Adjuvant RT Remains the Standard of Care at This Time

Ductal carcinoma in situ (DCIS) was first recognized in the 1970s. Within a decade, it became appreciated as a significant clinical entity due to the widespread implementation of breast cancer screening programs.[1] More than 60,000 cases of DCIS are diagnosed in the United States annually, accounting for approximately one-quarter of new breast cancer diagnoses each year.[2] DCIS is, in fact, a premalignant lesion, but appropriate management is critical. When untreated, it can progress to invasive cancer and ultimately death; in 2005, retrospective series of cases managed without active treatment demonstrated a breast cancer mortality rate of approximately 10%[3] to 20%[4] with small numbers of cases. More recent data demonstrate a rate of 3.3% with treatment of DCIS.[5] This difference is largely attributed to the approximately 10% risk of invasive ipsilateral breast tumor recurrence (IBTR) observed even in the treated population (without radiation therapy [RT]), and the associated increase in breast cancer mortality.[4-7] Current management of DCIS is driven by multiple landmark trials showing that lumpectomy should be coupled with RT to reduce rates of local recurrence (particularly invasive recurrence) and later with anti-estrogen therapy to maximize local control.[8-12] However, the clinical and genomic landscape of DCIS is now better understood, and treatment can be risk stratified to limit not only the intensity and toxicities of treatment, but also its physical, emotional, and financial consequences.

The fundamental role of RT in the treatment of DCIS was established by four landmark trials randomizing post-lumpectomy patients to adjuvant RT vs no RT: the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-17 trial,[8] SweDCIS,[9] the European Organisation for Research and Treatment of Cancer 10853 trial,[10] and the UK Coordinating Committee on Cancer Research trial.[11] Each study demonstrated that the addition of RT reduced the risk of any IBTR by approximately 50%.[8-11] All four studies showed a statistically significant reduction in invasive recurrences with RT, a notable finding, given that recurrences are associated with increased breast cancer mortality.[4,12] That said, none of these trials nor a meta-analysis of these studies demonstrated an overall survival (OS) benefit from the use of RT.[13]

Because of the observed lack of an OS benefit with RT, omission of RT in “low-risk” DCIS has been investigated. The Eastern Cooperative Oncology Group (ECOG) E5194 trial prospectively followed more than 700 women with margins ≥ 3 mm and either low-/intermediate-grade DCIS measuring ≤ 2.5 cm or high-grade DCIS measuring ≤ 1.0 cm.[14] At 12 years, the overall rate of IBTR was 14% in women with grade 1/2 disease but was 25% in those with grade 3 disease, with no plateau in recurrences noted for either group-an unacceptably high rate in either cohort. The Dana-Farber experience provides additional data on observation after surgical resection in women with grade 1/2 disease < 2.5 cm mammographically and wide margins (≥ 1 cm).[15] Even in this low-risk population, the 8-year local recurrence rate was > 13%, with one-third of patients having an invasive recurrence.

The Radiation Therapy Oncology Group (RTOG) 9804 trial also evaluated the omission of RT in DCIS; however, in contrast to the single-arm approach used in the ECOG and Dana-Farber studies, low-risk women were randomized to RT vs no RT following breast-conserving surgery (BCS).[16] Low-risk criteria were slightly different from those used in the ECOG study and included grade 1/2 disease, extent of DCIS ≤ 2.5 cm, and margins ≥ 3 mm. This study closed due to poor accrual. Nonetheless, its findings are notable: even in this low-risk population, the reduction in the IBTR rate with the use of RT was significant (from a 7% IBTR rate without RT to 1% with RT at 7-year follow-up; 

 < .001). In addition, RT was well tolerated: acute grade 3 toxicity was similar in both arms (about 4%), and late grade 3 toxicity was < 1% in the RT arm. RTOG 9804 echoes the ECOG study in that the recurrence risk was approximately 1% per year in low-risk patients who omitted RT, with neither study clearly demonstrating factors predictive of invasive recurrences. Notably, these studies did not require routine use of anti-estrogen therapy; rates of treatment with anti-estrogen agents ranged from 0% in the Dana-Farber trial, to 30% in the ECOG study, to 62% in both arms of RTOG 9804. The benefit of adjuvant RT would likely have been less substantial if all women had, indeed, received anti-estrogen therapy; however, even in the closely monitored setting of an active clinical trial, high compliance rates are difficult to achieve, as demonstrated by the 70% compliance rate seen in NSABP B-35, a trial specifically evaluating endocrine therapy.[17]

