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. Author manuscript; available in PMC: 2026 Oct 10.
Published in final edited form as: Ann Surg Oncol. 2025 Sep 10;33(1):50–59. doi: 10.1245/s10434-025-18095-x

Trends in Patient-Reported Outcomes After Breast-Conserving Surgery and Partial-Breast Versus Whole-Breast Irradiation

Julia M Chandler 1, Minji Kim 2, Varadan Sevilimedu 3, Tiana V Le 1, Jonas A Nelson 2, Lior Z Braunstein 4, Monica Morrow 1, Minna K Lee 1, Audree B Tadros 1
PMCID: PMC13650987  NIHMSID: NIHMS2210191  PMID: 40928574

Abstract

BACKGROUND:

Although several trials have demonstrated the oncologic safety of partial-breast irradiation (PBI) compared to whole-breast irradiation(WBI), data on patient-reported outcomes are mixed. Here we compare breast satisfaction and chest well-being using the BREAST-Q questionnaire among patients undergoing PBI vs WBI.

METHODS:

We identified patients undergoing lumpectomy and radiation and analyzed their BREAST-Q scores preoperatively and postoperatively at 6 months, 1, 2, and 3 years. We stratified patients by type of radiation and compared breast satisfaction and chest well-being scores over time and with univariate and multivariate analyses(MVA).

RESULTS:

From 2017-2022, 6,374 patients underwent lumpectomy and radiation and responded to the BREAST-Q at ≥1 timepoint. For both breast satisfaction and chest well-being, patients undergoing PBI had higher preoperative scores. For breast satisfaction, scores increased for both groups postoperatively and remained above baseline through 3 years of follow-up; for chest well-being, scores decreased postoperatively and gradually increased. On MVA, radiation type was not significantly associated with either breast satisfaction or chest well-being at any postoperative time point. At 2 years postop, receipt of adjuvant chemotherapy was associated with worse breast satisfaction, and BMI <20 was associated with improved chest well-being.

CONCLUSIONS:

Patients undergoing PBI and WBI had similar breast satisfaction and chest well-being at all postoperative timepoints. Other patient- and treatment-related variables such as BMI, axillary surgery, and need for chemotherapy were significantly associated with long-term breast satisfaction and chest well-being. These findings support the use of PBI as an alternative to WBI in terms of patient-reported outcomes in eligible patients.

Keywords: patient-reported outcomes, partial-breast irradiation, whole-breast irradiation, breast-conserving therapy

INTRODUCTION

Radiotherapy has consistently been shown to reduce the risk of local recurrence and improve survival following lumpectomy for early-stage breast cancer.1–3 Traditionally, patients have received whole-breast irradiation (WBI) following lumpectomy. However, multiple randomized trials and a recent large meta-analysis have demonstrated the oncologic safety of partial-breast irradiation (PBI) as a feasible alternative to WBI, and this approach has become increasingly common.4–17 PBI has been associated with decreased toxicity compared to WBI as it limits radiation to the tumor bed and a surrounding margin, whereas with traditional WBI the entire breast is irradiated.

PBI has been performed with multiple methods including brachytherapy, intraoperative radiotherapy, and external beam radiation. Meta-analyses have demonstrated similar locoregional control with PBI vs WBI among appropriately selected patients.7,18 PBI has also been demonstrated to have lower acute toxicity (typically defined as occurring within a few weeks of radiation treatment), compared to WBI. However, the data regarding late toxicity (typically defined as occurring within months to years of treatment) and cosmesis following PBI compared to WBI are mixed.19,20,21 In a meta-analysis examining cosmesis following PBI vs WBI, PBI was associated with worse cosmesis, with the data being heavily weighted by outcomes from the RAPID trial, in which patients received twice-daily dosing.5 Different techniques, such as prescribed dose and varying fractionation schedules for delivery of PBI, play a large role in the differences in cosmetic outcomes. Further, data regarding cosmesis in these trials is often comprised of physician assessment, which has been demonstrated to overestimate cosmetic outcomes and underestimate toxicities compared to patient assessment.22–24

Here we use prospectively collected results of the BREAST-Q, a validated patient-reported outcome tool of breast satisfaction and quality of life, to compare breast satisfaction and chest well-being among a contemporary cohort of patients undergoing PBI with a uniform technique vs WBI for treatment of breast cancer at a single institution.

