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Breast Radiotherapy Symptoms Under-Recognised

Patient experience of acute adverse events after breast radiotherapy may be under-recognised by their physicians
14 Dec 2020
Breast Cancer;  Complications/Toxicities of Treatment;  Radiation Oncology

Author: By Lynda Williams, Senior medwireNews Reporter 


medwireNews: Acute adverse events associated with breast irradiation are not fully recognised by physicians, with Black women and younger patients most likely to have their symptoms missed, suggests a study presented during the 2020 San Antonio Breast Cancer Symposium. 

Reshma Jagsi, from the University of Michigan in Ann Arbor, USA, reported findings from the MROQC quality initiative conducted at 29 practices with 13,725 patients who had completed radiation after lumpectomy between 2012 and 2020. 

In all, 37,593 physician CTCAE assessments were paired with patient-reported outcome (PRO) questionnaires for pain, pruritus, oedema and fatigue that were completed by 9941 patients during radiotherapy. The CTCAE and PRO assessments were completed on the same day or within 3 days of each other. 

Overall, 34.5% of patients reported moderate or severe pain on the Brief Pain Inventory in the preceding 24 hours but this was under-recognised by physicians in 30.9% of patients, defined as clinicians grading pain as absent on the CTCAE when the patient had reported it as moderate, or giving a low score when the patient had described it as severe. 

Using an adapted form of the Skindex assessment, 30.6% of patients said they were bothered by pruritus and 23.9% from oedema “often or all of the time”, but these symptoms were under-recognised by physicians in 36.7% and 51.4% of patients, respectively.  

And while 24.9% described having “significant fatigue most of the time or always”, physicians reported no fatigue in 18.8% of these cases. 

Moreover, 53.2% of the 5510 patients who experienced substantial symptoms during radiotherapy had at least one of the four symptoms under-recognised, reported Reshma Jagsi. 

Multivariate analysis indicated that patients who were Black or of other non-Asian race were significantly more likely to have symptoms under-recognised than their White counterparts (OR=1.9 and 1.8, respectively).  

And this was also true for patients younger than 50 years old or aged 50–59 years compared with participants aged 60–69 years (odds ratio [OR]=1.4 and 1.2, respectively), as well as for patients who received conventional fractionation (OR=1.2), those without a supraclavicular field (OR=1.3) and patients treated outside an academic centre (OR=1.1). 

Forest plot analysis of under-ascertainment of symptoms confirmed that “there was systematic under-recognition of symptoms in our racial and ethnic minority patients in the sample, with a remarkable odds ratio there for our Black patients”, Reshma Jagsi emphasized. 

“In conclusion, patient reported outcomes collection appears essential for trials because relying on the CTCAE to detect adverse events during breast radiotherapy clearly misses important symptoms”, the presenter said. 

“Prior work has suggested this already for acute radiotherapy-related [gastrointestinal] symptoms and this work shows that this is also true for the acute symptoms associated with breast radiation therapy”, she continued. 

Reshma Jagsi emphasized: “Perhaps even more importantly, this work reveals that physicians are systematically missing substantial symptoms in certain patients, including patients who are younger or of Black or other race. 

“Therefore, improving symptom detection is important […] for its own sake to help us treat our patients, we can’t help our patients if we don’t recognise the symptoms they are experiencing, and it also may be a targetable mechanism by which we may reduce disparities in radiotherapy experiences and outcomes.” 


Abstract GS3-07. Jagsi R, Griffith KA, Vicini F, et al. Identifying patients whose symptoms are under-recognized during breast radiotherapy: Comparison of patient and physician reports of toxicity in a multicenter cohort. 2020 San Antonio Breast Cancer Symposium; 8–11 December. 

medwireNews (www.medwireNews.com) is an independent medical news service provided by Springer Healthcare. © 2020 Springer Healthcare part of the Springer Nature group

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