Breast appearance and function after breast conserving surgery and radiotherapy

Early Toxicity and Patient-Reported Cosmetic Outcomes in Patients Treated With Adjuvant Proton-Based Radiotherapy After Breast-Conserving Surgery

INTRODUCTION

To evaluate the dosimetric data, early toxicity, and patient-reported cosmetic outcomes in breast cancer patients treated with adjuvant proton-based radiotherapy (RT) after breast-conserving surgery.

MATERIALS AND METHODS

We performed a retrospective review of our institutional database to identify breast cancer patients treated with breast-conserving surgery followed by proton-based RT from 2015 to 2020. Patient-reported cosmetic outcomes were graded as excellent, good, fair, or poor. Early toxicity outcomes were graded by the treating physician during treatment. Dose-volume histograms were reviewed to obtain dosimetry data.

RESULTS

We identified 21 patients treated with adjuvant proton-based RT. Median whole breast dose delivered was 46.8 Gy (range, 40.0-50.4 Gy). Target volumes included the regional lymph nodes in 17 patients (81%). Seventeen patients (81%) received a lumpectomy boost. The median planning target volume V95 was 94% (range, 77%-100%), V100 71% (range, 60%-97%), V110 2% (range 0%-18%), and median max point dose was 115% (range, 105%-120%). The median ipsilateral breast V105 was 367.3 cc (range, 0-1172 cc) and V110 was 24.1 cc (range, 0-321.3 cc). Grade 2 and 3 dermatitis occurred in 62% and 14% of patients, respectively. Grade 2 and 3 pain was reported by 33% and 10% of patients, respectively. Median follow-up at the time of cosmetic evaluation was 27 months (range, 5-42 months). Four patients (21%) reported fair cosmetic outcome and 15 patients (79%) reported good or excellent cosmetic outcome. No poor cosmesis was reported.

CONCLUSION

Adjuvant proton-based radiotherapy after breast-conserving surgery is well tolerated with acceptable rates of acute toxicities and a high rate of good-to-excellent patient-reported cosmetic outcomes.

Breast-specific factors determine cosmetic outcome and patient satisfaction after breast-conserving therapy: Results from the randomized COBALT study

BACKGROUND AND OBJECTIVES

To identify breast-specific factors and the role of tumor, treatment, and patient-related items in influencing patient opinion on cosmesis and satisfaction after breast-conserving therapy (BCT).

METHODS

Data from the randomized COBALT study was used. At 3, 12, and 36 months, 128 patients with T1-T2 breast cancer completed a questionnaire on breast-specific factors and overall cosmetic outcome and patient satisfaction, using a 4-point Likert scale.

RESULTS

There was a strong positive correlation between breast-specific factors, overall cosmetic outcome,and satisfaction at all time-points. Excellent/good cosmetic outcomes and satisfaction decreased during follow-up. A shift was noted in the degree of influence of the various breast-specific factors. At 3 years, symmetry factors such as size, shape, and nipple position largely determined a patient's opinion on the final cosmesis, followed by firmness. The risk of an unacceptable outcome was associated with young age and large excision volumes.

CONCLUSION

A questionnaire including breast-specific questions provides important information on final cosmetic results and satisfaction after BCT. These outcomes can also be of great value as quality indicators and pre-operative counseling. The major influence of breast-specific factors on asymmetry underlines the importance of achieving an optimal excision volume at the initial procedure.

The long-term outcome of adjuvant hypofractionated radiotherapy and conventional fractionated radiotherapy after breast-conserving surgery for early breast cancer: a prospective analysis of 107 cases

Background

This study aimed to evaluate the long-term outcomes of hypofractionated and conventional fractionated radiotherapy after breast-conserving surgery in patients with early-stage breast cancer. In addition, cosmetic and delayed toxic effects in the breast were also investigated.

