The cosmetic outcome in early breast cancer treated with sector resection with or without radiotherapy. Uppsala-Orebro Breast Cancer Study Group

Autologous fat transplantation prior to permanent expander implant breast reconstruction enhances the outcome after two years: a randomized controlled trial

Radiotherapy is important in breast cancer treatment. A side effect of the treatment is fibrosis that decreases the possibility for a successful breast reconstruction with expanders and with high patient satisfaction with the result. The most common option for mastectomized, irradiated women wishing for a breast reconstruction is autologous tissue transplantation. However, some patients are not suitable for flap surgery. Fifty mastectomized and irradiated women were included in a randomized controlled trial. They underwent breast reconstruction with expanders and were allocated 1:1 to either receive pre-treatment with autologous fat transplantation (AFT) or not. Primary outcomes were frequency of reoperations and complications. Secondary outcomes were number of days in hospital, number of outpatient visits to surgeon or nurse and patient reported outcome as reported with Breast Q. Follow-up time was 2 years. Fifty-two per cent of the intervention group and 68% of the controls underwent reoperations (p = 0.611). Thirty-two per cent of the intervention group and 52% of the controls had complications (p = 0.347). The median number of consultations with the nurse was four in the intervention group and six in the control group (p = 0.002). The AFT patients were significantly more satisfied with their breasts and psychosocial well-being after 2 years. They also had higher increase in satisfaction with breasts, psychosocial well-being, and sexual well-being when comparing baseline with 2 years postoperatively. This randomized controlled trial indicates benefits of AFT prior to breast reconstruction with expanders, especially on patient reported outcome even if the study sample is small.

'Breast Cosmesis After Breast-Conserving Therapy' Who is the Judge, Patient or Surgeon?

INTRODUCTION

More than 80% of newly diagnosed breast cancers are managed with breast-conserving therapy (BCT). Preservation of cosmetically acceptable breasts is an inherent aim of all breast-conserving efforts-this can, however, be difficult to assess objectively. Compounding this is the difference in perception of breast cosmesis between patients and surgeons. This study compares the concordance of a new subscale-based cosmetic score (TCS) with the patient's perception.

METHOD

Eastern Health Breast and Cancer Centre conducted this study on patients who had completed their BCT and radiotherapy. Participation was voluntary and involved permitting an assessor (breast surgery fellow or consultant) to grade cosmetic outcomes to generate a Total Cosmesis Score (TCS). The patients blinded to this assessment were then asked to complete the postoperative segment of the BCT module of the Breast-Q questionnaire. TCS from surgeon assessment was compared against patient assessment (questions BQ1i and BQ1k specifically). Cohen's kappa was calculated to define the strength of the inter-rater agreement.

RESULTS

One hundred twelve patients with a mean age of 59 (range 27-89) participated in the study. TCS was low in 26% and high in 74% of participants. 76% and 69% of participants were satisfied when answering Breast-Q questions 'How your lumpectomy breast looks?' and 'How you look in the mirror unclothed?' respectively (Cohen's k = 0.464, 95% CI 0.337-0.591, p < 0.01). The agreement between the TCS and the patient assessment was poor (Cohen's k = 0.172, 95% CI - 0.020-2.093, p = 0.067).

CONCLUSION

Cosmetic outcomes scored using TCS by surgeons do not match patient's own assessment of the cosmetic result.

Breast cancer patient-reported outcome of factors influencing cosmetic satisfaction after breast-conserving therapy

Background

The aim of this study was to investigate which factors patients considered to be important for determining the degree of cosmetic satisfaction with regards to perceived body image after previous breast-conserving therapy (BCT).

Methods

Outcomes considered relevant by the patients were first identified using interviews. A questionnaire based on this group input was then devised and added to the physician-based Sneeuw questionnaire. Next, a quantitative study using this questionnaire was conducted in Dutch patients treated at least 6 months earlier for (non-) invasive breast cancer by BCT. Exclusion criteria were: previous mastectomy or BCT of the contralateral breast, BCT with nipple resection, metastatic disease, local recurrence or (previous) plastic breast surgery. Descriptive statistics were used throughout.

Results

A total of 149 patients (aged 36–87 years) completed the questionnaire. From this focus group input, the top three factors in overall importance (important or very important) for satisfaction were: ‘wearability of bra’ (67%), ‘breast sensitivity’ (59%) and ‘asymmetry’ (51%). Younger patients (< 55 years) considered ‘breast size’ to be most important, whereas ‘wearability of bra’ was most frequently reported by older patients (> 55 years). Time since BCT did not significantly influence the rating of relevant factors.

Conclusion

Patients consider ‘wearability of bra’, ‘breast sensitivity’ and ‘asymmetry’ as the most important factors when assessing their satisfaction with regards to cosmetic outcome and body image. These factors should be addressed in routine clinical practice during (pre) counseling.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12282-021-01287-0.

Ten-year follow up of cosmetic outcome, overall survival, and disease-free survival in endoscope-assisted partial mastectomy with filling of dead space using absorbable mesh for stage ≤ IIA breast cancer: comparison with conventional conservative method

BACKGROUND

Data on long-term cosmetic outcome, overall survival, and disease-free survival of endoscope-assisted partial mastectomy (EAPM) for breast cancer are scarce. Thus, we examined these outcomes after a 10-year follow-up period, and compared with conventional conservative method (CCM).

PATIENTS AND METHODS

Data on 257 patients with stage ≤ IIA breast cancer who underwent CCM (n = 125) or EAPM (n = 132) were analyzed. Cosmetic outcome at 2, 5, and 10 years was evaluated by 5 criteria (breast retraction assessment, nipple deviation, atrophy, skin change, scar). For overall mortality, breast cancer-specific mortality, and recurrence, the risk by operation method was tested by Cox proportional hazard models.

RESULTS

EAPM performed significantly better than CCM in terms of cosmetic outcomes for location B at 2, 5, and 10 year-follow ups. As for cosmetic outcomes by individual criteria, EAPM had significantly higher proportions of satisfactory results for scar across all follow-up periods, and atrophy at 2-year and 10-year follow-up. There were no significant differences in terms of overall mortality, breast cancer-specific mortality, and recurrence between EAPM and CCM. The rates of patients who experienced local recurrence were similar between CCM and EAPM.

CONCLUSION

EAPM is better than CCM in terms of long-term cosmetic outcome, especially for location B. As a surgical treatment for breast cancer, EAPM is comparable to CCM in terms of mortality and recurrence.

