Patients with early-stage breast cancer may be at low risk of dying of their disease, but they experience a high burden of physical and psychological symptoms long after their treatment has ended, according to data presented during the 2021 American Society of Breast Surgeons Annual Meeting.¹ Results of a patient-reported outcome survey showed that nearly 50% of survivors of early-stage breast cancer reported three or more clinically significant long-term symptoms and concerns. The most common issues cited included hot flashes (due to endocrine therapy), fatigue, back and joint pain, and anxiety.

Jessica Schumacher, PhD, MS

“The high burden of symptoms experienced by early-stage survivors has important implications for their quality of life after cancer treatment,” said lead study author, Jessica Schumacher, PhD, MS, Associate Professor of Surgery at the University of Wisconsin School of Medicine and Public Health, Madison. “The use of patient-reported outcome surveys allows for an opportunity to comprehensively evaluate and identify unrecognized needs.”

More than 3.5 million breast cancer survivors in the United States currently receive follow-up care for the detection of recurrence, treatment adherence, and symptom management. Although approximately two-thirds of survivors are diagnosed at an early stage and are thus at a low risk of dying of their disease, said Dr. Schumacher, little is known about the symptom experience of survivors with early-stage disease.

“Much of the work to date has been focused on describing the symptom experience of women diagnosed with later-stage disease,” she explained. “The objective of this study was to assess the prevalence of ongoing symptoms and concerns experienced by breast cancer survivors diagnosed at an early stage with completed treatment.”

Study Methods

For this study, Dr. Heather Neuman and her research team included women with stage I to II breast cancer diagnosed with estrogen receptor– or progesterone receptor–positive, HER2-negative disease—a patient population at low risk of recurrence not regularly treated with chemotherapy. Women enrolled had to be between 6 months and 6 years postdiagnosis.

Survivors were approached to participate in the clinic at the time of their regular follow-up visit within the University of Wisconsin breast program. Two weeks later, survivors were sent a link to a survey of self-reported symptoms and concerns based on American Cancer Society and ASCO Breast Cancer Survivorship guidelines (released in 2016).

“We assessed symptoms and concerns with validated instruments and a broad domain of survey items, including the signs of recurrence and side effects after treatment, breast symptoms, questions relating to endocrine or hormonal medication side effects and adherence, lymphedema, chest and breast pain, sexuality questions, social support, and mental health,” said Dr. Schumacher.

The researchers first identified the presence or absence of a particular symptom. Then, they summarized symptoms based on whether they were experienced at established thresholds of clinical significance.

Symptoms or Concerns Widely Reported

Of 130 patients approached in the clinic, 101 consented, and 94 completed the survey, responding to a minimum of two survey items. According to Dr. Schumacher, 53% of survivors were younger than age 65, and 21% were younger than age 50. On average, participants were 2.5 years from diagnosis, and 96.8% and 90.4% of survivors were diagnosed with T1 or T2 and/or node-negative disease, respectively, reflecting the inclusion criteria for a cohort of survivors of early-stage disease. Data also showed that 71% of survivors had undergone breast-conserving surgery, and 87% reported currently being on endocrine therapy.

“Women responding to our survey experienced extensive symptoms,” said Dr. Schumacher. She noted that only 6% of women reported not experiencing any symptoms or concerns. “Although 16% of women reported one to two symptoms, 78% reported three or more symptoms. When we restricted symptoms and concerns to those that reached clinical significance, 37% reported one to two symptoms, and 49% reported three or more symptoms,” she added.

The most common symptoms experienced included hot flashes, fatigue, back pain, joint pain, and headache. The prevalence of significant anxiety was also high (approximately 30%), and survivors reported issues with taking endocrine therapy, including skipping doses. After examining groupings of specific symptom clusters experienced by patients, however, the researchers found no dominant clusters.

Given the high proportion of patients who reported three or more concerns, Dr. Schumacher acknowledged that many of these topics may not be routinely discussed or addressed during time-limited follow-up visits. It may be difficult to address other concerns, such as sexual health or body image issues, in the clinic given their complex and sensitive nature. Nevertheless, the use of patient-reported outcome assessments represents an important opportunity to improve survivorship care, she said. “We’re considering integrating this into a previsit self-assessment tool that measures symptoms and concerns we might be worried about,” Dr. Schumacher concluded. “Then, the provider can focus on these items during the meeting, given the time-limited nature of the encounters.” 

Commentary

Sarah Blair, MD, FACS

Session moderator during the 2021 American Society of Breast Surgeons Annual Meeting, Sarah Blair, MD, FACS, Vice Chair of Academic Affairs for the Department of Surgery at University of California San Diego, urged widespread dissemination of these survey findings.

“I was struck by how important these data are,” said Dr. Blair. “Every day, I see patients who tell me they have breast pain and are worried about recurrence because of this pain. It’s critical that we find a way to disseminate these data to our patients; this way, they will be reassured that these symptoms are to be expected, that this is not out of the norm, and that this doesn’t mean [their] cancer has come back,” she concluded. 

DISCLOSURE: Dr. Schumacher and Dr. Blair reported no conflicts of interest.

REFERENCE

1. Schumacher JR, et al: Ongoing symptoms experienced by low-risk breast cancer survivors following active treatment. 2021 American Society of Breast Surgeons Annual Meeting. Abstract 238. Presented April 30, 2021.