While local recurrence is certainly clinically and psychologically taxing, some argue that since no randomized trial has shown an OS benefit with adjuvant RT, post-lumpectomy RT is not needed for many patients with DCIS. Instead, the concept would be that clinicians should initiate close surveillance as part of follow-up care, and salvage therapy when indicated. However, the failure to demonstrate improved survival with RT does not mean that it does not exist; it may be that because the breast cancer–specific mortality associated with DCIS is low (approximately 3% at 10 years), the sample size needed to detect a statistically significant improvement in OS is prohibitively large. This is where population-based data become helpful, not only because large databases can provide information about national practices, but also because they include enough patients to enable clinicians to evaluate treatment approaches of potential significance with respect to a disease site for which outcomes are generally very favorable. An analysis of Surveillance, Epidemiology, and End Results data by Sagara et al[18] provides some insight into the treatment and outcomes associated with DCIS across the United States. The authors evaluated more than 30,000 patients, detecting a low breast cancer mortality rate of 2%, but an improvement was noted with the addition of RT (1.8% with RT vs 2.1% without RT). Despite this improvement, approximately 40% of patients with DCIS never received RT. Notably, RT improved survival in patients with three important risk factors: high nuclear grade tumors, younger age (< 60 years), and larger tumor size; these are findings that individual randomized controlled trials have not been able to demonstrate. Additionally, the study specifically evaluated the utility of the patient prognostic score initially developed by Smith et al in 2006,[19] which incorporates grade, age, size, and comedo histology. Sagara’s study showed that patients with prognostic scores of 4 or 5 (with 5 being the highest score) had a nearly 70% reduction in breast cancer mortality with the use of RT, with an absolute difference of 4% in those with scores of 5 (

 = .03).[18] This result is comparable to findings from the Early Breast Cancer Trialists’ Collaborative Group meta-analysis of invasive cancers, which is often quoted as evidence of a mortality benefit from use of RT with BCS in early-stage invasive breast cancer.[20]

Given the changing landscape of DCIS treatment paradigms, the use of prognostic indices may help to delineate which patients will most likely benefit from RT. The aforementioned Smith prognostic score is an effective tool for making this assessment; another scoring method, the Van Nuys Prognostic Index, has been neither widely used nor consistently externally validated.[21] Analysis of tumor genetics represents a novel strategy to risk-stratify DCIS patients into low- , intermediate- , and high-risk groups.[21] A study evaluating a subset of patients from the aforementioned ECOG trial found that rates of invasive recurrence were 4%, 12%, and 19% for low- , intermediate- , and high-risk patients, respectively.[22] More recently, this genetic assay was validated in a larger patient cohort, and again showed that the Oncotype DX DCIS Score was predictive of local recurrence; however, concerns remain regarding the high rate of recurrences in the low-risk group (13% at 10 years; 5% invasive) and the cost effectiveness of such an approach.[23,24] There are limited data to support the use of currently available prognostic tools or tumor genetics to define which patients require adjuvant RT. However, in some cases these tools may help to individualize the shared decision that patients and clinicians ultimately make regarding the use of RT.