METHODS

Study Population

We identified patients who had undergone breast-conserving surgery with radiation therapy for treatment of stage 0-3 breast cancer and had completed at least one BREAST-Q survey from January 2017 through December 2022. We excluded patients if they had a history of prior radiation therapy or if their radiation treatment details were unavailable. 85% (992/1,163) of patients undergoing PBI received external beam radiation therapy with a regimen of 40Gy in 10 once-daily fractions over the course of 2 weeks. 8% (97/1,163) received 24 Gy in 3 once-daily fractions, and 6% (74/1,163) received 30Gy in 5 once-daily fractions. Radiation therapy was delivered using intensity-modulated radiation therapy. We defined the planning target volume as the clinical target volume (i.e., the resection cavity or postoperative seroma) plus a 1.5- to 2.0-cm margin, and it needed to be less than 35% of the total ipsilateral breast volume.25 The majority of patients undergoing WBI received 42.4 Gy in 16 once-daily fractions, often followed by a 10-Gy boost to the tumor cavity in four fractions. The study was approved by the Memorial Sloan Kettering Cancer Center Institutional Review Board.

Data Collection

We routinely administered the BREAST-Q survey to all patients undergoing breast conservation surgery during the study period as part of standard of care. Data were collected from BREAST-Q surveys administered preoperatively and at 6 months, 1 year, 2 years, and 3 years postoperatively. Six months was chosen to represent the “early” post-treatment assessment as it is the earliest assessment we had available, and two years was chosen to represent the “late” post-treatment assessment. We collected BREAST-Q data from an institutional database in August 2023.

Patient, Tumor, and Treatment Variables

We abstracted patient, tumor, and treatment characteristics from a prospectively maintained institutional database and from the medical record. Variables abstracted included age; race; ethnicity; marital status; body mass index (BMI); smoking status; history of psychiatric diagnosis; pathologic tumor and nodal stage; extent of axillary surgery; systemic therapy; and radiation therapy, including duration of treatment, number of fractions delivered, radiation therapy boost, and use of regional nodal irradiation.

Questionnaire and Outcomes

We compared two modules of the BREAST-Q, Satisfaction with Breasts (hereafter referred to as “breast satisfaction”) and Physical Well-being of the Chest (hereafter referred to as “chest well-being”), between PBI and WBI cohorts at each of the time points collected. The breast satisfaction subscale measures satisfaction with how you appear clothed and unclothed, how symmetric your breasts are, and how the shape and contour of the breast compares to the nonoperative side. The chest well-being subscale measures pulling/tightness in your breast area, pain in your breast area, and difficulty lifting or moving your arms. Previous validation studies have identified a minimal important difference of 4 points for breast satisfaction and 3 points for chest well-being.26

Statistical Analysis

We calculated descriptive statistics for all patient demographic variables, clinicopathologic characteristics of the cancer, and treatment details, including surgical treatment, systemic treatment, and radiation therapy. We compared the variables between the PBI and WBI groups using Wilcoxon rank-sum tests for continuous variables and Pearson’s chi-square tests for categorical variables. We calculated median scores for breast satisfaction and chest well-being for the PBI and WBI groups at each time point and plotted the results in box plots to compare raw scores over time. For breast satisfaction and chest well-being scores, we conducted multivariable linear regression analyses at an “early” postoperative time point of 6 months and a “late” postoperative time point of 2 years, with variables selected a priori to be included in the model. To be included in each of the analyses, patients needed to have a baseline score and also a breast satisfaction and/or chest well-being score at the given time point. We set the type I error rate to 0.05 and used R Statistical Software, Version 4.2 (R Core Team, 2022) for all statistical analyses.

