Strahlentherapie und Onkologie

, Volume 195, Issue 1, pp 21–31 | Cite as

Comparison of brachytherapy and external beam radiotherapy boost in breast-conserving therapy: Patient-reported outcome measures and aesthetic outcome

  • I. KindtsEmail author
  • A. Laenen
  • M. Christiaens
  • H. Janssen
  • E. Van Limbergen
  • C. Weltens
Original Article



This study aimed to estimate the probability of an unfavourable aesthetic outcome (AO) 2 years after breast-conserving therapy (BCT) and evaluate the possible influence of brachytherapy (BT) and external beam radiotherapy (EBRT) boost on patient-reported outcomes (PROs) and AO.

Patients and methods

Patients treated with BCT starting April 2015 were prospectively included. Selection of the boost technique followed an in-house flowchart based on the depth of the tumour bed. An electron boost was performed for a superficial clinical target volume (maximum 28 mm under the epidermis), a BT boost was proposed in all other cases. Patients were followed-up for 2 years. AO was scored by the BCCT.core software and the patient. Further PROs were measured with the EORTC QLQ-C30, QOL-BR23 and the BIBCQ questionnaires.


The analysis included 175 patients, 80 received a BT boost and 95 an EBRT boost. BT patients were significantly older; had a higher breast cup and band size, body mass index and surgical specimen weight of the wide excision; more seroma at baseline and less positive surgical section margins than patients in the EBRT group, and more patients drank alcohol. Cancer- and breast cancer-specific quality of life (QOL) and body image did not differ between the boost techniques over time. Although mean scores for breast symptoms and sexual enjoyment did differ significantly over time (p = 0.05 and < 0.01, respectively), the effect was due to differences before boost administration. Measured with BCCT.core, AO was unfavourable in 28% of patients 2 years after treatment (31% scored by the patient) and results were similar in the BT and EBRT groups.


Using the presented flowchart (See Verhoeven et al. [16]), AO and PROs on QOL or body image up to 2 years after BCT are not influenced by the boost technique.


Breast neoplasms Questionnaires Patient reported outcome measures Toxicity Quality of life 

Vergleich von Brachytherapie und perkutaner Boost-Strahlentherapie nach brusterhaltender Therapie: Patientenbewertung und ästhetisches Ergebnis



Ziel war es, die Wahrscheinlichkeit eines ungünstigen ästhetischen Ergebnisses (AE) 2 Jahre nach brusterhaltender Therapie (BCT) abzuschätzen sowie den möglichen Einfluss von Brachytherapie (BT) und perkutanem Strahlentherapie(ERBT)-Boost auf patientenberichtete Ergebnisse (PBE) und AE zu beurteilen.

Patienten und Methoden

Prospektiv inkludiert wurden Patientinnen, die ab April 2015 mit BCT behandelt wurden. Die Auswahl der Boost-Technik erfolgte über einen hauseigenen Ablaufplan abhängig von der Tiefe des Tumorbetts. Ein Elektronenboost wurde durchgeführt bei einem oberflächlichen klinischen Zielvolumen (weniger als 29 mm unter der Epidermis), ein BT-Boost bei allen anderen Fällen. Die Patientinnen wurden bis zu 2 Jahre nachbeobachtet. Das AE wurde durch die Patientinnen und die BCCT.core-Software bewertet. Weitere PBE wurden mit dem EORTC QLQ-C30, QOL-BR23 und dem BIBCQ-Fragenbogen gemessen.


Die Studie beinhaltete 175 Patientinnen: 80 bekamen einen BT- und 95 einen ERBT-Boost. Patientinnen der BT-Gruppe waren signifikant älter, hatten eine größere Brustgröße, einen größeren Brustumfang, einen größeren Body-Mass-Index, höheres chirurgisches Probengewicht der breiten Exzision, mehr Serom zu Beginn der Analyse, weniger positive Resektionsränder und mehr Alkoholkonsum als die der ERBT-Gruppe. Krebs- oder brustkrebsspezifische Lebensqualität (QOL) und Körperbild unterschieden sich zwischen beiden Boost-Techniken im Zeitverlauf nicht signifikant. Durchschnittswerte für Symptome der Brust und sexuellen Genuss waren im Zeitverlauf zwar signifikant unterschiedlich zwischen beiden Gruppen, waren aber Unterschieden vor Verabreichung des Boosts geschuldet (jeweils p = 0,05 und < 0,01). Gemessen mit BCCT.core war das AE bei 28 % der Patientinnen 2 Jahre nach Behandlung ungünstig (31 % bewertet durch die Patientinnen); die Ergebnisse beider Gruppen waren vergleichbar.