Cosmetic assessment in brachytherapy (interventional radiotherapy) for breast cancer: A multidisciplinary review

PURPOSE

This review was to focus on breast brachytherapy cosmetic assessment methods state of the art and to define the advantages and disadvantages related to.

METHODS AND MATERIALS

We conducted a literature review of the major experience on breast brachytherapy cosmetic assessment methods in several databases (PubMed, Scopus, and Google Scholar databases). To identify the relevant works, a task force screened citations at title and abstract level to identify potentially relevant paper. An expert board reviewed and approved the text. The assessment systems were classified into three main groups: (1) the Oncological Toxicity Scales, (2) the Independent Patients Perspective Measures, (3) the Patient-Related Outcome Measures. Each cosmetic assessment method was evaluated following six parameters: (1) anatomical site, (2) advantages, (3) disadvantages, (4) subjective/objective, (5) quantitative/qualitative, (6) computers or pictures needs.

RESULTS

Eleven assessment methods were selected. Three methods were classified as Oncological Toxicity Scale, six in the Independent Patients Perspective Measures classification, and two as Patient-Related Outcome Measures. Six methods are subjective, while eight are objective. Four systems are classified as quantitative, four as qualitative while three both. Five systems need informatics support. Moreover, each method was discussed individually reporting the main characteristics and peculiarities.

CONCLUSIONS

Cosmesis is one major end point for the patient who has a malignancy of low lethal potential. In modern personalized medicine, there is a need for standardized cosmetic outcome assessments to analyze and compare the results of treatments. No gold standard methods currently exist. The result of this review is to summarize the various cosmesis methods, defining the strengths and weaknesses of each one and giving a line in research and clinical practice.

Re-excision rate after sector resection for breast cancer: A 5-year retrospective cohort study

BACKGROUND

Positive margins after Breast conserving surgery (BCS) for breast cancer can result in local recurrence (LR) requiring further surgery. This can lead to unnecessary patient anxiety, poor prognosis and impose additional economic burden to our health system. The aim of this study is to assess the rate of re-excision for positive margins after BCS using the sector resection technique.

METHODS

This single centre retrospective cohort study included all women who underwent BCS using sector resection between the years of 2012 and 2016. A total of 456 patients underwent sector resection. We evaluated the margin status, re-excision rates and their predictive risk factors.

RESULTS

415 (91%) patients had clear margins. 41 (9%) patients underwent further re-excision for positive or close margin. 75.6% of those patients had DCIS and 51% had invasive carcinoma involving the margins. Patient and tumour characteristics associated with an increased risk of positive margin were women under the age of 50 (p = 0.19), tumours >50 mm (p = 0.001), grade-2 (p = 0.48) and grade-3 (p = 0.63), HER-2 positivity (p = 0.02), sentinel lymph node positivity (p = 0.03), and patients undergoing axillary lymph node dissection (p = 0.01).

CONCLUSION

BCS using the sector resection technique has a low re-excision rate for positive margins. Younger patients and aggressive tumour biology are important predictive risk factors for positive margins.

Role of radiotherapy in women over the age of 65 after breast conserving surgery for breast cancer: A 5-year retrospective study

BACKGROUND/OBJECTIVE

This study aimed to analyse the local recurrence (LR) and breast cancer related mortality (BCRM) in older women who underwent breast-conserving surgery (BCS) with and without adjuvant radiotherapy (XRT).

METHODS

This retrospective study included a total of 299 women who underwent BCS for early breast carcinoma, between the years of 2007 and 2011. Predictive risk factors, local recurrence (LR) and breast cancer related mortality (BCRM) were assessed with a mean follow-up period of 84 months.

RESULTS

Women over the age of 65 in the XRT and No-XRT groups showed similar incidence of LR (5.8% vs 5%, p = 0.838). Women over 65 years old with XRT had a higher rate of BCRM (5.8% vs 0%, p = 0.05). Resection margins >5 mm had a lower rate of BCRM (HR 0.395, p = 0.05). Women under the age of 65, invasive ductal carcinoma, grade-3 tumours, HER-2 positive, triple negative, lympho-vascular invasion, axillary lymph node positivity, high breast density on mammography were associated with increased risk of LR and BCRM.

CONCLUSIONS

XRT in women over the age of 65 did not decrease the risk of LR. Adjuvant XRT in older women should be offered to selective patients with high risk patient and tumour factors.

Fraction size in radiation therapy for breast conservation in early breast cancer

BACKGROUND

Shortening the duration of radiation therapy would benefit women with early breast cancer treated with breast conserving surgery. It may also improve access to radiation therapy by improving efficiency in radiation oncology departments globally. This can only happen if the shorter treatment is as effective and safe as conventional radiation therapy. This is an update of a Cochrane Review first published in 2008 and updated in 2009.

OBJECTIVES

To assess the effect of altered radiation fraction size for women with early breast cancer who have had breast conserving surgery.

SEARCH METHODS

We searched the Cochrane Breast Cancer Specialised Register (23 May 2015), CENTRAL (The Cochrane Library 2015, Issue 4), MEDLINE (Jan 1996 to May 2015), EMBASE (Jan 1980 to May 2015), the WHO International Clinical Trials Registry Platform (ICTRP) search portal (June 2010 to May 2015) and ClinicalTrials.gov (16 April 2015), reference lists of articles and relevant conference proceedings. No language or publication constraints were applied.

SELECTION CRITERIA

Randomised controlled trials of altered fraction size versus conventional fractionation for radiation therapy in women with early breast cancer who had undergone breast conserving surgery.

DATA COLLECTION AND ANALYSIS

Two authors performed data extraction independently, with disagreements resolved by discussion. We sought missing data from trial authors.

MAIN RESULTS

We studied 8228 women in nine studies. Eight out of nine studies were at low or unclear risk of bias. Altered fraction size (delivering radiation therapy in larger amounts each day but over fewer days than with conventional fractionation) did not have a clinically meaningful effect on: local recurrence-free survival (Hazard Ratio (HR) 0.94, 95% CI 0.77 to 1.15, 7095 women, four studies, high-quality evidence), cosmetic outcome (Risk ratio (RR) 0.90, 95% CI 0.81 to 1.01, 2103 women, four studies, high-quality evidence) or overall survival (HR 0.91, 95% CI 0.80 to 1.03, 5685 women, three studies, high-quality evidence). Acute radiation skin toxicity (RR 0.32, 95% CI 0.22 to 0.45, 357 women, two studies) was reduced with altered fraction size. Late radiation subcutaneous toxicity did not differ with altered fraction size (RR 0.93, 95% CI 0.83 to 1.05, 5130 women, four studies, high-quality evidence). Breast cancer-specific survival (HR 0.91, 95% CI 0.78 to 1.06, 5685 women, three studies, high quality evidence) and relapse-free survival (HR 0.93, 95% CI 0.82 to 1.05, 5685 women, three studies, moderate-quality evidence) did not differ with altered fraction size. We found no data for mastectomy rate. Altered fraction size was associated with less patient-reported (P < 0.001) and physician-reported (P = 0.009) fatigue at six months (287 women, one study). We found no difference in the issue of altered fractionation for patient-reported outcomes of: physical well-being (P = 0.46), functional well-being (P = 0.38), emotional well-being (P = 0.58), social well-being (P = 0.32), breast cancer concerns (P = 0.94; 287 women, one study). We found no data with respect to costs.