Methods

A total of 107 female patients were recruited and randomly classified into the hypofractionated radiotherapy (HF) group (53 participants) and the conventional fractioned radiotherapy (CF) group (54 participants). The HF group was subjected to the following treatments: whole-breast irradiation (± irradiation of the infra-supraclavicular region) at 42.56 Gy/16 fractions + tumor bed boost at 7.98 Gy/3 fractions. The CF group received the following treatments: whole-breast irradiation (± irradiation of the infra-supraclavicular region) at 50 Gy/25 fractions + tumor bed boost at 10 Gy/5 fractions.

Results

The 10-year local recurrence (LR) rate, tumor-specific survival rate, disease-free survival rate, and overall survival rate of the HF and CF groups were 9.6% vs. 7.9% (P=0.712); 88.1% vs. 90.1% (P=0.738); 81.1% vs. 82.9% (P=0.792); and 86.5% vs. 88.5% (P=0.748), respectively. The 10-year rates of patients with good or excellent cosmetic results in the HF and CF groups were 72.7% vs. 67.4% (P=0.581), respectively. The 10-year rates of patients with delayed toxicity-free effects in the skin and the rates of patients with toxicity-free subcutaneous tissues in the HF and CF groups were 70.5% vs. 65.2% (P=0.595) and 52.3% vs. 47.8% (P=0.673), respectively.

Conclusions

Hypofractionated and CF showed comparable long-term efficacy, cosmetic effects, and delayed toxic effects. Hence, HF may be used as an alternative to conventional fractionated radiotherapy.

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.

Does Concurrent Radiochemotherapy Affect Cosmetic Results in the Adjuvant Setting After Breast-Conserving Surgery? Results of the ARCOSEIN Multicenter, Phase III Study: Patients’ and Doctors’ Views

PURPOSE

To evaluate the cosmetic results of sequential vs. concurrent adjuvant chemotherapy with radiotherapy after breast-conserving surgery for breast cancer, and to compare ratings by patients and physicians.

METHODS AND MATERIALS

From 1996 to 2000, 716 patients with Stage I-II breast cancers were included in a multicenter, Phase III trial (the ARCOSEIN study) comparing, after breast-conserving surgery with axillary dissection, sequential treatment with chemotherapy first followed by radiotherapy vs. chemotherapy administered concurrently with radiotherapy. Cosmetic results with regard to both the overall aspect of the breast and specific changes (color, scar) were evaluated in a total of 214 patients (107 in each arm) by means of questionnaires to both the patient and a physician whose rating was blinded to treatment allocation.

RESULTS

Patients' overall satisfaction with cosmesis was not statistically different between the two arms, with approximately 92% with at least satisfactory results (p = 0.72), although differences between the treated and untreated breasts were greater after the concurrent regimen (29% vs. 14% with more than moderate differences; p = 0.0015). Physician assessment of overall cosmesis was less favorable, with lower rates of at least satisfactory results in the concurrent arm (60% vs. 85%; p = 0.001). Consequently, the concordance for overall satisfaction with cosmesis between patients and doctors was only fair (kappa = 0.62).

CONCLUSION

After breast-conserving surgery, the concurrent use of chemotherapy with radiotherapy is significantly associated with greater differences between the breasts. These differences do not translate into patients' lessened satisfaction with cosmesis.

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 outcome of breast conservative treatment for early stage breast cancer

PURPOSE

To evaluate the cosmetic outcome of breast conservative therapy and to examine the degree of agreement between the patients' and oncologists' ratings. We also analyze the influence of several factors on cosmesis.

METHODS AND MATERIALS

We retrospectively evaluated 145 patients with primary breast cancer treated by local excision and radiotherapy between January 2000 and May 2001. Cosmetic outcome was evaluated by doctors and patients and was scored as excellent, good, fair or poor.

RESULTS

73% of patients rated cosmesis as excellent or good while the percentage was 71% when rated by radiation oncologists. The degree of cosmesis concordance evaluated by oncologists and patients was low (kappa = 0.3). In our study the variables which significantly influence on the cosmetic outcome were concomitant adjuvant chemotherapy (p = 0.04) and radiation therapy boost, either by electron beam or brachytherapy (p = 0.013).

