Comparison of subjective, objective and patient-reported cosmetic outcomes between accelerated partial breast irradiation and whole breast radiotherapy: a prospective propensity score-matched pair analysis

  • Tabassum WadasadawalaEmail author
  • Shwetabh Sinha
  • Vani Parmar
  • Shalini Verma
  • Mithila Gaikar
  • Sadhana Kannan
  • Monidipa Mondal
  • Rima Pathak
  • Urvashi Jain
  • Rajiv Sarin
Original Article



To compare the early cosmetic outcomes after whole breast radiotherapy (WBRT) and accelerated partial breast irradiation (APBI) by various cosmetic assessment methods.


APBI was delivered using multiplane interstitial brachytherapy as per standard guidelines. Majority of women in WBRT cohort received hypo-fractionated external beam radiotherapy using bitangential portals and mega-voltage photons along with sequential boost to the tumor bed. Single cross-sectional assessment (18–36 months post-treatment completion) of the breast cosmesis was done by RO, SO and the patient using the modified Harvard scale and by photographic assessment using the BCCT.core software. The two cohorts were propensity score-matched using menopausal status, size of surgical cavity, size of tumor in greatest dimension, median number of lymph nodes dissected, treatment with adjuvant chemotherapy and treatment with hormonal therapy.


A total of 64 APBI patients were matched with 99 WBRT patients of the entire cohort of 320. At a median follow-up of 25 months, cosmetic results were significantly better for APBI as compared to WBRT cohort by all methods of evaluation (excellent/good: RO:75% vs 38.4%, p = 0.0001; SO: 54.7% vs 37.4%, p = 0.009; patient: 87.5% vs 58.6%, p = 0.001 and BCCT: 73.4% vs 51.6%, p = 0.001). Individual parameters that were significantly better in APBI cohort included size and shape of breast as well as location and shape of NAC. Better results for individual BCCT parameters (pLBC, pBRE, pBAD) were also seen.


Overall cosmetic outcomes as well as individual subdomains are significantly better with APBI as compared to WBRT by all methods of assessment of cosmesis when matched for various factors.


APBI Cosmesis Brachytherapy Late toxicity 



We would like to thank INESC Porto breast research group for providing us with BCCT.core v 3.1 software.


This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Compliance with ethical standards

Conflict of interest

None of the authors have any potential conflict of interest to disclose.