AUTHORS' CONCLUSIONS

We found that using altered fraction size regimens (greater than 2 Gy per fraction) does not have a clinically meaningful effect on local recurrence, is associated with decreased acute toxicity and does not seem to affect breast appearance, late toxicity or patient-reported quality-of-life measures for selected women treated with breast conserving therapy. These are mostly women with node negative tumours smaller than 3 cm and negative pathological margins.

In Search of a Gold Standard Scoring System for the Subjective Evaluation of Cosmetic Outcomes Following Breast-Conserving Therapy

The absence of a widely accepted method for aesthetic evaluation following breast-conserving surgery for breast cancer limits the ability to evaluate cosmetic outcomes. In this study, two different panel scoring approaches were compared in an attempt to identify a gold standard scoring system for subjectively assessing cosmetic outcomes following breast-conserving therapy. Standardized photographs of each participant were evaluated independently by twelve health care professionals involved in breast cancer diagnosis and treatment using the Danoff four-point scale. Individual Danoff scores were combined using two methods, a random sample "three-panel" score and an iterative "Delphi-panel" score, in order to create a final cosmetic score for each patient. Agreement between these two aggregative approaches was assessed with a weighted kappa (wk) statistic. Patient and professional recruitment occurred at two separate tertiary care multi-disciplinary breast health centers. Women with unilateral breast cancer who underwent breast-conserving therapy (segmental mastectomy or lumpectomy and radiotherapy) and were at least 2 years after radiotherapy were asked to participate. Ninety-seven women were evaluated. The Delphi approach required three rounds of evaluation to obtain greater than 50% agreement in all photographs. The wk statistic between scores generated from the "three-panel" and "Delphi-panel" approaches was 0.80 (95% CI: 0.71-0.89), thus demonstrating substantial agreement. Evaluation of cosmetic outcomes following breast-conserving therapy using a "three-panel" and "Delphi-panel" score provide similar results, confirming the reliability of either approach for subjective evaluation. Simplicity of use and interpretation favors the "three-panel" score. Future work should concentrate on the integration of the three-panel score with objective and patient-reported scales to generate a comprehensive cosmetic evaluation platform.

The impact of the sentinel node concept on the aesthetic outcome of breast cancer conservative surgery

BACKGROUND

The sentinel node (SN) concept has brought numerous advantages to women with breast cancer. Sparing axillary node anatomy and physiology may enhance the cosmetic results of breast cancer conservative surgery, either owing to less breast edema or to a better tolerance to the effects of surgery and radiotherapy. Our aim was to compare the cosmetic outcome of two randomized groups of patients, on a subjective and objective basis.

METHODS

A consecutive series of breast cancer patients (n = 60) submitted to partial mastectomy plus axillary dissection or partial mastectomy plus SN biopsy (included in a randomized trial) was photographed. Photos were analysed in three ways: by seven different observers according to seven features from poor to excellent; two observers estimated the percentage of breast retraction assessment (pBRA); or by the BCCT.core 1.0(®) software.

RESULTS

The panel subjective analysis showed a benefit in terms of the skin colour for the patients submitted to SN biopsy only. This group of patients did not show any advantage in terms of pBRA estimates even after the complex BCCT.core appraisal.

CONCLUSIONS

The sentinel node concept is not associated with improvements in the aesthetic outcome of breast cancer conservative treatment.

Comparative study of surgical margins and cosmetic outcome in lumpectomy versus segmental resection in breast cancer

OBJECTIVE

The aim of the present retrospective study was to compare two breast-conserving techniques, segmental resection and standard lumpectomy, for the treatment of breast cancer regarding their oncological safety. Quality of life aspects were evaluated by assessing the respective postsurgical cosmetic results.

PATIENTS AND METHODS

190 women with breast cancer located in the superior and lateral quadrant were included in the study. Sixty patients were treated with segmental resection (group 1), whereas 130 underwent standard lumpectomy (group 2). Tumor sizes were determined and excised tissue specimens were analyzed for positive or negative resection margins. Patients were given a 16-item questionnaire for the postsurgical self-assessment of the cosmetic outcome.

RESULTS

No statistically significant difference was found concerning the number of positive resection margins between the groups (25 vs. 30%, p = 0.46). Exceptions were ventral margins, which predominated in group 2 (p = 0.016). Group 1 revealed a significantly larger maximum tumor size with negative margins as compared to group 2 (26.6 vs. 17.0 mm). General satisfaction with the cosmetic results was comparable between groups.

CONCLUSIONS

Segmental resection surgery, as a method of breast conservation therapy, can be used to treat larger breast lesions as compared to standard lumpectomy.

Fraction size in radiation treatment for breast conservation in early breast cancer

BACKGROUND

Shortening the duration of radiation therapy would benefit women with early breast cancer treated with breast conserving surgery. It may also improve access to radiation therapy by improving efficiency in radiation oncology departments globally. This can only happen if the shorter treatment is as effective and safe as conventional radiation therapy. This is an updated version of the original Cochrane Review published in Issue 3, 2008.

OBJECTIVES

To determine the effect of altered radiation fraction size on outcomes for women with early breast cancer who have undergone breast conserving surgery.

SEARCH STRATEGY

We searched the Cochrane Breast Cancer Group Specialised Register, MEDLINE, EMBASE and the WHO ICTRP search portal to June 2009, reference lists of articles and relevant conference proceedings. We applied no language constraints.

SELECTION CRITERIA

Randomised controlled trials of unconventional versus conventional fractionation in women with early breast cancer who had undergone breast conserving surgery.

DATA COLLECTION AND ANALYSIS

The authors performed data extraction independently, with disagreements resolved by discussion. We sought missing data from trial authors.