One common concern regarding adjuvant RT for DCIS is the duration of treatment. However, randomized data in the invasive setting have demonstrated equivalent clinical outcomes and toxicity with hypofractionated whole-breast irradiation (delivered over a period of 3 weeks) vs standard radiation (of 5 weeks’ duration).[25,26] Data on the use of hypofractionation for DCIS are derived from single-institution studies as well as regional analyses from Canada.[27,28] Additionally, the use of accelerated partial-breast irradiation allows completion of adjuvant RT in ≤ 1 week, without compromising local control, and is a standard-of-care option in appropriately selected women with DCIS.[29] In selected patients, hypofractionation and accelerated partial-breast irradiation are attractive options, since they reduce the treatment duration by ≥ 50% (increasing patients’ ability to receive and complete adjuvant RT) and are associated with favorable oncologic and cosmetic outcomes. At this time, guidelines from the American College of Radiology[30] and the National Comprehensive Cancer Network[31] support routine use of adjuvant RT in all patients with DCIS, since no subgroup who can safely forgo RT has been clearly identified-with the caveat that older patients and/or those with significant comorbidities may be considered for lumpectomy alone. In the context of these guidelines, several factors provide a good foundation for treatment decision making: patient age; comorbidities; and the potential for locoregional recurrence, based on factors such as tumor grade, margins, and receptor status. It is also important to bear in mind that patients with grade 3 disease or positive margins are at particularly high risk of recurrence. Current studies, including those evaluating nonoperative management (COMET, ClinicalTrials.gov identifier: NCT02926911) and RT technique (BONBIS, ClinicalTrials.gov identifier: NCT00907868; and Trans-Tasman Radiation Oncology Group [TROG] 07.01, ClinicalTrials.gov identifier: NCT00470236), will further refine the DCIS treatment paradigm.

In conclusion, although data continue to emerge regarding the management of DCIS, at this time RT following BCS remains the standard of care for most patients. RT has consistently been shown to decrease not only local recurrences but also invasive recurrences, which are associated with an increase in breast cancer mortality. Current tools, including prognostic scores and tumor genetics, have failed to identify a cohort for whom RT confers no benefit with respect to invasive recurrences. A diagnosis of DCIS warrants frank discussion between a physician and his or her patient, to enable shared decision making based on what absolute recurrence risk is deemed tolerable in light of patient preferences and comorbidities.

The authors have no significant financial interest in or other relationship with the manufacturer of any product or provider of any service mentioned in this article.

 Virnig BA, Tuttle TM, Shamliyan T, Kane RL. Ductal carcinoma in situ of the breast: a systematic review of incidence, treatment, and outcomes. J Natl Cancer Inst. 2010;102:170-8.

 Ward EM, DeSantis CE, Lin CC, et al. Cancer statistics: breast cancer in situ. CA Cancer J Clin. 2015;65:481-95.

 Collins LC, Tamimi RM, Baer HJ, et al. Outcome of patients with ductal carcinoma in situ untreated after diagnostic biopsy: results from the Nurses Health Study. Cancer. 2005;103:1778-84.

 Sanders ME, Schuyler PA, Dupont WD, Page DL. The natural history of low-grade ductal carcinoma in situ of the breast in women treated by biopsy only revealed over 30 years of long-term follow-up. Cancer. 2005;103:2481-4.

 Narod SA, Iqbal J, Giannakeas V, et al. Breast cancer mortality after a diagnosis of ductal carcinoma in situ. JAMA Oncol. 2015;1:888-96.

 Eusebi V, Feudale E, Foschini MP, et al. Long-term follow-up of in situ carcinoma of the breast. Semin Diagn Pathol. 1994;11:223-35.

 Wapnir IL, Dignam JJ, Fisher B, et al. Long-term outcomes of invasive ipsilateral breast tumor recurrences after lumpectomy in NSABP B-17 and B-24 randomized clinical trials for DCIS. J Natl Cancer Inst. 2011;103:478-88.

 Fisher B, Costantino J, Redmond C, et al. Lumpectomy compared with lumpectomy and radiation therapy for the treatment of intraductal breast cancer. N Engl J Med. 1993;328:1581-6.

 Holmberg L, Garmo H, Granstrand B, et al. Absolute risk reductions for local recurrence after postoperative radiotherapy after sector resection for ductal carcinoma in situ of the breast. J Clin Oncol. 2008;26:1247-52.

 Julien JP, Bijker N, Fentiman IS, et al. Radiotherapy in breast-conserving treatment for ductal carcinoma in situ: first results of the EORTC randomised phase III trial 10853. EORTC Breast Cancer Cooperative Group and EORTC Radiotherapy Group. Lancet. 2000;355:528-33.