CONCLUSION

The cosmetic outcome of breast conserving therapy was good. There was a similar rating by the patient and radiation oncologist, but the level of concordance between patients and doctors was low. Factors that significantly influence the cosmesis appear to be concomitant adjuvant chemotherapy and radiation therapy boost.

Cosmesis from the patient's and the doctor's view

PURPOSE

Long-term cosmesis from the patient's perspective is compared to the doctor's appraisal. Factors that determine judgment of cosmesis are analyzed. Also, a patient questionnaire was designed to screen for normal tissue reactions and is evaluated.

METHODS AND PATIENTS

With structured questions, patients rated their satisfaction considering cosmesis, the difference in overall appearance, and specific changes of the breast. Two doctors rated cosmesis and radiation late effects (LENT/SOMA). Ratings were compared, and the relative impact of single items was studied. Two hundred eighty-seven patients with unilateral breast carcinoma were examined after a median follow-up of 8 years. They were treated between 1981 and 1995 with lumpectomy and radiotherapy of the breast with 1.8-2.5 Gy fractions with a median total dose of 55 Gy (range: 50-65 Gy).

RESULTS

One hundred sixty-one patients rated cosmesis as satisfying, 73 patients rated it as acceptable, and 25 patients as poor. Eighty-nine patients noted severe changes of appearance. Severe firmness and extensive scars were the most frequent complaint; the most important single item for judging cosmesis as poor was highly visible scars. Generally, doctors rated cosmesis less favorably (satisfactory, 150 patients; poor, 43 patients). Severe fibrosis was more important than discoloration of the breast or scars. Correlation between patients' and doctors' rating of cosmesis was modest (Cohen's weighted kappa 0.29), whereas the doctor's rating correlated well (0.55). Specificity and sensitivity of the questionnaire item for severe fibrosis (using doctors' judgments as gold standard) was 0.8; Cohen's weighted kappa was 0.34 (95% confidence interval: 0.21-0.48).

CONCLUSION

Rating of cosmesis is subjective. Patients' satisfaction with cosmesis is greater than the doctors' and is determined not only by radiation late effects, but also by factors unrelated to the appearance of the breast. Severe fibrosis may be detected by a patient questionnaire.

Dose-volume analysis of radiotherapy for T1N0 invasive breast cancer treated by local excision and partial breast irradiation by low-dose-rate interstitial implant

PURPOSE

To evaluate the toxicity of partial breast irradiation (RT) using escalating doses of low-dose-rate interstitial implant as the sole adjuvant local therapy for selected T1N0 breast cancer patients treated by wide local excision. The results of a European Organization for Research and Treatment of Cancer study have demonstrated a significant local control benefit using external beam RT to 65 Gy compared with 50 Gy. Thus, the tolerance of escalating doses of partial breast RT should be determined, because this approach may become a standard treatment for patients with early-stage breast cancer.

METHODS AND MATERIALS

Between 1997 and 2001, 48 patients with T1N0M0 breast cancer were enrolled into an institutional review board-approved Phase I/II protocol using low-dose-rate brachytherapy implants after wide local excision and lymph node staging surgery. Brachytherapy was started 3-4 days after surgery at a dose rate of 50 cGy/h, using (192)Ir sources evenly spaced to cover 3 cm around the resection margins. Typically, 2-3 planes were used, with a median of 14 catheters (range 10-16). The total dose was escalated in three groups: 50 Gy (n = 19), 55 Gy (n = 16), and 60 Gy (n = 13). The implant volume was calculated and used to classify patients into quartiles: 76-127 cm(3) (n = 12), 128-164 cm(3) (n = 12), 165-204 cm(3) (n = 12), and >204 cm(3) (n = 12). Cosmesis, patient satisfaction, treatment-related complications, mammographic abnormalities, rebiopsies, and disease status were recorded at each scheduled patient visit.