MAIN RESULTS

Four trials reported on 7095 women. The women were highly selected: tumours were node negative and 89.8% were smaller than 3 cm. Where the breast size was known, 87% had small or medium breasts. The studies were of low to medium quality. Unconventional fractionation (delivering radiation therapy in larger amounts each day but over fewer days than with conventional fractionation) did not affect: (1) local recurrence risk ratio (RR) 0.97 (95% CI 0.76 to 1.22, P = 0.78), (2) breast appearance RR 1.17 (95% CI 0.98 to 1.39, P = 0.09), (3) survival at five years RR 0.89 (95% CI 0.77 to 1.04, P = 0.16). Acute skin toxicity was decreased with unconventional fractionation: RR 0.21 (95% CI 0.07 to 0.64, P = 0.007).

AUTHORS' CONCLUSIONS

Two new studies have been published since the last version of the review, altering our conclusions. We have evidence from four low to medium quality randomised trials that using unconventional fractionation regimens (greater than 2 Gy per fraction) does not affect local recurrence, is associated with decreased acute toxicity and does not seem to affect breast appearance or late toxicity for selected women treated with breast conserving therapy. These are mostly women with node negative tumours smaller than 3 cm and negative pathological margins. Long-term follow up (> 5 years) is available for a small proportion of the patients randomised. Longer follow up is required for a more complete assessment of the effect of altered fractionation.

Breast pseudotumoral radionecrosis as a late radiation-induced injury: a case report

Introduction

New therapies and treatment protocols have led to improved survival rates in many cancers. The improved rates are such that patients are now living long enough to experience some negative long-term side effects of the initial therapy.

Case presentation

We report the case of a 65-year-old Caucasian woman who presented with a rare case of pseudotumoral radionecrosis, a late radiation-induced injury, after combined surgical and cobalt radiation therapy for the treatment of adenocarcinoma of the right breast. The patient underwent resection of this benign, yet progressively growing and painful tumor. A cosmetically satisfying result was achieved by reconstruction of the thoracic wall with a polypropylene mesh and a latissimus dorsi muscle flap.

Conclusion

With improved overall survival, new management strategies for late side effects of therapy are becoming of crucial importance for affected patients. In the future, improving toxicity-free survival will be as important as achieving disease-free survival or local tumor control.

Fraction size in radiation treatment for breast conservation in early breast cancer

BACKGROUND

Shortening the duration of radiation therapy would benefit women with early breast cancer treated with breast conservation. It may also improve access to radiation therapy by improving efficiency in radiation oncology departments globally. This can only happen if the shorter treatment is as effective and safe as conventional radiation therapy.

OBJECTIVES

To assess the effects of altered fraction size on women with early breast cancer who have undergone breast conserving surgery.

SEARCH STRATEGY

We searched the Cochrane Breast Cancer Group Specialised Register (June 2006), MEDLINE (November 2006), EMBASE (November 2006), reference lists for articles, and relevant conference proceedings. No language constraints were applied.

SELECTION CRITERIA

Randomised controlled trials of unconventional versus conventional fractionation in women with early breast cancer who had undergone breast conserving surgery.

DATA COLLECTION AND ANALYSIS

Data extraction was performed independently by the authors with disagreements resolved by discussion. Missing data was sought by contacting the authors concerned.

MAIN RESULTS

Two trials were included and reported on 2644 women. The women were highly selected with node negative tumours smaller than 5 cm and negative pathological margins; 46% of the women had a cup separation size of less than 25 cm. The studies were of high quality. Data for local recurrence and breast appearance were not available in a form which could be combined. Unconventional fractionation (delivering radiation therapy in larger amounts each day but over fewer days than with conventional fractionation) did not appear to affect: (1) local-recurrence free survival (absolute difference 0.4%, 95% CI -1.5% to 2.4%), (2) breast appearance (risk ratio (RR) 1.01, 95% CI 0.88 to 1.17; P = 0.86), (3) survival at five years (RR 0.97, 95% CI 0.78 to 1.19; P = 0.75), (4) late skin toxicity at five years (RR 0.99, 95% CI 0.44 to 2.22; P = 0.98, or (5) late radiation toxicity in sub-cutaneous tissue (RR 1.0, 95% CI 0.78 to 1.28; P = 0.99).

AUTHORS' CONCLUSIONS

We have evidence from two high quality randomised trials that the use of unconventional fractionation regimes (greater than 2 Gy per fraction) does not affect breast appearance or toxicity and does not seem to affect local recurrence for selected women treated with breast conserving therapy. These are women with node negative tumours smaller than 5 cm and negative pathological margins. Two new trials have been published in March 2008. Their results are consistent with our findings. The results of these trials will be incorporated in the next update of this review.

Feasibility of accelerated partial breast irradiation using three-dimensional conformal radiation therapy for Japanese women: a theoretical plan using six patients' CT data

BACKGROUND

Several methods have been reported for accelerated partial breast irradiation (APBI), but in Japan, there are few facilities where brachytherapy or intra-operative radiotherapy is available. Japanese women have smaller physiques than American women in general. Thus, we developed external beam plans for APBI using computed tomography (CT) data of Japanese patients, to investigate whether APBI using three-dimensional conformal radiation therapy is safely applicable for Japanese women, while verifying the dose distributions.

METHODS

We used CT data from six Japanese patients with early breast cancer, which were obtained in routine clinical practice during whole breast irradiation (WBI) after wide excision, and made 32 APBI plans according to the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-39 and the Radiation Therapy Oncology Group (RTOG) 0413 protocol, which compared APBI with WBI. We then investigated the compliance to the dose constraints of the protocol.

RESULTS

None of 16 plans for the medial regions met the dose constraints regardless of laterality of the breast. The major reason was overdosage to the contralateral breast. Thirteen of 16 plans (81%) for the lateral regions met the dose constraints. The remaining three plans (19%) did not meet the dose limitation of the uninvolved normal breast, suggesting that a large ratio of the target to the breast was problematic.

CONCLUSIONS

In Japanese women, patients with a laterally located small tumor can be candidates for APBI using three-dimensional conformal radiation therapy.