 Houghton J, George WD, Cuzick J, et al. Radiotherapy and tamoxifen in women with completely excised ductal carcinoma in situ of the breast in the UK, Australia, and New Zealand: randomised controlled trial. Lancet. 2003;362:95-102.

 Fisher B, Dignam J, Wolmark N, et al. Tamoxifen in treatment of intraductal breast cancer: National Surgical Adjuvant Breast and Bowel Project B-24 randomised controlled trial. Lancet. 1999;353:1993-2000.

 Early Breast Cancer Trialists’ Collaborative Group, Correa C, McGale P, et al. Overview of the randomized trials of radiotherapy in ductal carcinoma in situ of the breast. J Natl Cancer Inst Monogr. 2010;2010:162-77.

 Solin LJ, Gray R, Hughes LL, et al. Surgical excision without radiation for ductal carcinoma in situ of the breast: 12-year results from the ECOG-ACRIN E5194 study. J Clin Oncol. 2015;33:3938-44.

 Wong JS, Chen YH, Gadd MA, et al. Eight-year update of a prospective study of wide excision alone for small low- or intermediate-grade ductal carcinoma in situ (DCIS). Breast Cancer Res Treat. 2014;143:343-50.

 McCormick B, Winter K, Hudis C, et al. RTOG 9804: a prospective randomized trial for good-risk ductal carcinoma in situ comparing radiotherapy with observation. J Clin Oncol. 2015;33:709-15.

 Margolese RG, Cecchini RS, Julian TB, et al. Anastrozole versus tamoxifen in postmenopausal women with ductal carcinoma in situ undergoing lumpectomy plus radiotherapy (NSABP B-35): a randomised, double-blind, phase 3 clinical trial. Lancet. 2016;387:849-56.

 Sagara Y, Freedman RA, Vaz-Luis I, et al. Patient prognostic score and associations with survival improvement offered by radiotherapy after breast-conserving surgery for ductal carcinoma in situ: a population-based longitudinal cohort study. J Clin Oncol. 2016;34:1190-6.

 Smith GL, Smith BD, Haffty BG. Rationalization and regionalization of treatment for ductal carcinoma in situ of the breast. Int J Radiat Oncol Biol Phys. 2006;65:1397-1403.

 Early Breast Cancer Trialists’ Collaborative Group, Darby S, McGale P, et al. Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10,801 women in 17 randomised trials. Lancet. 2011;378:1707-16.

 Silverstein MJ, Poller DN, Waisman JR, et al. Prognostic classification of breast ductal carcinoma-in-situ. Lancet. 1995;345:1154-7.

 Solin LJ, Gray R, Baehner FL, et al. A multigene expression assay to predict local recurrence risk for ductal carcinoma in situ of the breast. J Natl Cancer Inst. 2013;105:701-10.

 Rakovitch E, Nofech-Mozes S, Hanna W, et al. A population-based validation study of the DCIS Score predicting recurrence risk in individuals treated by breast-conserving surgery alone. Breast Cancer Res Treat. 2015;152:389-98.

 Raldow AC, Sher D, Chen AB, et al. Cost effectiveness of the Oncotype DX DCIS Score for guiding treatment of patients with ductal carcinoma in situ. J Clin Oncol. 2016;34:3963-8.

 Haviland JS, Owen JR, Dewar JA, et al. The UK Standardisation of Breast Radiotherapy (START) trials of radiotherapy hypofractionation for treatment of early breast cancer: 10-year follow-up results of two randomised controlled trials. Lancet Oncol. 2013;14:1086-94.

 Whelan TJ, Pignol JP, Levine MN, et al. Long-term results of hypofractionated radiation therapy for breast cancer. N Engl J Med. 2010;362:513-20.

 Ciervide R, Dhage S, Guth A, et al. Five year outcome of 145 patients with ductal carcinoma in situ (DCIS) after accelerated breast radiotherapy. Int J Radiat Oncol Biol Phys. 2012;83:e159-e164.