RESULTS

Patient, Tumor, and Treatment Characteristics

During the study period, a total of 6,374 patients underwent breast-conserving surgery and radiation, including 1,163 (18%) who underwent PBI and 5,211 (82%) who underwent WBI (Table 1). Patients who underwent PBI tended to be older (median age 63 years vs 57 years; P<0.001), were more likely to self-identify as White (77% vs 72%; P=0.001), were less likely to have a history of a psychiatric diagnosis (16% vs 22%; P<0.001), and had higher BMI (median 27 vs 26; P<0.001). Patients undergoing PBI were more likely to have a lower-stage tumor, with a higher proportion of patients in the PBI group having T1 tumors compared to those who received WBI (82% vs 62%; P<0.001).

TABLE 1.

Patient and Tumor Characteristics

Entire Cohort
N = 6,374		 PBI
N = 1,163		 WBI
N = 5,211		 P value
Patient Characteristics
Age, median (IQR) 59 (50, 66) 63 (57, 68) 57 (49, 65) <0.001
Race/ethnicity, n (%) <0.001
  Asian 645 (11) 111 (10) 534 (11)
  Black 519 (8) 66 (6) 453 (9)
  Hispanic 490 (8) 79 (7) 411 (8)
  White 4,426 (73) 858 (77) 3,568 (72)
  Unknown 294 38 256
Marital status, n (%) 0.07
  Married/partnered 4,361 (69) 798 (69) 3,563 (69)
  Single 1,042 (17) 168 (15) 874 (17)
  Divorced/separated 576 (9) 116 (10) 460 (9)
  Widowed 327 (5) 71 (6) 256 (5)
  Unknown 68 10 58
BMI, median (IQR) 26 (23, 30) 27 (23, 31) 26 (22, 30) <0.001
Smoking status, n (%) 0.13
  Never smoker 4,492 (71) 796 (69) 3,696 (71)
  Former smoker 1,689 (27) 335 (29) 1,354 (26)
  Current smoker 189 (3) 31 (3) 158 (3)
  Unknown 4 1 3
History of psychiatric disorder, n (%) 1,349 (21) 189 (16) 1,160 (22) <0.001
Tumor Characteristics
Pathologic tumor stage, n (%) <0.001
  T0 or Tis 1,036 (17) 164 (15) 872 (17)
  T1 4,017 (66) 910 (82) 3,107 (62)
  T2 1,008 (16) 41 (4) 967 (19)
  T3 59 (1) 0 (0) 59 (1)
  Unknown 254 4 206
Pathologic nodal stage, n (%) <0.001
  0 4,157 (82) 878 (100) 3,279 (79)
  1 776 (15) 1 (0.1) 775 (19)
  2 87 (1.7) 0 (0) 87 (2.1)
  3 31 (0.6) 0 (0) 31 (0.7)
  Unknown 1,323 284 1,039
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BMI body mass index, IQR interquartile range, PBI partial-breast irradiation, Tis tumor in situ, WBI whole-breast radiation

Nearly all patients who had nodal involvement and/or required an axillary lymph node dissection (ALND) underwent WBI (Table 2). Patients undergoing PBI were also less likely to have received chemotherapy (11% vs 35%; P<0.001).

TABLE 2.

