Beauty Is in the Eye of the Beholder: Cosmetic Outcomes After Precision Breast Intraoperative Radiation Therapy

Precision Breast Intraoperative Radiation Therapy (PB-IORT) is a novel form of IORT that combines computed tomography-guided treatment planning with high-dose-rate brachytherapy to deliver individualized radiation that spares the skin and chest wall. We analyzed cosmetic outcomes following PB-IORT as scored by breast clinicians, a plastic surgeon, and patients, and assessed the interrater reliability between the scores.

As part of a phase II clinical trial, the study cohort included 357 patients treated with PB-IORT who had up to 24 mo of follow-up data. At each follow-up visit, the patient, plastic surgeon, and breast clinicians completed the Harvard Cosmesis Scale and a survey that evaluates changes in breast pigmentation, shape, and size. Interrater agreement was assessed using Kappa statistics.

At 24 mo, 88.7% (95% confidence interval [CI]: 84.77, 92.61) of patients rated their cosmesis as "excellent" or "good' with the Harvard Cosmesis Scale; 93.7% (95% CI: 90.80, 96.14) and 80.3% (95% CI: 75.08, 85.50) of patients were rated similarly by the breast clinicians and the plastic surgeon, respectively. There was minimal agreement between patients, breast clinicians, and the plastic surgeon for all variables (Kappa <0.40). Breast clinicians rated cosmesis the most favorably.

PB-IORT delivers a single, high dose of radiation without compromising cosmetic outcomes. Cosmetic outcome scores from patients, breast clinicians, and the plastic surgeon had low interrater reliability. The patient's perspective is paramount when assessing cosmetic outcomes after breast surgery. We advocate that future studies include patient-reported outcomes as the primary means of evaluating cosmetic outcomes.