 Lalani N, Paszat L, Sutradhar R, et al. Long-term outcomes of hypofractionation versus conventional radiation therapy after breast-conserving surgery for ductal carcinoma in situ of the breast. Int J Radiat Oncol Biol Phys. 2014;90:1017-24.

 Shah C, Vicini F, Wazer DE, et al. The American Brachytherapy Society consensus statement for accelerated partial breast irradiation. Brachytherapy. 2013;12:267-77.

 Kaufman SA, Harris EE, Bailey L, et al. ACR Appropriateness Criteria® ductal carcinoma in situ. Oncology (Williston Park). 2015;29:446-58, 460-1.

 National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology. Breast cancer. Version 2.2017. Updated April 6, 2017. 

https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf

Articles

At this time RT following BCS remains the standard of care for most patients. Current tools, including prognostic scores and tumor genetics, have failed to identify a cohort for whom RT confers no benefit with respect to invasive recurrences.

POINT: Should Radiation Therapy After Surgery for Ductal Carcinoma In Situ Be Standard Practice?

RT Should Not Be Standard Practice After Surgery for DCIS

Widespread use of screening mammography in the Western world has led to a flood of diagnoses of ductal carcinoma in situ (DCIS), yet many of these cases involve only small clusters of microcalcifications that the expertise of radiologists and the sophistication of their imaging units bring to light.[1] Surgical excision of DCIS, to ensure that a detected lesion does not harbor invasive carcinoma, is standard practice. Given the diversity in presenting manifestations of DCIS, in terms of the extent and grade of lesions and the wide age range of affected patients, is a blanket recommendation to treat patients with adjuvant radiation therapy (RT) wise in this setting? Guidelines from the National Comprehensive Cancer Network have been revised to offer more nuanced advice on the management of DCIS, recommending that adjuvant breast RT be considered (or not) based on the recurrence risk of the individual patient.[2]

If there were universal benefit to breast RT, without any detriment, a universal recommendation would make good sense. However, the ultimate benefit-improved survival-does not exist. Any survival benefit is offset by harms to survival; therefore, no net survival benefit is realized. Four randomized trials of postoperative RT vs no RT were analyzed by the Early Breast Cancer Trialists’ Collaborative Group. Although RT provided a clear reduction in the risk of any subsequent in-breast event (approximately 28% vs 13% without RT at 10 years; 2

 < .00001), no survival advantage to RT was seen.[3] Indeed, some would object to the disadvantages to RT that emerged from this study; these included increased risks of lung, esophageal, and contralateral breast cancer; cardiovascular risks; and the rare risk of breast sarcoma.[4]

A universal recommendation aimed at reducing in-breast events from 28% to 13% in patients with DCIS would require delivering breast RT to 100 women to benefit 15. All 100 of those women would be at increased risk of cosmetic detriment, as evidenced by post-RT appearance rated “Fair to Poor” in 31% of patients in the Royal Marsden trial in 2005[5] and in 29% of those in the Canadian Trial in 2010.[6] Standard-fractionation whole-breast irradiation was associated with breast shrinkage at 10 years in 34% of patients in the START A trial and in 31% in the START B trial.[7] It is hoped that partial-breast irradiation will improve on these results, but since breast aesthetics are rated on the basis of contour and symmetry, it is not surprising that one randomized trial has already found cosmesis worse when compared with whole-breast irradiation. Techniques in breast irradiation are improving, and reduction of some of the current harms may be hoped for in future reports, but at least a decade of observation will be required to evaluate the impact of modified techniques of breast irradiation over the long term in DCIS.

A final caveat regarding an across-the-board recommendation for breast RT in DCIS concerns the women who experience a recurrence of any kind in the years following treatment. They will be likely to undergo mastectomy based on their prior RT rather than another excision and the possibility of additional irradiation.

