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Patient Experiences of Acute Toxicity From Breast Radiotherapy According to Fractionation Scheme


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In a study reported in the Journal of Clinical Oncology, Reshma Jagsi, MD, DPhil, and colleagues found differences in patient reports of acute toxicities according to fractionation scheme of whole-breast radiotherapy for breast cancer, with pain being reported more frequently in Black vs White patients, irrespective of fractionation scheme.

Study Details

The study involved prospectively collected data on patient-reported acute toxicity among 8,711 patients treated between 2012 and 2019 at 27 practices in the Michigan Radiation Oncology Quality Consortium. Multivariable models identified characteristics associated with breast pain, bother from itching, stinging/burning, swelling, or hurting of the treated breast, as well as fatigue within 7 days of completing whole-breast radiotherapy.


“In this large observational data set, substantial differences existed according to radiotherapy dose fractionation. Race-related differences in pain existed despite controlling for multiple other factors; additional research is needed to understand what drives these differences to target potentially modifiable factors. Intensifying supportive care may be appropriate for subgroups identified as being vulnerable to greater toxicity.”
— Reshma Jagsi, MD, DPhil, and colleagues

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Key Findings

A total of 4,443 patients received hypofractionated radiotherapy, and 4,268 received conventional fractionation. Moderate or severe breast pain was reported by 28.9% of patients in the hypofractionation cohort vs 45.7% of the conventional fractionation cohort. Frequent bother from at least one breast symptom was reported by 41.3% vs 60.7%. Severe fatigue was reported by 19.0% vs 27.3%.

On multivariate analysis, factors significantly associated with moderate or severe pain among patients receiving hypofractionation were: younger age (P < .001), higher body mass index (BMI; P < .001), Black race (P < .001) and other race (excluding Asian; P = .002), current or former smoking status (P < .001), larger breast volume (P = .002), lack of receipt of chemotherapy (P = .004), receipt of boost treatment (P < .001), and treatment at a nonteaching center (treatment at a teaching center associated with less pain, P = .009).

Among patients receiving conventional fractionation, factors significantly associated with moderate or severe pain were: younger age (P < .001), higher BMI (P = .003), Black race (P < .001) and other race (P = .002), diabetes (P = .001), current or former smoking status (P < .001), and larger breast volume (P < .001).

Among patients receiving hypofractionation, factors significantly associated with frequent bother from breast symptoms were: younger age, higher BMI, Black race and other race, former or current smoking status, larger breast volume, separation distance from medial and lateral tangential beam entry (separation distance), lack of receipt of chemotherapy, and receipt of boost treatment. Factors significantly associated with severe fatigue were younger age, higher BMI, Asian race, and former or current smoking status.

Among patients receiving conventional fractionation, factors significantly associated with frequent bother from breast symptoms were: younger age, Black race and other race, hypertension, diabetes, current or former smoking status, larger breast volume, separation distance, lack of receipt of chemotherapy, and use of a supraclavicular field. Factors significantly associated with severe fatigue were younger age, higher BMI, diabetes, former smoking status, and separation distance.  

The investigators concluded, “In this large observational data set, substantial differences existed according to radiotherapy dose fractionation. Race-related differences in pain existed despite controlling for multiple other factors; additional research is needed to understand what drives these differences to target potentially modifiable factors. Intensifying supportive care may be appropriate for subgroups identified as being vulnerable to greater toxicity.”

Dr. Jagsi, of the Department of Radiation Oncology, University of Michigan, Ann Arbor, is the corresponding author for the Journal of Clinical Oncology article.  

Disclosure: The study was supported by Blue Cross Blue Shield of Michigan and the Blue Care Network of Michigan as part of the Blue Cross Blue Shield of Michigan Value Partnerships Program. For full disclosures of the study authors, visit ascopubs.org.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
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