Treatment Characteristics

Overall
N=6,374		 PBI
N=1,163		 WBI
N=5,211		 P value
Surgery Characteristics
Laterality, n (%) 0.010
  Unilateral 6,158 (97) 1,138 (98) 5,020 (96)
  Bilateral 216 (3) 25 (2) 191 (4)
Axillary Surgery, n(%) <0.001
  None 1,086 (17) 255 (22) 831 (16)
  SLNB 4,924 (77) 904 (78) 4,020 (77)
  ALND 364 (6) 4 (0.3) 360 (7)
Radiation Characteristics
Duration in days, median (IQR) 21 (18, 22) 13 (11, 13) 21 (21, 22) <0.001
Delivered fractions (Gy), median (IQR) 16 (16, 16) 10 (10, 10) 16 (16, 16) <0.001
Boost, n (%) 4,155 (65) n/a 4,155 (80)
  Boost Dose (Gy), median (IQR) 1,000 (1,000, 1,000) n/a 1,000 (1,000, 1,000)
RNI, n (%) 390 (6) 0 390 (8)
  RNI Dose (Gy), median (IQR) 4,240 (4,240, 4,240) n/a 4,240 (4,240, 4,240)
Systemic Therapy Characteristics
Chemotherapy, n (%) <0.001
  None 4,107 (64) 1,033 (89) 3,074 (59)
  Neoadjuvant 850 (13) 14 (1) 836 (16)
  Adjuvant 1,417 (22) 116 (10) 1,301 (25)
Aromatase Inhibitor, n (%) 1,458 (23) 217 (19) 1,241 (24) <0.001
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ALND axillary lymph node dissection, IQR interquartile range, n/a not applicable, PBI partial-breast irradiation, RNI regional nodal irradiation, SLNB sentinel lymph node biopsy, WBI whole-breast radiation

BREAST-Q: Breast Satisfaction

The PBI and WBI groups had similar BREAST-Q survey completion rates at all postoperative time points (Figure 1). For breast satisfaction, the PBI group had higher preoperative scores (64 vs 58; P=0.003) (Table 3 and Figure 2a). The scores for both groups increased at 6 months postoperatively and then decreased over time; at 3 years after the operation, both the PBI and WBI groups had scores that remained above baseline (72 vs 64 for PBI; 67 vs 58 for WBI).

Fig 1.

Fig 1.

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Response rates for (a) physical well-being of the chest; (b) satisfaction with breasts

TABLE 3.

Mean (SD) BREAST-Q Scores for PBI and WBI Cohorts by Time Since Surgery

PBI WBI P value
Preoperative
Breast Satisfaction 64 (53, 82) 58 (53, 82) 0.003
Chest Physical Well-Being 92 (80, 100) 85 (76, 100) <0.001
6 Months
Breast Satisfaction 82 (65, 100) 75 (61, 100) 0.002
Chest Physical Well-Being 76 (66, 89) 71 (60, 82) <0.001
1 Year
Breast Satisfaction 78 (63, 100) 72 (59, 100) <0.001
Chest Physical Well-Being 76 (66, 89) 71 (60, 82) <0.001
2 Years
Breast Satisfaction 75 (59, 100) 72 (57, 100) 0.002
Chest Physical Well-Being 82 (71, 100) 76 (66, 89) <0.001
3 Years
Breast Satisfaction 72 (59, 100) 67 (55, 88) 0.005
Chest Physical Well-Being 82 (66, 100) 80 (66, 89) 0.011
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PBI partial-breast irradiation, WBI whole-breast irradiation

Fig. 2.

Fig. 2.

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BREAST-Q scores by time since surgery, stratified by type of radiation. (a) Satisfaction with breasts. (b) Chest physical well-being. Pre Op preoperative.

On multivariable analysis, the type of radiation received was not a significant predictor of breast satisfaction at either 6 months or 2 years (Table 4). Preoperative breast satisfaction was a significant predictor of breast satisfaction (6 month: beta-coefficient, 0.23; 95% confidence interval [CI], 0.16 – 0.30; P<0.001. 2 years: beta-coefficient, 0.22; 95% CI, 0.15 – 0.29; P<0.001). More significant at 6 months was whether the patient had undergone ALND (beta-coefficient for breast satisfaction, −28; 95% CI, −40 to −17; P<0.001); however, this did not remain statistically significant at 2 years (beta coefficient, −6.8; 95% CI, −18 to 4.5; P=0.4). Timing of chemotherapy was also significant, with receipt of neoadjuvant chemotherapy being associated with improved breast satisfaction at 6 months (beta-coefficient, 13; 95% CI, 2.6 – 24; P=0.05) and receipt of adjuvant chemotherapy being associated with worse breast satisfaction at 2 years (beta-coefficient, −4.8; 95% CI, −8.7 to −0.95; P=0.03).