Factors Determining Esthetic Outcome after Breast Cancer Conservative Treatment

The aim of this study was to evaluate the factors that determine esthetic outcome after breast cancer conservative treatment, based on a consensual classification obtained with an international consensus panel. Photographs were taken from 120 women submitted to conservative unilateral breast cancer surgery (with or without axillary surgery) and radiotherapy. The images were sent to a panel of observers from 13 different countries and consensus on the classification of esthetic result (recorded as excellent, good, fair or poor) was obtained in 113 cases by means of a Delphi method. For each patient, data were collected retrospectively regarding patient characteristics, tumor, and treatment factors. Univariate and multivariate analysis were used to evaluate the correlation between these factors and overall cosmetic results. On univariate analysis, younger and thinner patients as well as patients with lower body mass index (BMI) and premenopausal status obtained better cosmetic results. In the group of tumor- and treatment-related factors, larger removed specimens, clearly visible scars, the use of chemotherapy and longer follow-up period were associated with less satisfactory results. On multivariate analysis, only BMI and scar visibility maintained a significant association with cosmesis. BMI and scar visibility are the only factors significantly associated with cosmetic results of breast cancer conservative treatment, as evaluated by an international consensus panel.

Cosmetic outcomes following breast conservation therapy: in search of a reliable scale

INTRODUCTION

Multiple scales to evaluate breast cosmesis following breast conserving treatment (BCT) have been developed, however reliability is a problem. Panel scores, where scores from two or more individuals are combined, were assessed to examine their effect on reliability for two different cosmetic scales.

METHODS

Women, two or more years following BCT, were recruited from a single breast centre. Photographs of each participant were evaluated independently by six health care professionals on two separate occasions. A simple four-point scale and more involved multi-item scale were used to assess cosmetic outcome. Reliability was assessed with the weighted kappa statistic for increasing panel sizes.

RESULTS

Ninety-nine women were evaluated. Intra rater reliability increased from 0.73 to 0.83 for the four-point scale, for increasing panel sizes, however 95% confidence intervals generally overlapped. A smaller and more unpredictable effect was seen on the multi-item subscale, range 0.69 to 0.73. Inter rater reliability increased from 0.68 to 0.93 for the four-point scale, and 0.75 to 0.96 for the multi-item scale, for increasing panel sizes; 95% confidence intervals did not overlap. A panel of three for either scale provided almost perfect kappa values with only small improvements with larger panel sizes.

CONCLUSIONS

Care should be used in interpreting results where cosmetic outcomes have been obtained from a single evaluator. Panel scores can be used to significantly improve inter-rater, but not intra rater reliability, for the scales studied. Comparable reliability, in combination with simplicity of use and interpretation, would favour the four-point scale for breast cosmetic evaluation over the multi-item scale.

Interobserver agreement and consensus over the esthetic evaluation of conservative treatment for breast cancer

Twenty-four experts from 13 different countries were asked to evaluate photographs taken of 60 women following conservative breast cancer treatment. The esthetic result of each case was classified as poor, fair, good or excellent. Agreement was evaluated using the kappa (k) and weighted kappa (wk) statistics, for all observers, male and female participants, those younger and older than 50 years, those seeing more than 250 cases a year, and those with previous publications in this area. Consensus was obtained by way of a modified Delphi approach, when more than 50% of participants provided the same classification. In a second round, consensual cases were disclosed and a revised opinion was asked in non-consensual ones. Agreement between all participants was fair (k=0.24, wk=0.37) and remained within the same range (k=0.20-0.31, wk=0.31-0.45) in the subgroups analyzed. First round consensus was obtained in 46 out of 60 cases (77%) and in the second round in 59 out of 60 cases (98%). Evaluation of the esthetic results of conservative treatment for breast cancer is only fairly reproducible when performed by experts working in different geographical areas. Consensus is obtainable if a relatively low threshold of agreement is considered acceptable.

A cosmetic evaluation of breast cancer treatment: A randomized study of radiotherapy boost technique

PURPOSE

To compare cosmetic results of two different radiotherapy (RT) boost techniques used in the treatment of breast cancer after whole breast radiotherapy and to identify factors affecting cosmetic outcomes.

METHODS AND MATERIALS

Between 1996 and 1998, 142 patients with Stage I and II breast cancer were treated with breast conservative surgery and adjuvant RT. Patients were then randomly assigned to receive a boost dose of 15 Gy delivered to the tumor bed either by iridium 192, or a combination of photons and electrons. Cosmetic evaluations were done on a 6-month basis, with a final evaluation at 36 months after RT. The evaluations were done using a panel of global and specific subjective scores, a digitized scoring system using the breast retraction assessment (BRA) measurement, and a patient's self-assessment evaluation. As cosmetic results were graded according to severity, the comparison of boost techniques was done using the ordinal logistic regression model. Adjusted odds ratios (OR) and their 95% confidence intervals (CI) are presented.

RESULTS

At 36 months of follow-up, there was no significant difference between the two groups with respect to the global subjective cosmetic outcome (OR = 1.40; 95%CI = 0.69-2.85, p = 0.35). Good to excellent scores were observed in 65% of implant patients and 62% of photon/electron patients. At 24 months and beyond, telangiectasia was more severe in the implant group with an OR of 9.64 (95%CI = 4.05-22.92, p < 0.0001) at 36 months. The only variable associated with a worse global cosmetic outcome was the presence of concomitant chemotherapy (OR = 3.87; 95%CI = 1.74-8.62). The BRA value once adjusted for age, concomitant chemotherapy, and boost volume showed a positive association with the boost technique. The BRA value was significantly greater in the implant group (p = 0.03). There was no difference in the patient's final self-assessment score between the two groups. Three variables were statistically associated with an adverse self-evaluation: an inferior quadrant tumor localization, postoperative hematoma, and concomitant chemotherapy.

CONCLUSIONS

Although this trial showed that at 36 months of follow-up, there were no significant differences in the overall global cosmetic scores between the implant boost group and the photon/electron boost group, telangiectasia was more severe and the BRA value was greater in the implant group.

Choosing observers for evaluation of aesthetic results in breast cancer conservative treatment

PURPOSE

The subjective evaluation of aesthetic results in conservative breast cancer treatment has largely been used without questioning the observer's skills. The aim of this study was to evaluate interobserver agreement of the aesthetic results of breast cancer conservative treatment in three groups of observers with different levels of experience.

METHODS AND MATERIALS

Photographs were taken of 55 women who had undergone conservative unilateral breast cancer treatment and 5 control women with no breast disease. The images were then distributed to 13 observers who were divided into three groups according to their experience in breast cancer treatment: experienced, medium experienced, and inexperienced. They were first asked to distinguish the patients from the controls and for the patients to identify the operated side. Subsequently, they were asked to classify the aesthetic result as excellent, good, fair, or poor. The accuracy in identifying controls, patients, and side of treatment was calculated individually for all observers. The interobserver agreement for the aesthetic result was calculated using observed agreement and multiple kappa statistic (kappa) in each of the three groups.

