A new study published in Radiotherapy and Oncology has identified substantial discrepancies between patient-reported symptoms and clinician-assessed toxicity following radiotherapy for prostate cancer, raising important questions about how treatment-related adverse effects are evaluated in clinical practice.
The study, titled “Patient-clinician symptom agreement before and after radiotherapy for prostate cancer: results from the randomized HYPO-RT-PC study,” was published in November 2026 and conducted by Ulrika Rönningås, Lars Beckman, Anna-Karin Wennstig, and Per Fransson.
Drawing on data from 1,180 men enrolled in the randomized HYPO-RT-PC trial, the researchers examined agreement between patients and clinicians in reporting urinary, bowel, and sexual symptoms before, during, and up to four years after radiotherapy.
The findings revealed consistently low agreement across several symptom domains. Clinicians frequently underestimated urinary and bowel symptoms, while problems related to sexual activity were more commonly rated as severe by clinicians than by patients.
The results highlight the importance of incorporating patient-reported outcome measures (PROMs) into routine oncology care to better understand the full impact of treatment-related toxicity.
When Patients and Clinicians See Different Symptoms
Radiotherapy remains a standard treatment option for patients with localized prostate cancer. Although advances in treatment delivery have improved precision, urinary, gastrointestinal, and sexual adverse effects remain important considerations during treatment and long-term follow-up.
Accurate assessment of these symptoms is essential for timely supportive care, treatment decisions, and the preservation of quality of life.
However, clinician assessments and patient experiences do not always align.
Previous research has documented differences between physician-rated toxicity and patient-reported symptoms, but evidence examining these discrepancies over extended follow-up periods has been limited.
The HYPO-RT-PC sub-study sought to address this gap by comparing patient and clinician assessments at five time points: baseline, the end of radiotherapy, and one, two, and four years after treatment.
Rather than comparing the effectiveness of radiotherapy schedules, the analysis focused specifically on how consistently patients and clinicians evaluated treatment-related symptoms.
Inside the HYPO-RT-PC Trial: Comparing Two Radiotherapy Schedules
The analysis included 1,180 patients with prostate cancer enrolled between 2005 and 2015 in the randomized HYPO-RT-PC trial.
Participants were allocated to one of two radiotherapy regimens:
- Conventional fractionation (CF): 2.0 Gy delivered in 39 fractions, involving 591 patients.
- Ultra-hypofractionation (UHF): 6.1 Gy delivered in seven fractions, involving 589 patients.
Patient-reported symptoms were collected using the Prostate Cancer Symptom Scale (PCSS), a 56-item questionnaire covering urinary, bowel, sexual, lifestyle, and treatment-related concerns.
For this analysis, researchers selected four predefined items addressing overall urinary symptoms, overall bowel symptoms, erectile function sufficient for intercourse, and sexual activity.
Clinicians assessed toxicity using the Radiation Therapy Oncology Group (RTOG) toxicity scale, applying acute toxicity criteria at baseline and at the end of radiotherapy and late toxicity criteria during subsequent follow-up.
Between 580 and 910 paired patient-clinician assessments were available across the five evaluation points.
Agreement was classified as perfect when ratings were identical, moderate when they differed by one point, and poor when they differed by two or more points.
Urinary Symptoms: The Largest Gap in Assessment
One of the most notable findings concerned urinary symptoms, for which patient-clinician agreement remained below 50% throughout the follow-up period.
At baseline, nearly half of patients reported having no urinary symptoms, compared with approximately 80% of clinician assessments.
This discrepancy persisted throughout treatment and follow-up, with patients consistently reporting greater urinary symptom severity.
The greatest disagreement occurred at the end of radiotherapy.
At this point, perfect agreement was observed in only 35.2% of assessments, while moderate agreement accounted for 46.1% and poor agreement for 18.8%.
Clinicians underestimated urinary symptoms in 52% of assessments at the end of treatment, the highest proportion recorded across the study’s evaluation points.
By comparison, perfect agreement at baseline was 49.8%, with poor agreement occurring in 10.5% of assessments.
Although agreement improved somewhat during follow-up, it remained limited. At four years, perfect agreement reached 48.4%, while 12.5% of assessments continued to demonstrate poor agreement.
These findings indicate that discrepancies in urinary symptom evaluation were not restricted to the acute treatment period but remained evident years after radiotherapy.
Bowel Toxicity: Disagreement Peaks at the End of Treatment
Bowel symptoms followed a similar pattern, although agreement was generally higher than for urinary symptoms.
At baseline, perfect agreement between patients and clinicians reached 76.2%, representing the highest level observed for bowel symptoms throughout the study.
However, agreement declined substantially by the end of radiotherapy.
At treatment completion, perfect agreement fell to 42.9%, while poor agreement increased to 18.5%.
Clinicians underestimated bowel symptom severity in 46% of assessments at this time point.
During subsequent follow-up, perfect agreement improved to 55.5% at one year, 57.4% at two years, and 56.7% at four years.
Nevertheless, differences between patient and clinician assessments persisted.
The researchers noted that agreement was lowest at the end of radiotherapy, when treatment-related symptoms are expected to be most prevalent.
Unlike some earlier studies in which clinicians tended to overestimate bowel symptoms after treatment, the HYPO-RT-PC analysis found that clinicians more commonly underestimated them.
Sexual Health: A Different Pattern of Disagreement
The study identified a contrasting pattern in the assessment of sexual symptoms.
While clinicians generally underestimated urinary and bowel toxicity, they tended to report greater severity of problems related to sexual activity than patients themselves.
For erectile dysfunction, the direction of disagreement changed over time.
Clinicians tended to overestimate erectile dysfunction at baseline and at the end of radiotherapy but underestimated it at two and four years after treatment.