All of these considerations argue for careful presentations of the options of therapy, including breast irradiation and/or hormonal therapy, in light of the specific patient risk factors, such as the extent of the DCIS lesion, the age of the patient, and the patient’s own preferences. Prognostic models have been sought, beginning with the Van Nuys Prognostic Index[8] and including the Memorial Sloan Kettering Cancer Center nomogram.[9] Although helpful, these have not been confirmed in multicenter studies of large populations, as illustrated by the challenge reported by Yi and colleagues in utilizing the Sloan Kettering nomogram for prediction of ipsilateral breast tumor recurrence in DCIS patients at MD Anderson Cancer Center.[10]

More recently, genomic analysis evolved into an important tool in the management of invasive breast cancer. In addition, there has been progress in efforts to define risk in DCIS using multigene assays; indeed, Dr. Clifford Hudis wrote a recent editorial in the 

 called, “Biology Before Anatomy in Early Breast Cancer-Precisely the Point.”[11] The Oncotype DX DCIS Score was applied to tissue obtained in the Eastern Cooperative Oncology Group (ECOG) E5194 trial of DCIS treated with excision alone (or with surgery plus tamoxifen in 30% of the study cohort). This assay placed 70% of the patients into a low-risk group, in which only 3.7% developing invasive breast cancer in 10 years.[12] The Oncotype DX DCIS Score was further validated in 3,320 women from Ontario.[13] These lesions included larger areas of DCIS than in the ECOG trial and smaller margin requirements for excision (1 mm vs 3 mm in the ECOG trial). The low-risk group comprised 62% of the study population; these patients had only an 8% risk of progressing to invasive breast cancer and only a 12.7% risk of developing any in-breast lesion. This important information about biologic risk can be integrated with risk factors such as patient age, size of the lesion, and tumor multifocality to provide a more granular picture of the risk that DCIS poses to an individual patient.

Clearly, to universally recommend breast irradiation for all women after excision of DCIS lesions ignores information now available to us that can spare the majority of women with DCIS the downsides of RT, but be applied in the treatment of DCIS patients at greater risk for invasive disease.

The author has no significant financial interest in or other relationship with the manufacturer of any product or provider of any service mentioned in this article.

 Sumner WE 3rd, Koniaris LG, Snell SE, et al. Results of 23,810 cases of ductal carcinoma-in-situ. Ann Surg Oncol. 2007;14:1638-43.

 Early Breast Cancer Trialists’ Collaborative Group, Correa C, McGale P, et al. Overview of the randomized trials of radiotherapy in ductal carcinoma of the breast. J Natl Cancer Inst Monogr. 2010;2010:162-77.

 Taylor C, Correa C, Duane FK, et al; Early Breast Cancer Trialists’ Collaborative Group. Estimating the risk of breast cancer radiotherapy: evidence from modern radiation doses to the lungs and heart and from previous randomized trials. J Clin Oncol. 2017 Mar 20. [Epub ahead of print]

 Yarnold J, Ashton A, Bliss J, et al. Fractionation sensitivity and dose response of late adverse effects in the breast after radiotherapy for early breast cancer: long-term results of a randomised trial. Radiother Oncol. 2005;75:9-17.

 Eblan MJ, VanderWalde NA, Zeman EM, Jones E. Hypofractionation for breast cancer: lessons learned from our neighbors to the north and across the pond. Oncology (Williston Park). 2014;28:536-46.

 Silverstein MJ, Poller DN, Waisman JR, et al. Prognostic classification of breast ductal-carcinoma-in-situ. Lancet. 1995;345:1154-7.

 Rudloff U, Jacks LM, Goldberg JI, et al. Nomogram for predicting the risk of local recurrence after breast-conserving surgery for ductal carcinoma in situ. J Clin Oncol. 2010;28:3762-9.

 Yi M, Meric-Bernstam F, Kuerer HM, et al. Evaluation of a breast cancer nomogram for predicting the risk of ipsilateral breast tumor recurrences in patients with ductal carcinoma in situ after local excision. J Clin Oncol. 2012;30:600-7.

 Hudis CA. Biology before anatomy in early breast cancer-precisely the point. N Engl J Med. 2015;373:2079-80.

 Solin LJ, Gray R, Baehner FL, et al. A multigene expression assay to predict local recurrence risk for ductal carcinoma in situ of the breast.
J Natl Cancer Inst. 2013;105:701-10.

