least one of the symptoms underrecognized by physicians.

Multivariate logistic regression analysis revealed that younger age and Black or other race were strongly associated with the likelihood of underrecognition of symptom severity. Patients younger than age 50 had 1.35 times higher likelihood of experiencing underrecognition compared with patients between the ages of 60 and 69 and 1.21 times higher likelihood compared with those between the ages of 50 and 59. Compared with White patients, Black patients were at 1.92 greater odds and members of other races were at 1.82 greater odds of symptom underrecognition.

Treatment factors were also associated with increased odds of physician underrecognition: patients not treated with a supraclavicular field, treatment with conventional fractionation compared with hypofractionation, and not being treated at an academic center.

“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 radiotherapy-related gastrointestinal symptoms. This research shows it is also true for breast radiation therapy,” Dr. Jagsi noted. 

DISCLOSURE: Dr. Jagsi has stock options as compensation for her advisory board role in Equity Quotient; has received personal fees from Amgen and Vizient and grants for unrelated work from the National Institutes of Health, the Doris Duke Foundation, the Greenwall Foundation, the Komen Foundation, and Blue Cross Blue Shield of Michigan for the Michigan Radiation Oncology Quality Consortium; has a contract to conduct an investigator-initiated study with Genentech; has served as an expert witness for Sherinian and Hasso and Dressman Benzinger LaVelle; and is an uncompensated founding member of TIME’S UP Healthcare and a member of the Board of Directors of ASCO.


1. Jagsi R, Griffith KA, Vicini F, et al: Identifying patients whose symptoms are under-recognized during breast radiotherapy. 2020 San Antonio Breast Cancer Symposium. Abstract GS3-07. Presented December 9, 2020.


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