RESULTS

The median follow-up for all patients was 23.1 months (range 2-43). Very good to excellent cosmetic results were observed in 91.8% of patients. Ninety-two percent of patients were satisfied with their cosmetic outcome and said they would choose brachytherapy again over the standard course of external beam RT. Six perioperative complications occurred: two developed bleeding at the time of catheter removal, two had abscesses, one developed a hematoma, and one had a nonhealing sinus tract requiring surgical intervention. Significant fibrosis (moderate-to-severe scarring and thickening of the skin and breast) was noted in only 4 patients; 1 had received 55 Gy and 3 had received 60 Gy. Abnormal posttreatment mammograms were seen in 19 patients. Eight patients underwent rebiopsy for abnormalities found either by mammography or on physical examination; all proved to be fat necrosis or post-RT changes. The rebiopsy rates appeared to correlate with doses >/=55 Gy (6 [75%] of 8 compared with 29 [60%]of 48 overall) and implant volumes >/=128 cm(3) (7 [87.5%] of 8 compared with 36 [75%] of 48 overall). To date, no local, regional, or distant recurrences have been observed.

CONCLUSION

Low-dose-rate implants up to 60 Gy were well-tolerated overall. With an implant dose of 60 Gy, the incidence of posttreatment fibrosis (25%) appeared to be increased. Only the long-term follow-up of this and other implant studies will allow an understanding of the total radiation dose necessary for tumor control and the volume of breast that requires treatment.

Late morbidity after treatment of breast cancer in relation to daily activities and quality of life: a systematic review

AIMS

Breast cancer treatment may result in long-term upper limb morbidity: reduced range of motion of the shoulder, muscle weakness of the arm and hand, lymph edema, pain and numbness. Relationship of this late morbidity with activities of daily life (ADL) and quality of life (QOL) is infrequently described and the strength of this relationship is not clear.

METHODS

A systematic review was performed to evaluate the results of studies, analyzing late morbidity of breast cancer treatment in relationship with ADL and/or QOL. A literature search over the last 20 years (1980-2000) was performed in the databases MEDLINE, EMBASE, PSYCHLIT and CANCERLIT. Methodological quality of selected articles was assessed and additional, aspects of treatment related late morbidity and the relationship to ADL and/or QOL were summarized.

RESULTS

From the 1642 yielded articles 15 fulfilled our primary selection criteria. Only six articles could be selected due to the inappropriate methodological quality. There was high variation in prevalence of pain (12-51%), impairments in range of motion (2-51%), edema (6-43%) and decreased muscle strength (17-33%). Four articles reported significant relationships between late morbidity of the upper limb and perceived disabilities in ADL/QOL. The strength of these relationships was rather low.

CONCLUSIONS

Few studies investigated the relationship between late morbidity of the upper limb after treatment of early breast cancer and ADL/QOL. Significant relationship between late morbidity and restrictions of daily activities and poorer QOL was reported, however, the strength of this relationship was rather low.

A shorter fractionation schedule for postlumpectomy breast cancer patients

PURPOSE

The purpose of this retrospective review was to determine the effectiveness of 40 Gy in 16 daily fractions in preventing local recurrence in postlumpectomy invasive breast cancer patients whose margins of resection were clear of tumor by at least 2 mm.

METHODS

Between September 1989 and December 1993, 294 breasts were treated with this regimen. The entire breast was treated, using a tangential parallel pair, with wedges as necessary, to a dose of 40 Gy in 16 daily fractions. No additional boost was given. The median duration of follow-up of surviving patients is 5.5 years. Recently, the patients' assessment of the cosmetic outcome of their treatment was obtained, using a mailed questionnaire.

RESULTS

The 5-year actuarial breast-relapse rate was 3.5%, with an overall 5-year survival and disease-specific survival of 87.8% and 92.1%, respectively. In response to the cosmesis questionnaire, 77% of patients stated they were either extremely or very satisfied with the overall appearance of the breast, 19.5% moderately satisfied, and 3.5% either slightly or not at all satisfied. The corresponding responses for overall level of comfort of the breast were 79%, 16.5%, and 4.5% respectively.