Unter Verwendung des vorgestellten Ablaufs hat die benutzte Boost-Technik bis zu 2 Jahre nach BCT keinen Einfluss auf AE und PBE im QOL oder Körperbild.


Brustneoplasien Fragebögen Patientenberichtete Ergebnisse Toxizität Lebensqualität 



This project is realized with the support of Kom op tegen Kanker.

Compliance with ethical guidelines

Conflict of interest

I. Kindts, A. Laenen, M. Christiaens, H. Janssen, E. VanLimbergen and C. Weltens declare that they have no competing interests.

Ethical standards

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1975 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Ferlay J, Soerjomataram I, Ervik M et al (2014) GLOBOCAN 2012 v1.1, Cancer incidence and. [Online] Lyon, France: International Agency for Research on Cancer. Accessed 25 Mar 2018Google Scholar
  2. 2.
    Fisher B, Anderson S, Bryant J et al (2002) Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med 347:1233–1241CrossRefPubMedGoogle Scholar
  3. 3.
    Litière S, Werutsky G, Fentiman IS et al (2012) Breast conserving therapy versus mastectomy for stage I–II breast cancer: 20 year follow-up of the EORTC 10801 phase 3 randomised trial. Lancet Oncol 13:412–419CrossRefPubMedGoogle Scholar
  4. 4.
    Senkus E, Kyriakides S, Ohno S et al (2015) Primary breast cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 26(Suppl5):v8–30 (on behalf of the ESMO Guidelines Committee)CrossRefPubMedGoogle Scholar
  5. 5.
    Desantis C, Ma J, Bryan L, Jemal A (2014) Breast Cancer Statistics. Ca Cancer J Clin 64:52–62CrossRefPubMedGoogle Scholar
  6. 6.
    Allemani C, Minicozzi P, Berrino F et al (2013) Predictions of survival up to 10 years after diagnosis for European women with breast cancer in 2000–2002. Int J Cancer 132:2404–2412CrossRefPubMedGoogle Scholar
  7. 7.
    Ewertz M, Jensen A (2011) Late effects of breast cancer treatment and potentials for rehabilitation. Acta Oncol 50:187–193CrossRefPubMedGoogle Scholar
  8. 8.
    Darby SC, Ewertz M, McGale P et al (2013) Risk of ischemic heart disease in women after radiotherapy for breast cancer. N Engl J Med 368:387–398CrossRefGoogle Scholar
  9. 9.
    Taylor C, Correa C, Duane F et al (2017) Estimating the risks of breast cancer radiotherapy: evidence from modern radiation doses to the lungs and heart and from previous randomized trials. J Clin Oncol 35:1641–1649CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Cardoso MJ, Cardoso JS, Vrieling C et al (2012) Recommendations for the aesthetic evaluation of breast cancer conservative treatment. Breast Cancer Res Treat 135:629–637CrossRefPubMedGoogle Scholar
  11. 11.
    Department of Health (2007) Guidance on the routine colletion of patient reported outcome measures (PROMS).
  12. 12.
    Friese C, Harrison J, Janz N et al (2017) Treatment-associated toxicities reported by patients with early-stage invasive breast cancer. Cancer 123:1925–1934CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Baumhauer J (2017) Patient-reported outcomes—are they living up to their potential? N Engl J Med 377:6–9CrossRefPubMedGoogle Scholar
  14. 14.
    Jalali R, Singh S, Budrukkar A (2007) Techniques of tumour bed boost irradiation in breast conserving therapy: current evidence and suggested guidelines. Acta Oncol 46:879–892CrossRefPubMedGoogle Scholar
  15. 15.
    Borger JH, Kemperman H, Smitt HS et al (1994) Dose and volume effect on fibrosis after breast conservation therapy. Int J Radiat Oncol Biol Phys 30:1073–1081CrossRefPubMedGoogle Scholar
  16. 16.
    Verhoeven K, Kindts I, Laenen A et al (2015) A comparison of three different radiotherapy boost techniques after breast conserving therapy for breast cancer. Breast 24:391–396CrossRefPubMedGoogle Scholar
  17. 17.
    Chen C, Cano S, Klassen A et al (2010) Measuring quality of life in oncologic breast surgery: a systematic review of patient-reported outcome measures. Breast J 16:587–597CrossRefPubMedGoogle Scholar
