Abstract GS3-07: Identifying patients whose symptoms are under-recognized during breast radiotherapy: Comparison of patient and physician reports of toxicity in a multicenter cohort
Authors: Jagsi Reshma , Griffith Kent A. , Vicini Frank , Boike Thomas , Dominello Michael , Gustafson Gregory , Hayman James A. , Moran Jean M. , Radawski Jeffrey , Walker Eleanor , Pierce Lori J. ,   on behalf of MROQC, the Michigan Radiation Oncology Quality Consortium
Published: February 2021

Abstract
BACKGROUND: Evaluating whether physicians (MDs) accurately detect symptoms in patients (pts) is important because recognition of symptoms facilitates supportive care and because clinical trials often rely on MD assessments using the Common Toxicity Criteria for Adverse Events (CTCAE).
METHODS: Breast cancer pts who received radiotherapy (RT) after lumpectomy at 29 practices were enrolled in a quality initiative, MROQC. Of 13,725 pts who completed RT between 1/1/2012 and 3/31/2020, 9,941 completed at least one pt-reported outcomes (PRO) questionnaire during RT. Where MD CTCAE assessments were available within 3 days of PRO evaluation, pt and MD ratings of 4 symptoms were compared. Pts reported breast pain via an approved modification of the Brief Pain Inventory, asking for ratings in the last 24 hours of pain at its worst, least, average, and “right now.” MDs were deemed to under-recognize pain when pts reported moderate pain (score 4-6) but MDs graded pain as 0 (absent) on the CTCAE, or when pts reported severe pain (score 7-10) but MDs’ CTCAE grade was ≤1. Bother from pruritis and edema were measured by modified scaled measures adapted from the Skindex. MDs were deemed to under-recognize pruritus and edema if they graded these as absent (grade 0) when pts reported bother often or all of the time from itching or swelling, respectively. MDs were deemed to under-recognize fatigue if they graded fatigue as absent (grade 0) when pts reported having significant fatigue most of the time or always.We describe the proportion of pts for whom under-recognition of at least 1 of these 4 symptoms occurred at least once during the treatment course and use multivariable logistic regression to evaluate predictors of this under-recognition, hypothesizing that it would be more common in racial minorities.
RESULTS: 3,434/9,940 pts (34.5%) reported substantial breast pain, 3,039/9,923 (30.6%) frequent bother from pruritus, 2,363/9,906 (23.9%) frequent bother from edema, and 2,209/8,860 (24.9%) severe fatigue. We could evaluate under-recognition in 9,868 pts, with 37,593 independent paired observations of pt and MD reports (35,797 on the same date and 1,796 within 3 days). Under-recognition existed in 2,094/6,781 (30.9%) observations of pt-reported moderate/severe pain, 748/2,039 (36.7%) of pt-reported frequent pruritis, 2,309/4,492 (51.4%) of pt-reported frequent edema, and 390/2,079 (18.8%) of pt-reported severe fatigue. Under-recognition of at least 1 of these 4 symptoms occurred at least once during the pt’s treatment course for 2,933/5,510 (53.2%) of the pts who reported at least 1 substantial symptom during RT.Factors independently associated with under-recognition were (Table): younger age (OR=1.4 and 1.2 for &lt;50 and 50-59 vs. 60-69, respectively), black or other race (OR=1.9 and 1.8 vs white, respectively), conventional fractionation (OR=1.2), not having a supraclavicular field (OR=1.3) and being treated at an academic center (OR=1.1).
CONCLUSIONS: PRO collection appears essential for trials because relying on the CTCAE to detect adverse events may miss important symptoms. Moreover, since MDs systematically miss substantial symptoms in certain patients, including pts who are younger or of black or other race, improving symptom detection may be a targetable mechanism to reduce disparities in RT experiences and outcomes.
Multivariable model of symptom under-recognitionOR95% CIpAge--0.001&lt;501.351.15-1.58&lt;0.00150-591.211.06-1.390.00660-691 (ref)--70+1.050.89-1.240.55Body Mass Index--0.67Underweight (&lt;18.5).790.52-1.200.27Normal(18.5-&lt;25).990.84-1.150.86Overweight (25-&lt;30)1 (ref)--Obesity I (30-&lt;35)1.010.87-1.180.87Obesity II (35-&lt;40)1.050.88-1.250.61Obesity III (40+)1.110.92-1.340.27Race--&lt;0.001White1 (ref)--Black1.921.65-2.23&lt;0.001Asian1.320.84-2.080.23Other1.821.24-2.660.002Supraclavicular field used (yes vs no)0.800.68-0.950.01Fractionation (conventionalvs hypo fractionation)1.151.02-1.300.02Boost to tumor bed (yes vs no)0.950.80-1.120.53Facility(Academic vs Community)1.131.01-1.270.04
Citation Format: Reshma Jagsi, Kent A. Griffith, Frank Vicini, Thomas Boike, Michael Dominello, Gregory Gustafson, James A. Hayman, Jean M. Moran, Jeffrey Radawski, Eleanor Walker, Lori J. Pierce, on behalf of MROQC, the Michigan Radiation Oncology Quality Consortium. Identifying patients whose symptoms are under-recognized during breast radiotherapy: Comparison of patient and physician reports of toxicity in a multicenter cohort [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr GS3-07.