TABLE 4.

Multivariable Analysis of BREAST-Q Scores Between PBI and WBI at 6 Months and 2 Years

At 6 months At 2 years
Estimate 95% CI P value Estimate 95% CI P value
Satisfaction with Breasts n = 771 n = 781
Preop SABTR score 0.23 0.16, 0.30 <0.001 0.22 0.15, 0.29 <0.001
Type of Radiation 0.3 0.6
 Partial (ref) - - - -
 Whole −1.8 −5.3, 1.6 −1.1 −4.9, 2.8
Age 0.10 −0.05, 0.26 0.20 0.02 −0.15, 0.19 0.8
BMI 0.30 0.5
 20-25 (ref) - - - -
 <20 −0.15 −5.7, 5.4 3.6 −2.6, 9.8
 >25 2.2 −0.85, 5.3 −0.18 −3.5, 3.1
History of psychiatric disorder −1.6 −5.1, 2.0 0.40 −1.1 −4.9, 2.6 0.5
pT 0.30 0.7
 pT0/is (ref) - - - -
 pT1 1.5 −4.5, 7.6 2.3 −4.5, 9.2
 pT2 4.0 −3.1, 11 −0.07 −7.8, 7.7
 pT3 −19 −48, 9.1 0.81 −17, 18
Axillary Surgery <0.001 0.4
 None (ref) - - - -
 SLNB −1.3 −6.7, 4.1 −3.6 −10, 2.8
 ALND −28 −40, −17 −6.8 −18, 4.5
Chemotherapy 0.05 0.03
 None (ref) - - - -
 Neoadjuvant 13 2.6, 24 −5.6 −14, 2.7
 Adjuvant −0.34 −4.1, 3.4 −4.8 −8.7, −0.95
Chest Physical Well-Being n = 794 n = 805
Preop PWB-CHEST score 0.40 0.32, 0.48 <0.001 0.38 0.30, 0.46 <0.001
Type of Radiation 0.5 0.5
 Partial (ref) - - - -
 Whole −1.0 −3.9, 1.8 1.1 −2.0, 4.1
Age 0.21 0.08, 0.34 0.001 0.00 −0.13, 0.14 >0.9
BMI 0.15 0.013
 20-25 (ref) - - - -
 <20 4.1 −0.53, 8.7 7.2 2.4, 12
 >25 −0.42 −2.9, 2.0 0.63 −1.9, 3.2
History of psychiatric disorder −2.5 −5.4, 0.43 0.09 −1.3 −4.3, 1.6 0.4
pT 0.4 0.7
 pT0/is (ref) - - - -
 pT1 −1.1 −6.1, 3.9 −1.8 −7.2, 3.6
 pT2 −0.12 −5.9, 5.7 −0.44 −6.6, 5.7
 pT3 14 −5.3, 34 −5.8 −19, 7.5
Axillary Surgery <0.001 0.30
 None (ref) - - - -
 SLNB −3.0 −7.5, 1.5 −3.9 −9.1, 1.2
 ALND −25 −33, −16 −5.9 −14, 2.7
Chemotherapy <0.001 0.02
 None (ref) - - - -
 Neoadjuvant −0.04 −7.7, 7.7 −8.8 −15, −2.5
 Adjuvant 7.2 4.1, 10 −1.8 −4.8, 1.3
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ALND axillary lymph node dissection, BMI body mass index, PBI partial-breast irradiation, Preop preoperative, PWB-CHEST physical well-being of the chest, SABTR satisfaction with breasts, SLNB sentinel lymph node biopsy, WBI whole-breast radiation.