CONCLUSION

This regimen is very effective at preventing recurrent breast cancer in this group of patients, and it provides a high level of patient satisfaction with cosmetic outcome. Its short duration offers the added advantage of a more efficient use of resources and greater patient convenience.

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.

Cosmetic outcome in patients receiving an interstitial implant as part of breast-conservation therapy

PURPOSE

To study factors related to breast cosmetic outcome in patients treated with an interstitial implant as part of breast-conservation therapy.

MATERIALS AND METHODS

One hundred fifty-six patients with stage I or II breast carcinoma who received 50 Gy of external-beam irradiation followed by a 20-Gy interstitial boost were examined. The dose homogeneity index (DHI) was calculated for each evaluable implant and was examined in light of other patient-, treatment-, and tumor-related variables previously demonstrated to affect cosmesis.

RESULTS

Of the variables examined, both the DHI (P = .021) and the total excision volume (P = .019) were significantly related to cosmetic outcome (excellent vs less than excellent) in a univariate model. In the multivariate analysis, only the total excision volume remained significant (P = .032). The mean total excision volume +/- SD in patients with excellent cosmetic outcome (81.8 cm3 +/- 84.0) was significantly less than that in patients with less than excellent cosmetic outcome (120 cm3 +/- 84). The probability of excellent cosmetic outcome linearly increased with an increase in DHI. The mean DHI was 0.74 +/- 0.12 for the cases with excellent cosmetic outcome and 0.68 +/- 0.10 for those with less than excellent cosmetic outcome.

CONCLUSION

To achieve optimal cosmesis, DHI should be maximized. The volume of tissue removed, however, remains the most significant determinant.

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.

Shoulder movement after the treatment of early stage breast cancer

At 18 months after surgery and post-operative radiotherapy, the function of the ipsilateral shoulder joint was assessed both subjectively and objectively in 141 patients with early stage breast cancer. Half of the patients said that function was reduced compared with before (any) treatment. Overall, 48% had measured limitation of at least one shoulder movement. Mastectomy patients had more problems than those who had a wide local excision (79% versus 35%) as did those (node positive patients) who had axillary irradiation (73%) compared with those who did not (35%). Patients with dysfunction of shoulder movement before radiotherapy had a 60% chance of persistent movement problems at 18 months, compared with 24% of those with normal postoperative function. Informal exercise did not appear to have had any impact on the development of movement limitation.

Cosmetic outcome of breast-conserving therapy in Chinese patients with early breast cancer

BACKGROUND

Breast-conserving surgery combined with radiotherapy has emerged as an alternative to mastectomy for women with early breast cancer, and cosmetic outcome has correlated closely with the psychosocial and physical well-being of the patient. Cosmetic outcome assessment after breast-conserving therapy in Chinese patients has so far not been conducted among the clinicians, the patients or their spouses.

METHODS

The cosmetic results from breast-conserving therapy were evaluated in a group of 33 patients who had been selected as suitable for undergoing local excision, axillary dissection and postoperative radiation therapy for early stage breast cancer. The success of the procedures was assessed by the patients, the clinicians and the patient's spouse, and their ratings were compared with each other.

RESULTS

Eighty per cent of the patients and their spouse were satisfied with the cosmetic outcome. Using McNemar's test, when the groups were evaluated on a case-by-case basis, there was a good level of concordance between the patients and their spouses, and that of the patients and the clinicians.

CONCLUSIONS

Evaluation of the cosmetic and psychosocial sequelae of breast cancer patients is essential when new approaches to treatment are introduced; our data suggest that cosmetically successful breast conservation is feasible in a selected group of Chinese women with early breast cancer.

Factors influencing cosmetic results after conservation therapy for breast cancer

PURPOSE

Host, tumor, and treatment-related factors influencing cosmetic outcome are analyzed for patients receiving breast conservation treatment.

