Early breast cancer: cosmetic and functional results after treatment by conservative techniques

Between January 1980 and December 1985, 121 patients with early breast cancer were referred to the Department of Radiation Oncology at Westmead Hospital for radiation therapy following initial tumour excision. After a median follow-up of 26 months, five patients developed a loco-regional recurrence (4%) and nine developed metastatic disease but with local control. There were 105 eligible patients who were sent a letter/questionnaire which included: a request to attend a clinic, to allow an objective assessment of the cosmetic result of the treated breast by two clinicians, questions regarding breast function as it affected quality of life, and a request that they undertake a self-assessment of the treated breast from a cosmetic point of view. Seventy-six patients attended for assessment of the following factors: whether surgery was optimal as determined by predefined criteria, measurement of breast oedema, arm oedema, breast retraction and telangiectasia, and an overall cosmetic assessment performed independently by both a radiation oncologist and surgeon. A physician not involved in management undertook a cosmetic assessment using standard photographs. Approximately 20% of patients replied that their choice of clothing had been affected by treatment, 10% were embarrassed and 70% experienced some continuing tenderness or discomfort in their treated breast. The extent of surgery was judged to be suboptimal in 22% but that proportion increased to 34% of cases referred from external clinics. The overall incidence of moderate or severe breast oedema was 9%, breast retraction 50%, telangiectasia 16% and arm oedema 21%. Those patients with longer follow-up (i.e., greater than 36 months) had a higher incidence of breast retraction (67%), telangiectasia (30%) and arm oedema (33%) but less breast oedema (7%). As expected, the patients rated the appearance of their breast more favourably than did clinicians. Overall, the result was rated as good or excellent by 75% of patients compared with 55% when the assessment was made by a surgeon or radiation oncologist. The main factor identified as contributing to a poor cosmetic result was the area of the iridium implant. The area of implant was larger when suboptimal surgery had been carried out, the main component of which was excessive length of scar.