BREAST-Q: Chest Well-Being

For chest well-being, the PBI group had a notably higher median score preoperatively (92 vs 85; P<0.001) (Table 3 and Figure 2b). Postoperatively, both groups saw an initial decrease in their scores, which then slowly increased over time, although at 3 years they had still not reached baseline levels (82 vs 92 for PBI; 80 vs 85 for WBI).

On multivariable analysis, the type of radiation received was again not a significant predictor of chest well-being at either 6 months or 2 years (6 months: WBI beta-coefficient, −1.0 [PBI reference]; 95% CI, −3.9 to 1.8; P=0.5. 2 years: WBI beta-coefficient, 1.1 [PBI reference]; 95% CI, −2.0 to 4.1; P=0.5) (Table 4). Preoperative score was a significant predictor at both time points (6 months: beta-coefficient, 0.40; 95% CI, 0.32 – 0.48; P<0.001. 2 years: beta-coefficient, 0.38; 95% CI, 0.30 – 0.46; P<0.001). Once again significant at 6 months was whether the patient had undergone ALND (beta-coefficient, −25, 95% CI, −33 to −16; P<0.001), although this was no longer significant at 2 years (beta-coefficient, −5.9; 95% CI, −14 to 2.7; P=0.30). At 2 years, lower BMI was also associated with improved chest well-being (beta-coefficient for BMI <20, 7.2 [BMI 20 – 25 reference]; 95% CI, 2.4 – 12; P=0.013). Timing of chemotherapy was also significant, with receipt of adjuvant chemotherapy being predictive of improved chest well-being at 6 months (beta-coefficient, 7.2; 95% CI, 4.1 – 10; P<0.001) and receipt of neoadjuvant chemotherapy being associated with worse chest well-being at 2 years (beta-coefficient, −8.8; 95% CI, −15 to −2.5; P=0.02).

DISCUSSION

In this cohort study of women undergoing lumpectomy and radiation therapy for the treatment of breast cancer, we found that patients treated with PBI vs WBI had similar levels of breast satisfaction and chest well-being at both early and late postoperative time points. There were other patient- and treatment-related variables, specifically BMI, type of axillary surgery, and timing of chemotherapy, that were more predictive of these patient-reported outcomes than the type of radiation received.

Breast Satisfaction

A key finding of our study is that both short- and long-term breast satisfaction did not differ among a cohort of patients treated with uniform PBI practice vs WBI. Consistent with our prior studies, breast satisfaction increased over time for both cohorts.27 Two recent meta-analyses indicate that in the trials of PBI vs WBI, cosmetic results have been mixed.7,28 One challenge of these analyses is that the trials use varying PBI dosing schedules, which complicates interpretation of the results. One relatively consistent finding is that PBI with a twice-daily dosing schedule may yield inferior cosmetic results compared to WBI.5,8,9 In our study, PBI practice was uniform, with 40 Gy delivered in 10 daily fractions using intensity-modulated radiotherapy. When looking only at prior studies evaluating daily fractionation schedules, there is a more consistent trend toward improved cosmesis with PBI. For example, in IMPORT-LOW, which randomized women with early-stage invasive cancer treated with breast-conserving surgery to WBI, reduced-dose WBI, or PBI (40 Gy in 15 daily fractions), there was a trend toward those undergoing reduced or partial-breast radiation having improved breast appearance, although this result was not statistically significant.13 Similarly, in the DBCG PBI study, in which patients undergoing breast conservation were randomly assigned to WBI vs PBI with the same 40 Gy in 15 daily fractions schedule, a greater proportion of patients in the PBI group reported good or excellent cosmesis at 3 and 5 years.6

Two variables in our multivariable analysis had a statistically and clinically significant association with breast satisfaction: receipt of ALND and timing of chemotherapy. Specifically, women who underwent ALND had significantly worse breast satisfaction at 6 months, but there was no effect of axillary surgery on breast satisfaction at 2 years. To our knowledge, no prior studies have looked at the impact of ALND on breast satisfaction. It is possible that women undergoing ALND were more likely to have larger tumors, and as a result have more cosmetically deforming surgery, thus resulting in decreased breast satisfaction in the immediate postoperative period. However, we adjusted for tumor size, which should have at least in part accounted for this effect. It is more likely that the axillary incision and tissue loss in the axillary region following ALND and radiation may lead to contour changes of the outer breast that are most significant at 6 months following surgery.