RESULTS

Inexperienced observers performed significantly worse than experienced observers in identifying controls, patients, and the side of treatment. Agreement of the aesthetic result was significantly greater in the group of experienced observers (kappa = 0.59) than in the medium experienced (kappa = 0.35) and inexperienced (kappa = 0.33) observers.

CONCLUSION

Previous experience in breast cancer conservative treatment should be considered a prerequisite for the evaluation of the aesthetic results.

Breast-Conserving Therapy in Patients with a Relatively Large (T2 or T3) Breast Cancer: Long-Term Local Control and Cosmetic Outcome of a Feasibility Study

Breast-conserving therapy is widely accepted as an appropriate method of primary treatment of T1 and T2 breast cancers that measure up to 5 cm. For safe and cosmetically acceptable breast-conserving therapy in patients with larger breast cancers, the tumor volume has to be reduced preoperatively, and lost tissue volume should be replaced after wide local excision. In 1993, the authors' group reported encouraging short-term results of a combination of preoperative radiotherapy, breast-conserving surgery, and immediate tissue replacement by myocutaneous (myosubcutaneous) latissimus dorsi flap transplantation in patients with relatively large T2 and T3 breast cancers. To evaluate the long-term oncologic local control and cosmetic outcome of this treatment modality, the authors studied the results obtained in 20 patients after a minimum follow-up of 5 years. The local control rate was 0.95, as locoregional recurrence was observed in one patient who refused adjuvant chemotherapy. Both the observed 5-year survival (0.75) and the actuarial 10-year survival (0.60) in the authors' series equaled that of more radical surgical therapy. The cosmetic outcome compared with that obtained by conventional breast-conserving therapy modalities for small breast cancers. In general, patient assessment of cosmetic outcome (2.8 of 3) was higher than the assessment of a professional panel (6.3 of 10). Of six criteria providing a detailed description of the cosmesis of the reconstructed breast and donor area, the symmetry and shape of the reconstructed breast were felt to be most important by the patients and professionals alike. The authors conclude that breast-conserving therapy combining preoperative irradiation and immediate myocutaneous (myosubcutaneous) latissimus dorsi flap reconstruction is an oncologically safe and cosmetically rewarding but logistically straining modality of treatment of relatively large T2 and T3 breast cancers.

Adjuvant Radiation Therapy After Breast-Conserving Surgery in Elderly Women with Early-Stage Breast Cancer: Controversy or Consensus?

Breast-conservation therapy (BCT), which consists of breast-conserving surgery (BCS) and postoperative radiation therapy (RT), provides similar levels of local control and survival compared with mastectomy. Although the incidence of breast cancer increases with age and the proportion of elderly women in the population continues to increase, clinical trials of BCT have included few women aged > or = 65 years, limiting the ability to establish clear consensus regarding optimal therapy in this population. This article examines the literature on BCT in elderly women with early-stage breast cancer. A systematic search of the Medline and CancerLit databases was conducted to identify articles specifically addressing BCT in elderly women. The outcomes evaluated were local control, disease-free survival, overall survival, and treatment-related toxicities. The lack of consensus in breast-conservation management in elderly patients is highlighted by a paucity of prospective data and numerous retrospective series reporting diverse treatment approaches with conflicting results. The available evidence from BCT trials with and without age subgroup analyses support BCS with postoperative RT as the standard approach associated with the most favorable local control outcomes. A low-risk subset of patients in whom RT may be omitted without compromising local control remains to be defined. Despite these findings, the use of standard therapy significantly decreases with advancing patient age. Although data specifically addressing BCT in elderly patients are limited, age should not preclude consideration of standard treatment strategies to optimize local disease control. Modern clinical trials with representative samples of elderly patients evaluating cancer recurrence and survival as well as functional and quality-of-life outcomes are needed to define optimal breast-conservation management for this important patient population.

Long-term radiation sequelae after breast-conserving therapy in women with early-stage breast cancer: an observational study using the LENT-SOMA scoring system

PURPOSE

To evaluate the long-term toxicity after breast-conserving therapy in women with early-stage breast cancer.

METHODS AND MATERIALS

Late toxicity according to the late effects of normal tissue-subjective, objective, management, and analytic (LENT-SOMA) criteria and cosmetic outcome (graded by physicians) were evaluated in 590 of 2943 women with early-stage breast cancer who were irradiated between 1983 and 1995 using the following fractionation schedules: group A, 1983-1987, 2.5 Gy 4x/wk to 60 Gy; group B, 1988-1993, 2.5 Gy 4x/wk to 55 Gy, group C, 1994-1995, 2.0 Gy 5x/wk to 55 Gy.

RESULTS

LENT-SOMA Grade 3-4 toxicity was observed as follows: group A (median follow-up 171 months; range 154-222 months), fibrosis 16% (7 of 45), telangiectasia 18% (8 of 45), and atrophy 4% (2 of 45); group B (median follow-up 113 months; range 78-164 months), pain 2% (8 of 345), fibrosis 10% (34 of 345), telangiectasia 10% (33 of 345), arm edema 1% (2 of 345), and atrophy 8% (27 of 345); and group C (median follow-up 75 months, range 51-96 months, n = 200), occurrence of Grade 3-4 late morbidity <or=2%. The cosmetic outcome was very good to acceptable in 78% (35 of 45) of patients in group A, 83% (286 of 345) in group B, and 94% (187 of 200) in group C.

CONCLUSION

In our population, the long-term side effects after breast-conserving therapy were not rare, but were mainly asymptomatic. The LENT-SOMA breast module is a practical tool to assess radiation-induced long-term toxicity.

Is postoperative radiotherapy after breast conserving surgery always mandatory? A review of randomised controlled trials

BACKGROUND AND AIMS

Breast-conserving surgery followed by radiotherapy, in order to prevent local recurrence, has been the treatment of choice ever since breast conserving surgery was introduced in clinical practice. Patient selection, type of surgery, dose and type of radiotherapy, however, may have an impact on the risk of local recurrence. The aim of this review is to synthesise the results from randomised trials and try and define a subgroup of patients in whom postoperative radiotherapy could be omitted.

METHOD

A literature search of Pub Med and The Cochrane randomised trials registry identified six trials comparing patients randomised to surgery alone or surgery plus radiotherapy, two trials comparing different radiotherapy modalities and one trial comparing different types of surgery.

RESULTS

Addition of postoperative radiotherapy reduce the risk of local recurrence by 2/3. The dose-intensity of radiotherapy and surgery has a positive impact on local control. Patients at low risk of local recurrence are patients > 55 years of age, with stage I tumours and favourable histology treated with adequate resection margins. No trial showed any positive effect of radiotherapy on survival.

