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Younger and African American patients face significantly increased odds of having their symptoms associated with radiation therapy under-treated by providers.
Younger and African American patients who receive radiation as part of their breast cancer treatment are at a greater risk of having providers under-recognize – and, therefore, under-treat – the negative side effects and symptoms that can occur with the therapy.
Pain, pruritus, edema, and fatigue are common complaints associated with radiotherapy. But, according to findings presented during the 2020 San Antonio Breast Cancer Symposium released on Dec. 9, doctors do not always take patient complaints as seriously as they should.
“Recognizing side effects is necessary for physicians to provide supportive care to help patients manage their symptoms,” said Reshma Jagsi, M.D., DPhil., deputy chair of the radiation oncology department and director of the Center for Bioethics and Social Sciences in Medicine at the University of Michigan. “Physicians sometimes miscalculate the severity of patients’ symptoms, which can lead to reduced quality of life.”
In fact, she explained, those miscalculations are common with younger patients. But, they are most pronounced among African American patients with almost all patients in that group having their symptoms go under-recognized. Identifying this issue is a step toward eliminating the differences that currently exist in cancer care, she said.
“Improving symptom detection is a potential way to reduce disparities in cancer treatment experiences and outcomes,” she said, “at least in the setting of breast radiation therapy.”
Jagsi’s team reached this conclusion by comparing patient-reported outcome evaluations with physician assessments (Common Terminology Criteria for Adverse Events – CTCAE) for 9,868 patients who were treated with radiotherapy after a lumpectomy. Patients received care in 29 practices that were enrolled in the Michigan Radiation Oncology Quality Consortium. For their results, the team concentrated on four symptoms reports: breast pain, pruritus, edema, and fatigue.
Using the 5-point CTCAE scoring, where a “0” score indicates no symptom and a “5” refers to a death-related symptom, the team determined patients had substantial symptoms if they reported moderate-to-severe pain, frequent-to-constant itching or swelling, and near constant-to-constant fatigue. In that context, if a provider gave these patients either a “0” or “1” score for any of these symptoms, the team labeled their response as an under-recognition.
Based on that analysis, Jagsi’s team determined that, when compared to white patients, African American patients had 92-percent increased odds for having their providers not accurately assess their symptoms. For patients of races other than African American or Asian, the increased odds were 82 percent. Patients younger than 60 also faced worse odds. Compared to the 60-to-69 age group, patients younger than 50 and those ages 50-to-59 were at 35 percent and 21 percent increased odds, respectively, of experiencing symptom under-recognition, the team reported.
Specifically, of the 5,510 patients who indicated they had at least one of these four symptoms, 53.2 percent said at least one went under-recognized. Individually, for patients who reported substantial symptoms, pain, pruritis, edema, and fatigue went under-recognized 30.9 percent, 36.7 percent, 51.4 percent, and 18.8 percent of the time.
Two other factors also contributed to symptom under-recognition, Jagsi said. Patients who were not treated with supraclavicular field or those treated with conventional fractionation also saw their providers take their symptoms less seriously.
Ultimately, what these findings potentially present, she said, is fallacious thinking that can lead to detrimental effects in treating women for breast cancer.
“It is possible that there is a misconception among medical professionals about the pain tolerance of patients based on age and race,” she said. “Our study identifies some concerning patterns that need to be evaluated in future research, along with opportunities for intervention to improve the quality and equity of cancer care delivery.”