Our multivariable analysis also indicated that women who underwent neoadjuvant chemotherapy had improved breast satisfaction at 6 months postoperatively compared to those who had no chemotherapy. At 2 years, this effect no longer held, and it was women who underwent adjuvant chemotherapy who had significantly decreased breast satisfaction. A number of prior studies have evaluated the impact of chemotherapy on breast cosmesis with mixed results. Ozmen et al. found that in a cohort of 284 patients undergoing breast-conserving therapy, physician-rated cosmetic outcome was worse among women who underwent adjuvant chemotherapy at a median of 3 years postoperatively.29 Other significant factors included larger tumors, tumors located in the retroareolar region, and receipt of WBI (compared to no radiation treatment). However, Dilworth et al. found no difference in cosmetic outcome for women undergoing chemotherapy before WBI, also noting that women undergoing WBI with conventional fractionation had more moist desquamation, whereas those undergoing WBI with hypofractionation did not.30 In a separate study from our own group, longer-term breast satisfaction at 3 years was not significantly different between patients receiving adjuvant vs neoadjuvant chemotherapy.31

Chest Well-Being

With regards to chest well-being, our study found no difference between patients who underwent PBI vs WBI at either 6 months or 2 years. Patients in both cohorts had a slight decrease in chest well-being in the first year after the operation, followed by gradual improvement in their scores, although even at 3 years postoperation they did not reach their preoperative chest well-being baseline. There are limited data available on chest and arm symptoms after PBI vs WBI. Of the large, randomized trials comparing external beam PBI with computed tomography planning vs WBI, only two reported on chest wall symptoms or side effects. In the RAPID trial, a higher percent of patients receiving PBI reported grade 2 or grade 3 chest-wall pain compared to those receiving WBI, although the absolute number of patients affected was quite small (grade 2, 2.4% vs <0.5%; grade 3, <0.5% vs 0).5 The IMPORT LOW trial reported on symptomatic rib fractures as a late adverse effect; they reported rare instances in all three study arms (WBI, 0.5%; reduced-dose, WBI 0.9%; PBI, 0.1%).13 In a smaller trial of 140 women randomized to daily PBI vs WBI, there were no significant differences in arm symptoms at 1 year as graded by the European Organisation for Research and Treatment of Cancer (EORTC) BR23, a breast cancer–specific patient-reported outcome measure.32,33 These are all consistent with our findings of no clinically meaningful difference in chest-wall symptoms between the regimens.

On multivariable analysis, axillary surgery and the use of neoadjuvant chemotherapy were associated with worse chest well-being (at 6 months and at 2 years, respectively). It is well known that axillary surgery, and specifically ALND, is associated with worse quality-of-life outcomes due to the risks of pain, lymphedema, and difficulty with arm movement. This was recently redemonstrated in the SENOMAC trial, which randomized women with clinically node-negative breast cancer and 1-2 positive sentinel lymph nodes to either completion ALND or no further axillary surgery, and found that women undergoing ALND had worse outcomes at 1 year for a variety of EORTC subscales, including those for pain and arm symptoms.34,35 It is worth noting that in our study, axillary surgery no longer had a statistically significant impact on chest well-being at 2 years. Prior studies on this topic have shown consistently that patients undergoing ALND have more chest pain and arm movement restriction compared to those undergoing sentinel lymph node biopsy.36,37 However, some studies have suggested that this effect diminishes over the course of long-term follow up.38

There remains hesitation to offer PBI to patients who have not had axillary staging. In the recent SOUND trial, which demonstrated the noninferiority of the omission of axillary surgery in patients with low-risk breast cancer and a negative preoperative axillary ultrasound, the vast majority of patients underwent WBI.39 It remains to be seen how the diminishing indications for axillary staging will impact the adoption of PBI regimens.