CONCLUSION

In most patients postoperative radiotherapy is an integral part of breast-conservation. Radiotherapy can be omitted in selected low risk patients.

The influence of patient, tumor and treatment factors on the cosmetic results after breast-conserving therapy in the EORTC 'boost vs. no boost' trial. EORTC Radiotherapy and Breast Cancer Cooperative Groups

PURPOSE

To analyze the influence of different patient, tumor, and treatment parameters on the cosmetic outcome after breast-conserving therapy at 3-year follow-up. A subjective and an objective cosmetic scoring method was used and the results of both methods were compared.

PATIENTS AND METHODS

In EORTC trial 22881/10882, 5569 early-stage breast cancer patients were treated with tumorectomy and axillary dissection, followed by tangential fields irradiation of the breast to a dose of 50 Gy in 5 weeks, at 2 Gy per fraction. A total of 5318 patients, having a microscopically complete tumorectomy, were randomized between no further treatment and a boost of 16 Gy to the primary tumor bed. The cosmetic result at 3-year follow-up was assessed by a panel for 731 patients, and by digitizer measurements, measuring the displacement of the nipple, for 1141 patients. Univariate and multivariate analyses were used to evaluate the correlation between various patient, tumor, and treatment factors and cosmesis.

RESULTS

The factors associated with a worsened cosmesis according to the panel evaluation were: an inferior tumor location, a large excision volume, the presence of postoperative breast complications, and the radiotherapy boost. According to the digitizer measurements, a central/superior tumor location, a large excision volume, an increased pathological tumor size, an increased radiation dose inhomogeneity, and an increased bra cup size resulted in an increased asymmetry in nipple position. It appeared that the evaluation of the nipple position (whether by panel or by digitizer) is only moderately representative of the overall cosmetic outcome.

CONCLUSION

To achieve a good cosmesis, it is necessary to excise the tumor with a limited margin, to avoid postoperative complications, to assess the need for a boost in the individual patient, and to give the radiation dose as homogeneously as possible. As far as the method of evaluation is concerned, the panel evaluation is the most appropriate method for giving an overall impression of the cosmetic result after breast-conserving therapy (BCT). The use of the digitizer is recommended for comparing the cosmetic outcome of two different approaches to BCT or for analyzing cosmetic changes over time.

The cosmetic outcome in early breast cancer treated with breast conservation

AIMS

To measure the cosmetic outcome of breast-conserving surgery and identify the factors which influence cosmesis.

METHODS

A total of 254 patients with primary breast cancer treated by wide local excision, with or without radiotherapy, were subjectively assessed for cosmesis by a six-member panel using photographic evaluation and objectively by an independent observer using specific measurement.

RESULTS

Good to excellent cosmetic results were achieved in 184 (72%) patients on panel subjective assessment and 201 (79%) patients on objective assessment. Good correlation (P<0.001) and agreement were found between the panel's subjective photographic assessment and the objective assessment. The main factors found to affect cosmesis negatively were: medially located tumours; weight of specimen; re-excision procedures; radiotherapy; small breasts and longer scars.

CONCLUSION

These cosmetic results, combined with a low local recurrence rate following wide local excision, validate the operative method used.

Validation of the methods of cosmetic assessment after breast-conserving therapy in the EORTC "boost versus no boost" trial. EORTC Radiotherapy and Breast Cancer Cooperative Groups. European Organization for Research and Treatment of Cancer

PURPOSE

To evaluate both qualitative and quantitative scoring methods for the cosmetic result after breast-conserving therapy (BCT), and to compare the usefulness and reliability of these methods.

METHODS AND MATERIALS

In EORTC trial 22881/10882, stage I and II breast cancer patients were treated with tumorectomy and axillary dissection. A total of 5318 patients were randomized between no boost and a boost of 16 Gy following whole-breast irradiation of 50 Gy. The cosmetic result was assessed for 731 patients in two ways. A panel scored the qualitative appearance of the breast using photographs taken after surgery and 3 years later. Digitizer measurements of the displacement of the nipple were also made using these photographs in order to calculate the breast retraction assessment (BRA). The cosmetic results after 3-year follow-up were used to analyze the correlation between the panel evaluation and digitizer measurements.

RESULTS

For the panel evaluation the intraobserver agreement for the global cosmetic score as measured by the simple Kappa statistic was 0.42, considered moderate agreement. The multiple Kappa statistic for interobserver agreement for the global cosmetic score was 0.28, considered fair agreement. The specific cosmetic items scored by the panel were all significantly related to the global cosmetic score; breast size and shape influenced the global score most. For the digitizer measurements, the standard deviation from the average value of 30.0 mm was 2.3 mm (7.7%) for the intraobserver variability and 2.6 mm (8.7%) for the interobserver variability. The two methods were significantly, though moderately, correlated; some items scored by the panel were only correlated to the digitizer measurements if the tumor was not located in the inferior quadrant of the breast.

CONCLUSIONS

The intra- and interobserver variability of the digitizer evaluation of cosmesis was smaller than that of the panel evaluation. However, there are some treatment sequelae, such as disturbing scars and skin changes, that can not be evaluated by BRA measurements. Therefore, the methods of cosmetic evaluation used in a study must be chosen in a way that balances reliability and comprehensiveness.

Cosmetic assessment of breast-conserving surgery for primary breast cancer

The goals of breast-conserving treatment are to achieve local control and survival rates equivalent to mastectomy and to preserve breast cosmetic appearance. This paper specifically addresses the different ways of cosmetic assessment by the observer (subjective and objective assessments) and by the patient (self-assessment), and the factors which influence the cosmetic outcome, based on a review of the current literature.

Quality of life after breast conservation or mastectomy: a systematic review

BACKGROUND

For early breast cancer, survival after breast conservation is similar to that after mastectomy. Some women may not have a clear preference and wish to have further information about quality of life experienced after the alternative treatments. This paper describes a systematic review of randomized trials on mastectomy versus breast conservation for which there are data on quality of life or psychosocial outcomes.

METHODS

Literature was reviewed to find all randomized controlled trials comparing breast conservation to mastectomy, with quality of life or psychological effects as an outcome. Studies were then critically appraised by two reviewers independently and any disagreements about their quality and results resolved by discussion.