METHODS AND MATERIALS

Four-hundred and fifty-eight patients with evaluable records for cosmesis evaluation, a subset of 701 patients treated for invasive breast cancer with conservation technique between 1969 and 1990, were prospectively analyzed. In 243 patients, cosmetic evaluation was not adequately recorded. Cosmesis evaluation was carried out from 3.7 months to 22.3 years, median of 4.4 years. By pathologic stage, tumors were 62% T1N0, 14% T1N1, 15%, T2N0, and 9% T2N1. The majority of patients were treated with 4-6 MV photons. Cosmetic evaluation was rated by both patient and physician every 4-6 months. A logistic regression analysis was completed using a stepwise logistic regression. P-values of 0.05 or less were considered significant. Excellent cosmetic scores were used in all statistical analyses unless otherwise specified.

RESULTS

At most recent follow-up, 87% of patients and 81% of physicians scored their cosmetic outcome as excellent or good. Eighty-two percent of physician and patient evaluations agreed with excellent-good vs. fair-poor rating categories. Analysis demonstrated a lower proportion of excellent cosmetic scores when related to patient age > 60 years (p = 0.001), postmenopausal status (p = 0.02), black race (p = 0.0034), and T2 tumor size (p = 0.05). Surgical factors of importance were: volume of resection > 100 cm3 (p = 0.0001), scar orientation compliance with the National Surgical Adjuvant Breast Project (NSABP) guidelines (p = 0.0034), and > 20 cm2 skin resected (p = 0.0452). Extent of axillary surgery did not significantly affect breast cosmesis. Radiation factors affecting cosmesis included treatment volume (tangential breast fields only vs. three or more fields) (p = 0.034), whole breast dose in excess of 50 Gy (p = 0.0243), and total dose to tumor site > 65 Gy (p = 0.06), as well as optimum dose distribution with compensating filters (p = 0.002). Daily fraction size of 1.8 Gy vs. 2.0 Gy, boost vs. no boost, type of boost (brachytherapy vs. electrons), total radiation dose, and use of bolus were not significant factors. Use of concomitant chemotherapy with irradiation impaired excellent cosmetic outcome (p = 0.02). Use of sequential chemotherapy or adjuvant tamoxifen did not appear to diminish excellent cosmetic outcomes (p = 0.31). Logistic regression for excellent cosmetic outcome analysis was completed for age, tumor size, menopausal status, race, type of surgery, volume of breast tissue resected, scar orientations, whole breast radiation dose, total radiation dose, number of radiation fields treated, and use of adjuvant chemotherapy. Significant independent factors for excellent cosmetic outcome were: volume of tissue resected (p = 0.0001), type of surgery (p = 0.0001), breast radiation dose (p = 0.005), race (p = 0.002), and age (p = 0.007).

CONCLUSIONS

Satisfactory cosmesis was recorded in 81% of patients. Impaired cosmetic results are more likely with improper orientation of tylectomy and axillary incisions, larger volume of breast resection, radiation dose to the entire breast in excess of 50.0 Gy, and concurrent administration of chemotherapy. Careful selection of treatment procedures for specific patients/tumors and refinement in surgical/irradiation techniques will enhance the cosmetic results in breast conservation therapy.

The influence of breast size on late radiation effects and association with radiotherapy dose inhomogeneity

A prospective assessment of late changes in breast appearance in 559 patients after tumour excision and radiotherapy for early breast cancer noted a strong association with breast size. Only 3/48 (6%) patients with small breasts developed moderate or severe late changes compared with 94/423 (22%) with medium sized breasts and 34/88 (39%) patients with large breasts (p < 0.001). One possibility is that greater radiation changes are related to greater dose inhomogeneity in women with large breasts. To explore this hypothesis, radiation dose distributions were assessed in a separate group of 37 women in whom three-level transverse computer tomographic images of the breast in the treatment position were available. A significant correlation was found between breast size and dose inhomogeneity which may account for the marked changes in breast appearance reported in women with large breasts.