To universally recommend breast irradiation for all women after excision of DCIS lesions ignores information now available to us that can spare the majority of women with DCIS the downsides of RT, but be applied in the treatment of DCIS patients at greater risk for invasive disease.

COUNTERPOINT: Should Radiation Therapy After Surgery for Ductal Carcinoma In Situ Be Standard Practice?

How big a problem is burnout among oncologists?

 Oncologist burnout is a significant issue that directly impacts patient care and the success of the organizations-such as community practices and hospitals-where oncologists work. Burnout has been identified as an occupation-related syndrome that manifests as a result of the interaction between the oncologist and the organization. It is estimated that, for over a decade, approximately 45% to 80% of practicing oncologists in the United States, Europe, and Australia have experienced core symptoms associated with burnout. Some of the variability depends on medical oncology specialty, practice, healthcare systems, and screening tools utilized; however, burnout is clearly on the rise. Our ever-evolving healthcare system, and specifically that of the oncologic specialty, is a primary contributor to this increased incidence of burnout. It is due in part to the imbalance in practice priorities and increased individual and organizational expectations in providing quality care to many seriously ill patients and their families, while being forced to devote long hours to administrative demands and documentation in the electronic medical record system. As a result, clinician wellness is adversely impacted, and feelings of emotional exhaustion and cynicism arise. Unaddressed burnout adversely impacts oncologists’ relationships with their patients, the quality of care delivered, and the long-term health of the clinician. However, sadly, for many physicians, experiencing burnout has become a stigma. In general, society has ignored physician wellness, with the belief that physicians should simply “tough it out” alone and overcome challenges. Working harder is not the antidote. Oncologists are driven by a passion, a mission to serve seriously ill patients and their family members; yet, in the face of this dedication and current demands, they tend to forget about themselves, and do not provide self-compassion and self-care.

 When do signs of burnout typically first appear? What are those signs?

Burnout is a complex, insidious process gradually developing over an extended period of time. The signs of burnout vary. Although not well understood, for some oncologists, burnout may arise as early as during medical school and training.

Psychiatric disorders such as depression and posttraumatic stress disorders may be both precursors to the development of burnout, as well as consequences of burnout. Research has identified that residents and medical students have high rates of burnout and disproportionate rates of depression and suicide. Some of this arises from the medical training that physicians must undergo. The initial stage of burnout begins innocently, with a drive and compulsion to prove oneself to others. Yet, over time this motivation becomes eroded. After years of training as a student, intern, resident, and fellow in medical, surgical, or radiation oncology, by the time one finally assumes responsibilities as an independent clinician, one’s emotional health has already been adversely altered. The early, subtle stages of burnout then develop into the more prominent, long-lasting symptoms of physical and emotional exhaustion, cynicism and depersonalization, and low sense of professional accomplishment/feelings of ineffectiveness. These signs of burnout exist along a continuum characterized by a progression of distinctly unique symptoms, as well as an overlap of symptoms. It is a chronic process, and nearly every oncologist will experience burnout during his or her career.

Multiple individual and organizational risk factors have been consistently identified as contributors to burnout in medicine. Individual contributors are internal dispositional risk factors, including sociodemographics (younger age; single or unmarried marital status; and medical trainee status). Female gender has been associated with emotional exhaustion, while male gender presents with cynicism. Positive personality characteristics such as extraversion and conscientiousness, which are important to the role of the physician, have also been recognized as risk factors. Recent evidence has demonstrated new internal contributors to burnout. Physicians who experience unaddressed burnout are less likely to identify medicine as a calling or mission of one’s life work.

However, these individual risk factors are not the sole contributors to burnout in medicine. We know that external, organizational, and/or occupational risk factors have intensified the incidence of burnout. Empirical evidence reveals that changes in healthcare delivery and the healthcare system have only contributed to the problem. Occupational stressors are those work-related factors that are at odds with the clinician’s interpretation of the job. For example, recent data suggest that for every 1-hour patient visit, a physician is tasked with 2 hours of electronic medical record responsibilities. This results in less time devoted to direct patient care. Today, more than ever, oncologists are exposed to heightened responsibilities resulting in extended work hours, decreased time in direct patient care, loss of daily control, increased administrative tasks and use of electronic health record systems, limited decision making regarding patient care, vague job expectations, poor social support, and educational debt.