RESULTS

A total of six randomized trials met our inclusion criteria. In general, they are of poor quality. Women who had breast conservation had a more favourable body image of themselves than those who had mastectomy in all five studies in which it was examined. The evidence was statistically inconclusive for all the other dimensions measured, namely perceptions of psychological health, sexual health, physical health, fear of the future and global quality of life. Radiotherapy may be a determinant of poorer psychological health and body image.

CONCLUSIONS

Apart from body image, it is unclear whether breast conservation or mastectomy results in better psychosocial outcomes. Moreover, the studies were done before evidence was available to inform women about the equivalence of survival with these alternative treatments. Therefore there is inadequate information available to help many women decide about their choice of treatment in the future. Preference trials should be conducted, using standardized quality-of-life measures, in which women who are uncertain about which treatment to choose are randomized to breast conservation or mastectomy.

Cosmesis following complete local excision of breast cancer

BACKGROUND

With the establishment of the safety of breast conservation in early breast cancer, cosmesis has become an increasingly important end-point of treatment. The aim of the present study was to establish a model to assess breast cosmesis after complete local excision and to assess cosmesis achieved in patients who had surgery using the seroma technique.

METHODS

A total of 42 patients were retrospectively reviewed and assessed by independent clinical assessment by a surgeon, structured questionnaire and clinical photography.

RESULTS

A total of 86% of patients were rated by surgeon and patient as having a good or excellent cosmetic outcome. There was a high degree of concordance between independent clinical assessment and clinical photographic analysis.

CONCLUSIONS

A model has been established for the assessment of breast cosmesis; the technique of seroma formation without reconstruction of the defect results in good or excellent cosmesis in the majority of patients.

Local Control and Cosmetic Outcome after Sector Resection with or without Radiation Therapy for Early Breast Cancer

Breast conserving surgery and radiation therapy (RT) can achieve a more favorable cosmetic outcome than mastectomy in patients with early breast cancer. However, it is widely recognized that RT is an impediment to improving the cosmetic outcome. Between 1985 and 1993, 113 patients were enrolled in a prospective randomized study to examine whether or not RT could be avoided following sector resection in patients with Stage I and II (UICC) invasive breast cancer. There was no significant difference in the 8 year local recurrence free survival rate between the RT and non-RT groups (92.3% versus 89.8% respectively). The characteristics of suitable patients would be negative nodes and microscopically negative resection margins. In conclusion, sector resection without RT is a reasonable option for some patients with early breast cancer.

Method of localization and implantation of the lumpectomy site for high dose rate brachytherapy after conservative surgery for T1 and T2 breast cancer

PURPOSE

This article describes our technique of localization and implantation of the lumpectomy site of patients with T1 and T2 breast cancer. Our method was developed as part of our Phase I/II pilot study of high dose rate (HDR) brachytherapy alone after conservative surgery for early breast cancer.

METHODS AND MATERIALS

In March 1992, we started a pilot study of HDR brachytherapy to the lumpectomy site as the sole radiotherapy after conservative surgery for clinical T1 or T2 invasive breast cancer. Initially, the protocol required intraoperative placement of the interstitial needles at the time of definitive surgery to the breast. The protocol was then generalized to allow the implantation of the lumpectomy site after definitive surgery to the breast, either at the time of subsequent axillary nodal dissection or postoperatively. To date, five patients have been implanted intraoperatively at the time of definitive breast surgery. Twelve patients were implanted after definitive breast surgery, with 7 patients being done at the time of axillary nodal dissection and 5 patients postoperatively. We devised a method of accurately localizing and implanting the lumpectomy site after definitive breast surgery. The method relies on the previous placement of surgical clips by the referring surgeon to mark the lumpectomy site. For each patient, a breast mold is made with radio-opaque angiocatheters taped onto the mold in the supero-inferior direction. A planning CT scan is then obtained through the lumpectomy site. The volume of the lumpectomy site, the number of implant planes necessary, and the orientation of the implants are then determined from the CT scan. The angiocatheters provide a reference grid on the CT films to locate the entry and exit points of the interstitial needles on the plastic mold. The entry and exit points for reference needles are then transferred onto the patient's skin enabling implantation of the lumpectomy site. Needle positions with respect to the lumpectomy site are then verified using simulator radiographs.

RESULTS

Eight double plane implants and four single plane implants have been done using this method. Five implants were done using direct visualization. It has not been necessary to reorient the implant in any of the patients. If not for the presence of surgical clips, the size of the lumpectomy site cannot be separated from the surrounding normal breast tissue.

CONCLUSION

This technique is an accurate way to localize the lumpectomy site for HDR brachytherapy.

Breast-conserving surgery without radiotherapy

Radiotherapy effectively prevents local recurrences, but on the other hand still over 80% of non irradiated women are free from local relapse 5 years after breast surgery aiming at radical removal of the primary tumor. So far, there are no indications that radiotherapy to the breast after breast conservation saves lives. The marginal monetary cost for prevention of one local recurrence is about $41,000. Thus, one clinically relevant question is if there is a group of women where the benefits of radiotherapy after breast conservation is outweighed by psychosocial and medical side-effects. Unfortunately, we still lack information from several areas, which makes a detailed cost-benefit analysis uncertain today. The problem situation would change: 1) If we knew more about the pathogenesis of local recurrences and thus also could undertake preventive measures other than radiotherapy. 2) If there was more information on risk factors for local recurrence, and we could identify a low-risk group that could be spared treatment. 3) If there were more valid empirical information on the psychosocial side-effects--both of a local recurrence and of the radiotherapy. 4) If the long-term--positive and negative--effects of radiotherapy were better quantified. Until we have new information, postoperative radiotherapy after breast conservation remains the standard.

Role of surgery in invasive breast cancer

Surgery is still the single most important treatment modality for breast cancer. Even if some patients with early stage cancer are treated, and in a clinical sense cured, by surgery alone, adjuvant local and systemic treatments are required for most patients for the best possible tumor control. Surgery must be compatible and timed with other treatment modalities. It helps provide local control, which in some cases is enough for cure but in others is limited to being a means of palliation. Surgery provides the clinical team with material for diagnosis, for prognostication and for help in clinical decision making. The choice of the surgical procedure and its performance should be handled by surgeons, knowledgeable and interested in the field in order to obtain the best possible functional and cosmetic results. An algorithm for deciding the appropriate surgical treatment of the breast is presented. Surgical treatment of the axilla is controversial. Current debate indicates that exploration of the axilla can be safely omitted in some patient groups, but more research is needed. Other important areas for clinical surgical research are use of immediate breast reconstruction, choice of management when margins are involved with tumor growth after breast-sparing operations, and surgical approach to tumors which have been treated with chemotherapy preoperatively.