Among patients with breast cancer treated with radiotherapy, symptoms were commonly underrecognized in reports of pain, pruritus, edema, and fatigue, with younger patients and Black patients having significantly increased odds of symptom underrecognition. These findings were reported by Reshma Jagsi, MD, DPhil, and colleagues at the 2020 San Antonio Breast Cancer Symposium (Abstract GS3-07).

“Recognizing side effects is necessary for physicians to provide supportive care to help patients manage their symptoms,” said Dr. Jagsi, the Newman Family Professor and Deputy Chair of the Department of Radiation Oncology and Director of the Center for Bioethics and Social Sciences in Medicine at the University of Michigan. “Physicians sometimes miscalculate the severity of patients’ symptoms, which can lead to reduced quality of life. In our study, we found that physicians are more likely to miscalculate symptom severity when patients have certain characteristics, including patients who are younger and patients who are Black.”

Reshma Jagsi, MD, DPhil

Comparison of Patient-Reported Outcomes and Physician Assessments

The researchers compared patient-reported outcome evaluations with physician Common Terminology Criteria for Adverse Events (CTCAE) assessments among 9,868 patients with breast cancer who were treated with radiotherapy after lumpectomy at 29 practices across Michigan enrolled in the Michigan Radiation Oncology Quality Consortium (MROQC). Patient and physician ratings of four symptoms—breast pain, pruritus, edema, and fatigue—were collected independently and compared.

CTCAE grades range from 0 to 5, with grade 0 referring to an absent symptom and grade 5 referring to death related to the symptom. Patients were deemed to have substantial symptoms if they reported moderate or severe pain, if they reported bother often or all of the time from itching or swelling, or if they had significant fatigue most of the time or always.

Physicians were deemed to underrecognize pain when patients reported moderate pain that the physicians recorded as grade 0, or when patients reported severe pain that the physicians recorded as less than or equal to grade 1. Similarly, physicians were deemed to underrecognize pruritus or edema when they recorded these symptoms as grade 0 and patients reported bother often or all of the time from itching (pruritus) or swelling (edema). Lastly, physicians were deemed to underrecognize fatigue when they recorded this symptom as grade 0 and patients reported having significant fatigue most of the time or always.

Rates of Underrecognition

Underrecognition of pain, pruritus, edema, and fatigue was found in 30.9%, 36.7%, 51.4%, and 18.8% of reports in patients having substantial symptoms, respectively. Among the 5,510 patients who reported at least one substantial symptom during radiotherapy, 53.2% had underrecognition of at least one of the four symptoms.

To evaluate predictors of symptom underrecognition, the researchers performed multivariable logistic regression analyses. They found that several factors were associated with symptom underrecognition, including age, race, and treatment regimen.

Compared with patients aged 60 to 69, patients younger than 50 and patients aged 50 to 59 had 35% and 21% increased odds of symptom underrecognition, respectively. Compared with White patients, Black patients had 92% increased odds of symptom underrecognition, and patients of races other than Black or Asian had 82% increased odds of symptom underrecognition.

Other factors associated with symptom underrecognition included patients not treated with a supraclavicular field and patients treated with conventional fractionation compared with hypofractionation.

“It is possible that there is a misconception among medical professionals about the pain tolerance of patients based on age and race,” noted Dr. Jagsi. “Our study identifies some concerning patterns that need to be evaluated in future research, along with opportunities for intervention to improve the quality and equity of cancer care delivery.”

“Improving symptom detection is a potential way to reduce disparities in cancer treatment experiences and outcomes, at least in the setting of breast radiation therapy,” concluded Dr. Jagsi.

Limitations of the study include its observational nature.

Disclosure: This study and MROQC were sponsored by Blue Cross Blue Shield of Michigan (BCBSM) and the Blue Care Network as part of the BCBSM Value Partnership program. Dr. Jagsi receives support from the Susan G. Komen Foundation and the National Institutes of Health.