Whole-Breast Irradiation and Hypofractionated Boost in Breast Carcinoma: Multimodal Chronic Toxicity and Cosmetic Evaluations by Objective Tests

The aim of this study is to correlate chronic toxicity and multidimensional subjective/objective cosmetic evaluations in early stage breast cancer patients treated with conservative surgery, whole breast hypofractionated irradiation, and hypofractionated sequential boost. From a series of 586 patients treated with hypofractionated whole breast irradiation, 50 patients with high dose hypofractionated boost were selected for exhaustive result evaluation. Patients were treated at a dose of 2.67 Gy/fr, 5 fractions at week, as far as 40 Gy and a sequential boost at the same hypofractionated doses, up to 56 Gy according to risk factors for local relapse. Patients were evaluated at minimum follow-up of 2 years for: a) chronic toxicity by means RTOG scale, b) subjective cosmetic assessment by Harvard scale, c) self-cosmetic assessment by means a 11 item questionnaire, that was considered gold standard for all comparisons, d) objective evaluation of skin pigmentation and fibrosis parameters (elasticity and hydration) by means a skin tester (Multi-Skin-Center® MC-750-B2) and e) computer assisted photograph cosmetic and morphologic evaluations by BCCT-Core 2.0 software (UNESC, Porto University). Median follow-up was 3.2 years (range: 2-4.4 years). There were no local relapses. All patients presented mild acute skin toxicity (22 patients grade I, 24 patients grade II). Chronic toxicity was present in 20 patients (17 patients grade I, 3 patients grade II). Elasticity and erythema measured by skin tester showed differences between patients with or without chronic toxicity (P = 0.047 and P = 0.035 respectively). Patient cosmetic assessment resulted excellent in 26%, good in 64%, fair in 8% and bad in 2%. Overall score by photographic software correlated better to patient satisfaction than subjective physician evaluation (CC 0.36 vs 0.26; P = 0,016). The morphologic values on software assessment that best correlate with asymmetry perceived by patient were the BCE (Breast Compliance Evaluation) (P = 0,018), pBRA (proportion Breast Retraction Assessment) (P = 0,021) i pUNR (proportion Upward Nipple Retraction) (P = 0,023). There was also a correlation between RTOG toxicity score and overall software cosmetic values (P = 0,041). Hypofractionated boost is feasible with good results in terms of chronic toxicity and cosmesis. Outcomes seem best evaluated by objective tests.