Our study also demonstrated an association between chest well-being and the timing of chemotherapy. Adjuvant chemotherapy was associated with improved chest well-being at 6 months postoperatively, which may be due to the greater interval between surgery and receipt of radiation therapy in these patients. Neoadjuvant chemotherapy was associated with worse chest well-being at 2 years, which could be due to increased rates of breast fibrosis and lymphedema, as prior studies have demonstrated higher rates of arm lymphedema in patients undergoing neoadjuvant vs adjuvant chemotherapy.40

Advantages of PBI

PBI offers a number of potential advantages over WBI. From a clinical standpoint, there is a lower volume of tissue treated, allowing for potential sparing of nontarget tissues/organs and providing the opportunity for additional radiation to be given later should it be needed. There are also some practical benefits, including shorter treatment duration. In our study, patients undergoing PBI had a significantly shorter duration of treatment than those undergoing WBI (21 days vs 13 days), which can be of significant benefit for patients who are unable to take time off from work or for whom it is difficult to arrange transportation. Some radiation therapy regimens, such as that described in the FAST-Forward trial, are able to offer radiation courses as short as 5 days.41

Limitations and Strengths

Limitations of our study include that all data are from a single institution and may not be generalizable to other patient populations or to patients for whom a different PBI protocol is used. In addition, there are challenges inherent to working with patient-reported outcome data, namely that any given patient may not fill out the survey at every time point. As a result, the analyses at 6 months and at 2 years do not necessarily represent the same cohort of patients, and there may be selection bias as to which patients are filling out the survey at each time point. Furthermore, there are known disparities in who completes the BREAST-Q survey; thus, the results may be less representative for certain subgroups of patients, specifically those who are non-English speaking or of Black race.42 Finally, it is possible the nodal irradiation may impact patient reported outcomes in a similar manner to ALND. Our study also has a number of strengths, most notably the large sample size and the prospectively collected data. Future areas of study include evaluating patient-reported outcomes for a range of PBI protocols and for a more diverse patient population.

Conclusions

Patients undergoing PBI vs WBI after breast-conserving surgery have similar levels of breast satisfaction and chest physical well-being at both early and late postoperative time points. These findings support the use of PBI as an alternative to WBI in terms of patient-reported outcomes in appropriately selected patients.

Synopsis:

This study evaluates patient-reported outcomes for patients with breast cancer undergoing lumpectomy and partial- versus whole-breast irradiation. Type of radiation was not associated with breast satisfaction or chest physical well-being, supporting the use of partial-breast irradiation in eligible patients.

ACKNOWLEDGEMENTS

The preparation of this study was supported in part by NIH/NCI Cancer Center Support Grant P30CA008748 to Memorial Sloan Kettering Cancer Center, and this study was presented in podium format at the Society of Surgical Oncology SSO 2024 Annual Meeting, March 23, 2024, Atlanta, GA. Dr. Jonas A. Nelson discloses Professional Services and Activities with RTI Surgical. Dr. Lior Z. Braunstein discloses Professional Services and Activities with the Cancer Prevention & Research Institute of Texas. Dr. Monica Morrow discloses receipt of honoraria from Roche. All other authors have no conflict of interests or commercial interests to disclose.

Footnotes

Disclosures:

Julia M. Chandler, MD, MS: None

Minji Kim, BS: None

Varadan Sevilimedu, MBBS, DrPH: None

Tiana V. Le, BS: None

Jonas A. Nelson, MD, MPH: Professional Services and Activities with RTI Surgical

Lior Z. Braunstein, MD: Professional Services and Activities with the Cancer Prevention & Research Institute of Texas

Monica Morrow, MD: Honoraria from Roche

Minna K. Lee, MD: None

Audree B. Tadros, MD, MPH; None

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