Cosmetic and functional outcomes of breast conserving treatment for early stage breast cancer. 1. Comparison of patients' ratings, observers' ratings, and objective assessments

The cosmetic and functional results of breast conserving therapy were evaluated in a sample of 76 patients with early stage breast cancer, treated by wide local excision, axillary dissection and postoperative radiotherapy between 1975 and 1985. A comparison was made between patients' ratings, independent ratings by two observers (an oncology nurse and a radiation oncologist) and objective measurements. In approximately 40% of the cases, moderate to large differences in the appearance of the treated versus the untreated breast were reported by patients and clinical observers alike. When evaluated on an individual level, the observers' ratings showed relatively high inter-rater agreement (kappa = 0.64), but low levels of concordance were found between the patients' and observers' ratings (kappa < 0.10). Approximately half of the patients reported limited arm or shoulder function, generally mild in nature. Compared to the patients', the observers' ratings of arm edema were significantly lower, indicating 20% mild and 5% more severe swelling. Objective measures of cosmesis and function correlated moderately with the observers' and patients' ratings. Both cosmetic and functional results were found to be significantly related to time elapsed since treatment, with patients treated longer ago exhibiting more problems. The cosmetic and functional outcomes were not related to the patients' age. The results suggest that the patients' opinion can provide important additional information in the evaluation of cosmetic and functional results of breast conserving treatment.

Cosmetic and functional outcomes of breast conserving treatment for early stage breast cancer. 2. Relationship with psychosocial functioning

The relationship between cosmetic and functional results of breast conserving therapy and psychosocial functioning was examined in a sample of 76 patients with early stage breast cancer, who received treatment between 1975 and 1985. The patients were interviewed at their homes regarding breast cosmesis, arm functioning and psychosocial health, and subsequently attended the hospital for independent assessment of cosmetic and functional outcomes by clinical observers. High levels of psychological distress, disturbance of body image, and decreased sexual functioning were noted in approximately one-quarter of the study sample. About half of the patients expressed heightened concern with disease recurrence and their future health. Psychosocial problems were only modestly associated with treatment-related cosmetic and functional outcomes, as determined by clinical ratings and objective assessments. The patients' own ratings of breast cosmesis and arm functioning exhibited somewhat higher correlations with self-reported psychosocial functioning. In particular, a significant association was noted between the patients' ratings of overall cosmesis and arm edema and their body image (r = 0.48 and r = 0.43, respectively). The association between cosmetic and functional results and self-reported psychosocial health was strongest among those patients younger in age and treated longer ago. These findings suggest that, in order to evaluate the impact of breast conserving therapy on the patients' quality of life, the patients' own assessments of cosmetic and functional outcomes should be used as a primary source of information.

Primary breast irradiation in large-breasted or heavy women: analysis of cosmetic outcome

Treatment of early stage breast cancer with lumpectomy, axillary dissection, and radiation therapy is considered by many to be relatively contraindicated in heavy women or women with large or pendulous breasts. To quantitatively analyze this, we reviewed the cosmetic outcome in 257 patients. These patients were divided into "large" (89) and "average" (168) groups by one or more of the following criteria: weight greater than or equal to 80 kg, bra size greater than or equal to 40 in., cup size greater than or equal to D, and tangent separation greater than or equal to 23 cm. All patients were given cosmetic scores on a 1-10 scale by an independent observer for each of 8 cosmetic indices. These scores were analyzed at 1, 3, and 5 years follow-up (median 3 years). The average group scored higher than the large group on overall cosmesis (8.01 vs 7.34, p = 0.0004) and on 5 of 7 subindices (p = 0.0001 to 0.05) at 1 year. At 3 and 5 year follow-up only symmetry and retraction remained significantly different, favoring the average group. The largest difference noted at any point between the groups was 1.27 (retraction at 5 years, 8.54 vs 7.27, p = 0.0148). Therefore, although an inferior cosmetic result has been documented in the large group, we do not feel the magnitude of the difference mandates a change in our policy of offering all of these women breast-conserving therapy.