  18. 18.
    Ong W, Schouwenburg M, van Bommel A et al (2017) A standard set of value-based patient-centered outcomes for breast cancer. The International Consortium for Health Outcomes Measurement (ICHOM) initiative. Jama Oncol 3:677–685CrossRefPubMedGoogle Scholar
  19. 19.
    Kanatas A, Velikova G, Roe B et al (2012) Patient-reported outcomes in breast oncology: a review of validated outcome instruments. Tumori 98:678–688CrossRefPubMedGoogle Scholar
  20. 20.
    Aaronson N, Ahmedzai S, Bergman B et al (1993) The European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology. J Natl Cancer Inst 85:365–376CrossRefPubMedGoogle Scholar
  21. 21.
    Osaba D, Rodrigues G, Pymes J et al (1998) Interpreting the significance of changes in health-related quality of-life scores. J Clin Oncol 16:139–144CrossRefGoogle Scholar
  22. 22.
    Sprangers M, Groenvold M, Arraras J et al (1996) The European Organization for Research and Treatment of Cancer breast cancer-specific quality of life questionnaire module: first results from a three-country field study. J Clin Oncol 14:2756–2768CrossRefPubMedGoogle Scholar
  23. 23.
    Baxter NN, Goodwin PJ, Mcleod RS, Dion R, Devins G, Bombardier C (2006) Reliability and validity of the body image after breast cancer questionnaire. Breast J 12:221–232CrossRefPubMedGoogle Scholar
  24. 24.
    Harris J, Levene M, Svensson G, Hellman S (1979) Analysis of cosmetic results following primary radiation therapy for stages I and II carcinoma of the breast. Int J Radiat Oncol Biol Phys 5:257–261CrossRefPubMedGoogle Scholar
  25. 25.
    Cardoso JS, Cardoso MJ (2007) Towards an intelligent medical system for the aesthetic evaluation of breast cancer conservative treatment. Artif Intell Med 40:115–126CrossRefPubMedGoogle Scholar
  26. 26.
    Chow S, Shao J, Wang H (2008) Sample size calculations in clinical research, 2nd Ed. s.l. edn. Chapman & Hall/CRC (Biostatistics Series)Google Scholar
  27. 27.
    Ganz P, Rowland J, Desmond K, Meyerowitz B, Wyatt G (1998) Life after breast cancer: understanding women’s health-related quality of life and sexual functioning. J Clin Oncol 16:501–514CrossRefPubMedGoogle Scholar
  28. 28.
    Heil J, Dahlkamp J, Golatta M et al (2010) Aesthetics in breast conserving therapy: do objectively measured results match patients’ evaluations? Ann Surg Oncol 18:134–138CrossRefPubMedGoogle Scholar
  29. 29.
    Vrieling C, Collette L, Fourquet A et al (2000) The influence of patient, tumour and treatment factors on the cosmetic results after breast-conserving therapy in the EORTC ‘boost vs. no boost’ trial. Radiother Oncol 55:219–232 (EORTC Radiotherapy and Breast Cancer Cooperative Groups)CrossRefPubMedGoogle Scholar
  30. 30.
    Van Limbergen E, van der Schueren E, Van Tongelen K (1989) Cosmetic evaluation of breast conserving treatment for mammary cancer. 1. Proposal of a quantitative scoring system. Radiother Oncol 16:159–167CrossRefPubMedGoogle Scholar
  31. 31.
    Pezner R, Patterson M, Hill L et al (1985) Breast retraction assessment: an objective evaluation of cosmetic results of patients treated conservatively for breast cancer. Int J Radiat Oncol Biol Phys 11:575–578CrossRefPubMedGoogle Scholar
  32. 32.
    Triedman S, Osteen R, Harris J (1990) Factors influencing cosmetic outcome of conservative surgery and radiotherapy for breast cancer. Surg Clin North Am 70:901–916CrossRefPubMedGoogle Scholar
  33. 33.
    Kurtz J (1995) Impact of radiotherapy on breast cosmesis. Breast 4:163–169CrossRefGoogle Scholar
  34. 34.
    Poortmans P, Collette L, Horiot J et al (2009) Impact of the boost dose of 10 Gy versus 26 Gy in patients with early stage breast cancer after a microscopically incomplete lumpectomy: 10-year results of the randomised EORTC boost trial. Radiother Oncol 90:80–85CrossRefPubMedGoogle Scholar
