International comparison of cosmetic outcomes of breast conserving surgery and radiation therapy for women with ductal carcinoma in situ of the breast

18 August 2019

Ivo A. Olivotto, Emma Link, Claire Phillips, Timothy J. Whelan, Guy Bryant, Ian H. Kunkler, A. Helen Westenberg, Kash Purohit, Verity Ahern, Peter H. Graham, Mohamed Akra, Orla McArdle, Joanna J. Ludbrook, Jennifer A. Harvey, John H. Maduro, Carine Kirkove, Guenther Gruber,
Joseph D. Martin, Ian D. Campbell, Geoff P. Delaney, Boon H. Chua, on behalf of the BIG 03-07/TROG 07.01 trial investigators


To assess the cosmetic impact of breast conserving surgery (BCS), whole breast irradiation (WBI) fractionation and tumour bed boost (TBB) use in a phase III trial for women with ductal carcinoma in situ (DCIS) of the breast.

Materials and methods

Baseline and 3-year cosmesis were assessed using the European Organization for Research and Treatment of Cancer (EORTC) Cosmetic Rating System and digital images in a randomised trial of non-low risk DCIS treated with postoperative WBI +/ TBB. Baseline cosmesis was assessed for four geographic clusters of treating centres. Cosmetic failure was a global score of fair or poor. Cosmetic deterioration was a score change from excellent or good at baseline to fair or poor at three years. Odds ratios for cosmetic deterioration by WBI dose-fractionation and TBB use were calculated for both scoring systems.


1608 women were enrolled from 11 countries between 2007 and 2014. 85–90% had excellent or good baseline cosmesis independent of geography or assessment method. TBB (16 Gy in 8 fractions) was associated with a >2-fold risk of cosmetic deterioration (p < 0.001). Hypofractionated WBI (42.5 Gy in 16 fractions) achieved statistically similar 3-year cosmesis compared to conventional WBI (50 Gy in 25 fractions) (p > 0.18). The adverse impact of a TBB was not significantly associated with WBI fractionation (interaction p > 0.30).


Cosmetic failure from BCS was similar across international jurisdictions. A TBB of 16 Gy increased the rate of cosmetic deterioration. Hypofractionated WBI achieved similar 3-year cosmesis as conventional WBI in women treated with BCS for DCIS.