Identifying Patients Whose Symptoms Are Underrecognized During Treatment With Breast Radiotherapy

Abstract

for the Michigan Radiation Oncology Quality Consortium IMPORTANCE Understanding whether physicians accurately detect symptoms in patients with breast cancer is important because recognition of symptoms facilitates supportive care, and clinical trials often rely on physician assessments using Common Toxicity Criteria for Adverse Events (CTCAE).OBJECTIVE To compare the patient-reported outcomes (PROs) of patients with breast cancer who received radiotherapy from January 1, 2012, to March 31, 2020, with physicians' CTCAE assessments to assess underrecognition of symptoms. DESIGN, SETTING, AND PARTICIPANTSThis cohort study included a total of 29 practices enrolled in the Michigan Radiation Oncology Quality Consortium quality initiative. Of 13 725 patients with breast cancer who received treatment with radiotherapy after undergoing lumpectomy, 9941 patients (72.4%) completed at least 1 PRO questionnaire during treatment with radiotherapy and were evaluated for the study. Of these, 9868 patients (99.3%) were matched to physician CTCAE assessments that were completed within 3 days of the PRO questionnaires.EXPOSURES Patient and physician ratings of 4 symptoms (pain, pruritus, edema, and fatigue) were compared. MAIN OUTCOMES AND MEASURESWe used multilevel multivariable logistic regression to evaluate factors associated with symptom underrecognition, hypothesizing that it would be more common in racial and ethnic minority groups. RESULTSOf 9941 patients, all were female, 1655 (16.6%) were Black, 7925 (79.7%) were White, and 361 (3.6%) had Other race and ethnicity (including American Indian/Alaska Native, Arab/Middle Eastern, and Asian), either as self-reported or as indicated in the electronic medical record. A total of 1595 (16.0%) were younger than 50 years, 2874 (28.9%) were age 50 to 59 years, 3353 (33.7%) were age 60 to 69 years, and 2119 (21.3%) were 70 years or older. Underrecognition of symptoms existed in 2094 of 6781 (30.9%) observations of patient-reported moderate/severe pain, 748 of 2039 observations (36.7%) of patient-reported frequent pruritus, 2309 of 4492 observations (51.4%) of patient-reported frequent edema, and 390 of 2079 observations (18.8%) of patient-reported substantial fatigue. Underrecognition of at least 1 symptom occurred at least once for 2933 of 5510 (53.2%) of those who reported at least 1 substantial symptom. Factors independently associated with underrecognition were younger age (younger than 50 years compared with 60-69 years: odds ratio [

UpToDate®

“…Radiation dermatitis is the most common adverse effect of radiation therapy (RT) but may be underrecognized in some patients. In a cohort study that included nearly 10,000 patients from the United States with breast cancer who received RT and completed a patient-reported outcome questionnaire, 99 percent were matched to physician Common Terminology Criteria for Adverse Events (CTCAE) assessments 4. Among over 5500 individuals reporting at least one RT symptom of breast pain, pruritus, edema, and fatigue, underrecognition by the physician occurred in 53 percent.…”

Dermatitis por radiación en pacientes con cáncer de mama: un evento adverso omitido y emergente

“…No obstante, ante la ausencia de la sospecha diagnostica en atención primaria y omisión del tratamiento oportuno, esta condición puede representar un reto serio que afecte la calidad de vida y capacidad funcional del afectado (4,5) . De aquí, que los eventos adversos asociado a radiación, se han convertido en tópicos de interés en disciplinas como la cirugía oncológica de mama, oncología, cirugía plástica, dermatología, entre otras (3) .…”

“…Un estudio prospectivo que incluyó a 9,941 pacientes con cáncer de mama, pertenecientes al Michigan Radiation Oncology Quality Consortium, eventualmente recibieron radioterapia y, reportaron un seguimiento especial para la evaluación de manifestaciones no identificadas asociadas a toxicidad por radiación, y observaron que existió una omisión de síntomas de manera significativa (2094 casos de dolor moderado/severo; 748 casos de prurito frecuente; 2309 casos de edema frecuente; y 309 casos de fatiga significativa). Se estimó que tener edad < 50 años (OR 1.35; IC 95% 1.14-1.59, p <0.001), ser de raza afrodescendiente (OR 1.56; IC 95% 1.30-1.88, p <0.001), haber sido atendido por médico de sexo masculino (OR 1.54; IC 95% 1.20-1.99, p=0.002) y haber recibido radioterapia fraccionada de manera convencional (OR 1.26; IC 95% 1.10-1.45, p=0.002), fueron factores asociados al sub diagnóstico de las manifestaciones asociadas a toxicidad por cáncer de mama (4) .…”

“…Entonces, es apreciable que existe evidencia sólida que ha estudiado este evento adverso, con identificación precisa de factores de riesgo a través de estudios con muestras representativas, que son necesarios de conocer para evitar incurrir en sub diagnóstico. Pero también, para la elaboración de protocolos y guías adaptadas al contexto de cada ecología de la salud (6,7) , como puede ser por ejemplo en comunidades con predominancia de raza afrodescendiente, con elevada prevalencia de factores como diabetes y tabaquismo o, en mujeres jóvenes, donde se pudo evidenciar que existe mayor probabilidad de desarrollo de dermatitis aguda asociada a radiación y de presentación de sub diagnóstico (4,5) .…”

UpToDate®

“…underrecognition of radiation dermatitis in patients with breast cancer undergoing radiotherapy (may 2022) Radiation dermatitis is the most common adverse effect of radiation therapy (RT) but may be underrecognized in some patients. In a cohort study that included nearly 10,000 patients from the United States with breast cancer who received RT and completed a patient-reported outcome questionnaire, 99 percent were matched to physician Common Terminology Criteria for Adverse Events (CTCAE) assessments [1]. Among over 5500 individuals reporting at least one RT symptom of breast pain, pruritus, edema, and fatigue, underrecognition by the physician occurred in 53 percent.…”