Identification of all of these internal and external factors is crucial in developing both individual, and primarily organizational, oncologist wellness interventions tailored to prevent and target unaddressed burnout and to foster resilience.

Can clinician burnout affect patient care?

Long-term unaddressed burnout has a powerful adverse impact not only on patient care, but also on the overall oncologist-patient relationship, the quality of care delivered, and the physical and emotional health of the oncologist. Oncologists are benevolent, dedicated caregivers who tackle life-and-death decisions on a daily, if not hourly, basis with patients who are terminally ill or have serious and complex conditions, and with their family members. An oncologist experiencing burnout may believe he is effectively and appropriately addressing patients’ needs, but given the impossibility of balancing good quality care and meeting organizational demands, he falls short of meeting all demands, becoming inefficient. The oncologist trying to do more winds up accomplishing less. Consequently, the oncologist-patient relationship becomes damaged. As a result of the slow, insidious process of emotional erosion the oncologist experiences, patients may experience difficulty in effectively communicating with their oncologists, becoming less satisfied with their care.

What can be done to prevent or overcome burnout?

 Sadly, a quick overnight solution does not exist. Burnout may be prevented, and unaddressed burnout may be resolved over time. However, it is a process and a journey. Together with support from the organization, we may simultaneously optimize oncologist wellness and enhance the cancer patient care experience. Several strategies exist: individual (eg, sleep/physical activity, mindfulness, peer support, stress management), organizational (eg, work environment change, reduction in work hours), and institutional interventions (eg, physician wellness programs) have been found to be effective. First, we must assess and identify burnout.

We must first learn to recognize the signs of burnout in oncologists. Empowering oncologists at both the individual and organizational levels with tailored strategies is key to ensuring clinician wellness. Resilience is the key protective factor against burnout; it shapes the individual’s ability to rise from adversity, re-energize, re-engage, and reassume personal responsibilities. Psychological resilience should not involve focusing on the traumatic experience of being an oncologist. Resilience places emphasis on the individual’s strength, as well as the ability to meet adversity in work and life and positively adapt to it. Resilience entails learning how to thrive and overcome the adversity oncologists face every day.

Nonetheless, this all will not happen overnight. Mastering resilience takes time and effort. Practice makes perfect. Learning to become resilient is not innate; one is not simply born with this skill, but one can learn to cultivate it over time. Individual attitudes and behavior must change. It is important for the oncologist to set boundaries, go home early when possible to recharge, and ask for help from a colleague if a break is needed during the day.

However, the individual oncologist cannot accomplish this alone. This can only be facilitated through institutional leadership identifying core areas of need. Institutional support must change and physician wellness must become key. Burnout lectures, communication skills training, and formal effective resiliency training programs must be implemented in order to mitigate the effects of stress and prevent burnout. We must foster enthusiasm, self-compassion, and efficacy.

The whole of medicine must consider adopting and developing institutional interventions, similar to those of the military or technology companies that foster wellness and resilience, enabling individuals to thrive despite present hardships. Various medical institutions, such as Stanford University and the Mayo Clinic, have multidisciplinary physician wellness programs (“WellMD” and “Physician Well-Being,” respectively) designed to improve overall physician wellness and enhance professional fulfillment by providing assistance to physicians and their families.

In this interview we discuss the issue of burnout in oncology, including signs and risk factors, how it might affect patient care, and strategies for prevention.

Oncology Vol 31 No 8

POINT: Should Radiation Therapy After Surgery for Ductal Carcinoma In Situ Be Standard Practice?

COUNTERPOINT: Should Radiation Therapy After Surgery for Ductal Carcinoma In Situ Be Standard Practice?

Fay Hlubocky on Recognizing and Addressing Clinician Burnout