Ethical approval

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 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Haviland JS, Owen JR, Dewar JA, Agrawal RK, Barrett J, Barrett-Lee PJ, et al. The UK Standardisation of Breast Radiotherapy (START) trials of radiotherapy hypofractionation for treatment of early breast cancer: 10-year follow-up results of two randomised controlled trials. Lancet Oncol. 2013;14(11):1086–94.CrossRefGoogle Scholar
  2. 2.
    NCCN Guidelines for Patients®|Breast Cancer - Stages I and II [Internet]. Accessed 13 Oct 2018.
  3. 3.
    Polgár C, Major T, Fodor J, Németh G, Orosz Z, Sulyok Z, et al. High-dose-rate brachytherapy alone versus whole breast radiotherapy with or without tumor bed boost after breast-conserving surgery: seven-year results of a comparative study. Int J Radiat Oncol Biol Phys. 2004;60(4):1173–81.CrossRefGoogle Scholar
  4. 4.
    Coles CE, Griffin CL, Kirby AM, Titley J, Agrawal RK, Alhasso A, et al. Partial-breast radiotherapy after breast conservation surgery for patients with early breast cancer (UK IMPORT LOW trial): 5-year results from a multicentre, randomised, controlled, phase 3, non-inferiority trial. Lancet. 2017;390(10099):1048–60.CrossRefGoogle Scholar
  5. 5.
    Polgár C, Ott OJ, Hildebrandt G, Kauer-Dorner D, Knauerhase H, Major T, et al. Late side-effects and cosmetic results of accelerated partial breast irradiation with interstitial brachytherapy versus whole-breast irradiation after breast-conserving surgery for low-risk invasive and in-situ carcinoma of the female breast: 5-year results of a randomised, controlled, phase 3 trial. Lancet Oncol. 2017;18(2):259–68.CrossRefGoogle Scholar
  6. 6.
    Corica T, Nowak AK, Saunders CM, Bulsara MK, Taylor M, Williams NR, et al. Cosmetic outcome as rated by patients, doctors, nurses and BCCT.core software assessed over 5 years in a subset of patients in the TARGIT-A Trial. Radiat Oncol. 2018;13(1):68.CrossRefGoogle Scholar
  7. 7.
    Bhattacharya IS, Haviland JS, Kirby AM, Kirwan CC, Hopwood P, Yarnold JR, et al. Patient-reported outcomes over 5 years after whole- or partial-breast radiotherapy: longitudinal analysis of the IMPORT LOW (CRUK/06/003) phase III randomized controlled trial. J Clin Oncol. 2018;37(4):305–17.CrossRefGoogle Scholar
  8. 8.
    Polgar C, Major T, Sulyok Z, Takacsi-Nagy Z, Fodor J. Long-term toxicity and cosmetic results of partial versus whole breast irradiation: 10-year results of a phase III APBI trial. Int J Radiat Oncol Biol Phys. 2014;90(1):S133–S134134.CrossRefGoogle Scholar
  9. 9.
    Schäfer R, Strnad V, Polgár C, Uter W, Hildebrandt G, Ott OJ, et al. Quality-of-life results for accelerated partial breast irradiation with interstitial brachytherapy versus whole-breast irradiation in early breast cancer after breast-conserving surgery (GEC-ESTRO): 5-year results of a randomised, phase 3 trial. Lancet Oncol. 2018;19(6):834–44.CrossRefGoogle Scholar
  10. 10.
    Olivotto IA, Whelan TJ, Parpia S, Kim D-H, Berrang T, Truong PT, et al. Interim cosmetic and toxicity results from RAPID: a randomized trial of accelerated partial breast irradiation using three-dimensional conformal external beam radiation therapy. J Clin Oncol Off J Am Soc Clin Oncol. 2013;31(32):4038–45.CrossRefGoogle Scholar
  11. 11.
    Vera R, Trombetta M, Mukhopadhyay ND, Packard M, Arthur D. Long-term cosmesis and toxicity following 3-dimensional conformal radiation therapy in the delivery of accelerated partial breast irradiation. Pract Radiat Oncol. 2014;4(3):147–52.CrossRefGoogle Scholar
  12. 12.
    Munshi A, Kakkar S, Bhutani R, Jalali R, Budrukkar A, Dinshaw KA. Factors influencing cosmetic outcome in breast conservation. Clin Oncol. 2009;21(4):285–93.CrossRefGoogle Scholar
  13. 13.
    Gurram L, Wadasadawala T, Joshi K, Phurailatpam R, Paul S, Sarin R. Multi-catheter interstitial brachytherapy for partial breast irradiation: an audit of implant quality based on dosimetric evaluation comparing intra-operative versus post-operative placement. J Contemp Brachyther. 2016;8(2):116–21.CrossRefGoogle Scholar
  14. 14.
    Wadasadawala T, Sinha S, Verma S, Parmar V, Kannan S, Pathak R, et al. A prospective comparison of subjective and objective assessment of cosmetic outcomes following breast brachytherapy. J Contemp Brachyther. 2019;11(3):207–14.CrossRefGoogle Scholar
  15. 15.
    Aaronson NK, Bartelink H, van Dongen JA, van Dam FS. Evaluation of breast conserving therapy: clinical, methodological and psychosocial perspectives. Eur J Surg Oncol J Eur Soc Surg Oncol Br Assoc Surg Oncol. 1988;14(2):133–40.Google Scholar
  16. 16.
    Christie D, Sharpley C, Curtis T. Improving the accuracy of a photographic assessment system for breast cosmesis. Clin Oncol. 2005;17(1):27–31.CrossRefGoogle Scholar
  17. 17.
    Cardoso MJ, Cardoso JS, Oliveira HP, Gouveia P. The breast cancer conservative treatment. Cosmetic results—BCCT.core—Software for objective assessment of esthetic outcome in breast cancer conservative treatment: a narrative review. Comput Methods Progr Biomed. 2016;126:154–9.Google Scholar
  18. 18.
    Austin PC. Optimal caliper widths for propensity-score matching when estimating differences in means and differences in proportions in observational studies. Pharm Stat. 2011;10(2):150–61.CrossRefGoogle Scholar
  19. 19.
    Bodai BI, Tuso P. Breast cancer survivorship: a comprehensive review of long-term medical issues and lifestyle recommendations. Perm J. 2015;19(2):48–79.CrossRefGoogle Scholar
  20. 20.
    Friedman N. The effects of irradiation on breast cancer and the breast. CA Cancer J Clin. 1988;38(6):368–71.CrossRefGoogle Scholar
  21. 21.
    Dale RG, Jones B. The clinical radiobiology of brachytherapy. Br J Radiol. 1998;71(845):465–83.CrossRefGoogle Scholar
  22. 22.
    Meattini I, Saieva C, Miccinesi G, Desideri I, Francolini G, Scotti V, et al. Accelerated partial breast irradiation using intensity modulated radiotherapy versus whole breast irradiation: Health-related quality of life final analysis from the Florence phase 3 trial. Eur J Cancer. 2017;76:17–26.CrossRefGoogle Scholar
  23. 23.
    Sarin R. Partial-breast treatment for early breast cancer: emergence of a new paradigm. Nat Rev Clin Oncol. 2005;2(1):40–7.CrossRefGoogle Scholar
  24. 24.
    Gabani P, Cyr AE, Zoberi JE, Ochoa LL, Matesa MA, Thomas MA, et al. Long-term outcomes of APBI via multicatheter interstitial HDR brachytherapy: results of a prospective single-institutional registry. Brachytherapy. 2018;17(1):171–80.CrossRefGoogle Scholar
  25. 25.
    Fowble B, Fein DA, Hanlon AL, Eisenberg BL, Hoffman JP, Sigurdson ER, et al. The impact of tamoxifen on breast recurrence, cosmesis, complications, and survival in estrogen receptor-positive early-stage breast cancer. Int J Radiat Oncol Biol Phys. 1996;35(4):669–77.CrossRefGoogle Scholar
  26. 26.
    Volders JH, Negenborn VL, Haloua MH, Krekel NMA, Jóźwiak K, Meijer S, et al. Breast-specific factors determine cosmetic outcome and patient satisfaction after breast-conserving therapy: Results from the randomized COBALT study. J Surg Oncol. 2018;117(5):1001–8.CrossRefGoogle Scholar
  27. 27.
    Nahabedian MY, Tsangaris TN. Breast reconstruction following subcutaneous mastectomy for cancer: a critical appraisal of the nipple-areola complex. Plast Reconstr Surg. 2006;117(4):1083–90.CrossRefGoogle Scholar
  28. 28.
    Lagendijk M, Vos EL, Koning AHJ, Hunink MGM, Pignol JP, Corten EML, et al. TUmor-volume to breast-volume RAtio for improving COSmetic results in breast cancer patients (TURACOS); a randomized controlled trial. BMC Cancer [Internet]. 2017 [cited 2018 Oct 15];17.
  29. 29.
    Hepel JT, Arthur D, Shaitelman S, Polgár C, Todor D, Zoberi I, et al. American Brachytherapy Society consensus report for accelerated partial breast irradiation using interstitial multicatheter brachytherapy. Brachytherapy. 2017;16(5):919–28.CrossRefGoogle Scholar
  30. 30.
    Cochrane RA, Valasiadou P, Wilson ARM, Al-Ghazal SK, Macmillan RD. Cosmesis and satisfaction after breast-conserving surgery correlates with the percentage of breast volume excised. Br J Surg. 2003;90(12):1505–9.CrossRefGoogle Scholar
  31. 31.
    Jagsi R, Li Y, Morrow M, Janz N, Alderman A, Graff J, et al. Patient-reported quality of life and satisfaction with cosmetic outcomes after breast conservation and mastectomy with and without reconstruction: results of a survey of breast cancer survivors. Ann Surg. 2015;261(6):1198–206.CrossRefGoogle Scholar
  32. 32.
    Kim MS, Sbalchiero JC, Reece GP, Miller MJ, Beahm EK, Markey MK. Assessment of breast aesthetics. Plast Reconstr Surg. 2008;121(4):186e–e194194.CrossRefGoogle Scholar

