Doctor-Patient Discord in Reporting Radiation Toxicity

Common acute side effects of radiation therapy (RT) for breast cancer often go underrecognized by physicians, new research showed.

In a study of nearly 10,000 patients who completed a patient-reported outcome (PRO) questionnaire, 51.4% of physician observations underrecognized patients’ frequent discomfort from swelling, 30.9% underrecognized moderate or severe pain, 36.7% underrecognized frequent discomfort from itching, and 18.8% of physician observations underrecognized severe fatigue, according to Reshma Jagsi, MD, DPhil, of the University of Michigan in Ann Arbor.

Among the 5,510 patients reporting at least one substantial symptom among these four symptoms evaluated, 53.2% had their symptom underrecognized by their physician.

“Patient-reported outcomes collection is essential for trials, because relying on the common toxicity criteria for adverse events [CTCAE] to detect adverse events based on physician report will miss important symptoms,” Jagsi said during a media presentation at the virtual San Antonio Breast Symposium (SABCS). “Prior work has actually suggested this for acute gastrointestinal symptoms associated with radiation treatment, and this work shows that it’s also true for the acute symptoms associated with breast radiotherapy.”

Several demographic factors were independently associated with underrecognition of these symptoms:

• Age <50 vs age 60-69 (OR 1.35, 95% CI 1.15-1.58, P=0.0002)

• Age 50-59 vs age 60-69 (OR 1.21, 95% CI 1.06-1.39, P=0.0059)

• Black vs white race (OR 1.92, 95% CI 1.65-2.23, P<0.0001)

• Other vs white race (OR 1.82, 95% CI 1.24-2.66, P=0.0021)

“Improving symptom detection may actually be a targetable mechanism to reduce disparities in radiation therapy experiences and outcomes,” Jagsi suggested.

Type of RT and treatment location were also associated with differences in symptom reporting:

• Conventional fractionation (OR 1.15, 95% CI 1.02-1.30, P=0.0192)

• Supraclavicular field use (OR 0.80, 95% CI 0.68-0.95, P=0.0122)

• Treatment at academic center (OR 1.13, 95% CI 1.01-1.27, P=0.0372)

Virginia Kaklamani, MD, of UT Health San Antonio in Texas, and a panelist during the press briefing, said she was surprised by the level of underrecognition considering what patients were reporting themselves.

“It’s also surprising that young women as well as racial minorities was where that issue was even more pronounced,” she said. “We need to do a better job, that’s really what it is. We need to conduct studies where patient-reported outcomes are being reported, and we as physicians need to listen more to our patients.”

Jagsi said the key is improving physician-patient communication, and that the findings shouldn’t be viewed just within radiation oncology.

“We as physicians all across the board can do better going forward,” she said. “I think that involves a spectrum of potential interventions beginning with our own potential unconscious biases, which we all know that we have. Are there certain patients we expect to be more vulnerable and to whom we apply stricter scrutiny? And perhaps are we not spending as much time as needed to detect symptoms in other groups?”

She also brought up the issue of trust between the patient and physician, and said symptoms need to be discussed in a way where physicians are truly finding out the information they need to support their patients.

The study examined 13,725 breast cancer patients who received RT following a lumpectomy at 29 practices from 2012 to 2020 and were enrolled in the Michigan Radiation Oncology Quality Consortium (MROQC), a state-wide quality initiative. Of these, 9,941 completed at least one PRO questionnaire during the study period.

Overall, moderate or severe pain was reported in 34.5% of patients, frequent bother from pruritus in 30.6%, frequent bother from edema in 23.9%, and severe fatigue in 24.9%.

Investigators had access to 37,593 paired observations of physician reports and PROs, involving 9,868 patients. The vast majority (95%) were recorded on the same date, and the remaining were reported within 3 days of each other.

Patients reported their pain levels using a modified version of the breast brief pain inventory, with moderate pain being a score of 4-6 on the 10-point scale. This was considered to have been underrecognized if physicians gave a CTCAE grade of 0, meaning absent. Severe pain (score of 7-10 on the breast brief pain inventory) was considered underrecognized if physicians gave it a CTCAE grade ≤1, which connotes mild pain.

Breast swelling and itching were considered underrecognized if physicians gave those a CTCAE grade of 0 when patients said on PROs that they were bothered either often or all of the time by these symptoms. Similarly, fatigue was deemed underrecognized if physicians said the symptom was absent when patients reported having significant fatigue most of the time or always on PROs.