Perfect agreement for erectile dysfunction was 66.1% at baseline and 66.5% at the end of radiotherapy. This declined to 56.4% at one year, 50.0% at two years, and 44.1% at four years.
Correlations between patient and clinician ratings for erectile dysfunction were generally low to moderate, with no significant correlation at the two-year follow-up.
In contrast, assessments of problems related to sexual activity demonstrated consistently stronger correlations, exceeding 0.70 at every time point.
Despite these stronger correlations, clinicians continued to rate problems related to sexual activity as more severe than patients did.
The findings illustrate the complexity of evaluating sexual health after prostate cancer treatment, particularly when assessments depend on information communicated during clinical consultations.
The researchers emphasized the importance of structured sexual health assessment and open communication to ensure that concerns affecting patients’ quality of life are appropriately recognized.
Does Radiotherapy Fractionation Influence Symptom Agreement?
The researchers also investigated whether the type of radiotherapy schedule influenced agreement between patients and clinicians.
Using generalized estimating equations for repeated measures, they compared patterns of agreement between the conventional and ultra-hypofractionated treatment groups.
Overall, there was little evidence that radiotherapy fractionation significantly influenced agreement.
For urinary symptoms, no significant differences in agreement were identified over time or by treatment type.
Similarly, no significant differences between treatment groups were observed for erectile dysfunction or sexual activity at any assessment point.
The principal exception involved bowel symptoms, for which significant differences in agreement between conventional and ultra-hypofractionated radiotherapy were observed at the end of treatment and at one-year follow-up.
The researchers noted that patients receiving ultra-hypofractionated radiotherapy had previously reported worse urinary and bowel symptoms at these time points, which may have influenced reporting patterns.
However, the reasons for the observed differences were not specifically investigated.
Beyond Toxicity Grades: Why Patient-Reported Outcomes Matter
The findings raise broader questions about the limitations of relying exclusively on clinician-rated toxicity scales.
Clinical toxicity assessments provide standardized information about adverse events, but they may not fully capture how symptoms are experienced by individual patients.
Patient-reported outcome measures offer a complementary perspective by documenting symptoms directly from patients, including their perceived severity and impact on daily life.
The researchers acknowledged that differences in assessment tools may partly explain the observed disagreement.
The PCSS and RTOG scales were developed for different purposes and are not directly equivalent. Their wording, structure, and levels of detail may influence how symptoms are recorded and interpreted.
Consequently, discrepancies should not necessarily be attributed solely to communication difficulties between patients and clinicians.
The study also discussed the potential value of combining clinician-rated Common Terminology Criteria for Adverse Events (CTCAE) with the patient-reported version, PRO-CTCAE, to improve symptom assessment.
However, previous research indicates that underreporting by clinicians can persist even when these approaches are used together.
These findings reinforce the need for systematic integration of patient-reported outcomes into oncology care rather than relying on a single assessment method.
From Questionnaires to Clinical Conversations
Collecting patient-reported information is an important first step, but the researchers emphasized that collection alone may not be sufficient.
Structured review and discussion of patient-reported outcomes during consultations could help identify discrepancies, improve communication, and support earlier recognition of treatment-related symptoms.
Potential strategies include digital symptom-reporting platforms, automated alerts when symptom thresholds are exceeded, and routine review of patient-reported concerns during follow-up appointments.
Such approaches may help clinicians recognize symptoms that would otherwise remain underestimated and facilitate timely supportive interventions.
The findings are consistent with the European Society for Medical Oncology (ESMO) Clinical Practice Guideline supporting the routine use of patient-reported outcome measures throughout cancer care.
The researchers also highlighted the importance of establishing agreement early in treatment, noting that previous research has associated greater initial patient-clinician agreement with improved subsequent agreement and clinical outcomes.
Future studies will be needed to determine whether interventions designed to strengthen communication and symptom monitoring translate into improved long-term outcomes and quality of life.
Interpreting the Findings: Strengths and Limitations
The study’s principal strengths include its large patient population, prospective randomized trial setting, standardized follow-up procedures, and repeated paired assessments extending to four years after radiotherapy.
These features provided an opportunity to examine both acute and long-term patterns of agreement between patient-reported symptoms and clinician-rated toxicity.
Nevertheless, several limitations should be considered.
The participants received treatment between 2005 and 2015, during which radiotherapy techniques differed from many contemporary approaches.
Advances such as image-guided radiotherapy, fiducial markers, and rectal spacers may reduce treatment-related toxicity and influence the symptom burden experienced by patients today.
In addition, clinicians used the RTOG toxicity scale, which has largely been superseded by CTCAE-based assessment approaches in contemporary practice.
The analysis was also restricted to urinary, bowel, and sexual symptoms. Other relevant outcomes, including fatigue and overall quality of life, were not evaluated.
Finally, because the study was conducted within a randomized clinical trial with standardized assessment procedures, its findings may not fully reflect symptom reporting in routine clinical settings.
Closing the Gap Between Clinical Assessment and Patient Experience
The HYPO-RT-PC sub-study provides further evidence that clinician-rated toxicity does not always reflect the severity of symptoms experienced by patients undergoing radiotherapy for prostate cancer.
Across multiple assessment points, clinicians consistently underestimated urinary and bowel symptoms, while the evaluation of sexual health revealed more complex patterns of disagreement.
Importantly, these discrepancies persisted beyond treatment completion and remained evident during long-term follow-up.
The findings emphasize that accurate toxicity monitoring requires both clinical evaluation and direct patient input.
Integrating validated patient-reported outcome measures into routine radiotherapy practice, alongside structured communication and appropriate clinical interpretation, may help improve symptom recognition and support more responsive, patient-centered care.
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