Copyright information

© The Japanese Breast Cancer Society 2019

Authors and Affiliations

  • Tabassum Wadasadawala
    • 1
    Email author
  • Shwetabh Sinha
    • 2
  • Vani Parmar
    • 3
  • Shalini Verma
    • 2
  • Mithila Gaikar
    • 4
  • Sadhana Kannan
    • 5
  • Monidipa Mondal
    • 2
  • Rima Pathak
    • 2
  • Urvashi Jain
    • 3
  • Rajiv Sarin
    • 1
  1. 1.Department of Radiation Oncology, Advanced Centre for Treatment, Research and Education in Cancer, Tata Memorial CentreHomi Bhabha National InstituteNavi MumbaiIndia
  2. 2.Department of Radiation Oncology, Tata Memorial CentreHomi Bhabha National InstituteMumbaiIndia
  3. 3.Department of Surgical Oncology, Advanced Centre for Treatment, Research and Education in Cancer, Tata Memorial CentreHomi Bhabha National InstituteNavi MumbaiIndia
  4. 4.Clinical Research Secretariat, Tata Memorial CentreHomi Bhabha National InstituteMumbaiIndia
  5. 5.Department of Biostatistics, Advanced Centre for Treatment, Research and Education in Cancer, Tata Memorial CentreHomi Bhabha National InstituteNavi MumbaiIndia

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