  35. 35.
    Fourquet A, Campana F, Mosseri V et al (1995) Iridium-192 versus cobalt-60 boost in 3–7 cm breast cancer treated by irradiation alone: final results of a randomized trial. Radiother Oncol 34:114–120CrossRefPubMedGoogle Scholar
  36. 36.
    Budrukkar AN, Sarin R, Shrivastava SK, Deshpande DD, Dinshaw KA (2007) Cosmesis, late sequelae and local control after breast-conserving therapy: influence of type of tumour bed boost and adjuvant chemotherapy. J Clin Oncol 19:596–603CrossRefGoogle Scholar
  37. 37.
    van Limbergen E, Briot E, Drijkoningen M (1990) The source-skin distance measuring bridge: a method to avoid radiation teleangiectasia in the skin after intersitital therapy for breast cancer. Int J Radiat Oncol Biol Phys 18:1239–1244CrossRefPubMedGoogle Scholar
  38. 38.
    Poortmans P, Bartelink H, Horiot JC et al (2004) The influence of the boost technique on local control in breast conserving treatment in the EORTC ‘boost versus no boost’ randomised trial. Radiother Oncol 72:25–33CrossRefPubMedGoogle Scholar
  39. 39.
    Kelemen G, Varga Z, Lázár G et al (2012) Cosmetic outcome 1–5 years after breast conservative surgery, irradiation and systemic therapy. Pathol Oncol Res 18:421–427CrossRefPubMedGoogle Scholar
  40. 40.
    Vrieling C, Collette L, Fourquet A et al (2000) The influence of patient, tumour and treatment factors on the cosmetic results after breast-conserving therapy in the EORTC ‘boost vs. no boost’ trial. Radiother Oncol 55:219–232 (EORTC Radiotherapy and Breast Cancer Cooperative Groups)CrossRefPubMedGoogle Scholar
  41. 41.
    van der Laan HP, Dosma WV, Maduro JH et al (2007) Three-dimensional conformal simultaneously integrated boost technique for breast-conserving radiotherapy. Int J Radiat Oncol Biol Phys 68:1018–1023CrossRefPubMedGoogle Scholar
  42. 42.
    Bantema-Joppe EJ, Schilstra C, de Bock GH et al (2012) Simultaneous integrated boost irradiation after breast-conserving surgery: physician-rated toxicity and cosmetic outcome at 30 months’ follow-up. Int J Radiat Oncol Biol Phys 83:e471–e477CrossRefPubMedGoogle Scholar
  43. 43.
    Dellas K, Vonthein R, Zimmer J et al (2014) Hypofractionation with simultaneaous integrated boost for early breast cancer. Strahlenther Onkol 190:646–653 (ARO Study Group)CrossRefPubMedGoogle Scholar
  44. 44.
    Lansu J, Essers M, Voogd A et al (2015) The influence of simultaneous integrated boost, hypofractionation and oncoplastic surgery on cosmetic outcome and PROMs after breast conserving therapy. Eur J Surg Oncol 41:1411–1416CrossRefPubMedGoogle Scholar
  45. 45.
    Gradishan WJ, Anderson BO (2017) National comprehense cancer network guidelines breast cancer. Version 2. Accessed 25 Mar 2018 (on behalf of the NCCN Breast Cancer Panel Members)Google Scholar
  46. 46.
    Turesson I, Nyman J, Holmberg E, Odén A (1996) Prognostic factors for acute and late skin reactions in radiotherapy patients. Int J Radiat Oncol Biol Phys 36:1065–1075CrossRefPubMedGoogle Scholar
  47. 47.
    Hennigs A, Hartmann B, Rauch G et al (2015) Long-term objective cosmetic outcome after breast-conserving therapy. Breast Cancer Res Treat 153:345–351CrossRefPubMedGoogle Scholar
  48. 48.
    Immink JM, Putter H, Bartelink H et al (2012) Long-term cosmetic changes after breast-conserving treatment of patients with stage I–II breast cancer and included in the EORTC ‘boost versus no boost’ trial. Ann Oncol 23:2591–2598CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Oncology, Experimental Radiation OncologyKU Leuven—University of LeuvenLeuvenBelgium
  2. 2.Department of Radiation OncologyUniversity Hospitals LeuvenLeuvenBelgium
  3. 3.Leuven Biostatistics and Statistical Bioinformatics Centre (L-Biostat)KU Leuven UniversityLeuvenBelgium

Personalised recommendations