Background: Breast cancer (BC) in low–middle income country commonly presents as large operable/locally advanced BC (LO/LABC). Advances in treatment have gradually increased the probability of breast conservation in this population. Hypo-fractionated whole breast radiotherapy (HF-WBI) has become the standard of care. Literature on cosmesis in high-risk BC after HF-WBI is sparse. Hence, we evaluated the cosmesis, late effects (LE) and patient-reported outcome measures (PROM) and factors affecting it in women with high-risk BC.

Materials and methods: Patients who underwent upfront breast-conserving surgery (BCS) or after neoadjuvant chemotherapy underwent physical cosmetic assessment (CA), LEs evaluation and PROM using European Organisation for Research and Treatment of Cancer, Radiation Therapy Oncology Group and BR23 questionnaire, respectively. Patient, tumour and treatment-related factors were correlated with CA, LE and PROM by univariate and multivariate analysis.

Results: 186 women underwent BCS, but only 82 could participate due to COVID-19 pandemic. Prevalence of high-risk features were: >3 cm tumour in 37%, 50% node positive, 100% received chemotherapy (CT), grade 3 in 57% and Her-2 (enriched)/TNBC in 70%. At a median follow-up of 5 years, we found 56% of patients had adverse global cosmesis. Factors responsible for adverse cosmesis were tumour size [>3 cm, HR 2.3], node positivity [HR 0.3], receipt of CT [HR 6.5], large resection volumes [HR 4.6], large breast volume [HR 1] and supraclavicular radiotherapy in 43% [HR 0.7]. Dosimetric factors found significant for adverse cosmesis were breast volume receiving 107% dose (> than 10 cubic centimetres (cc), HR 5) and breast volume receiving 100% dose (> than 120 cc, HR 5). The incidence of arm oedema was 6%, shoulder stiffness 20%, brachial plexopathy 4% and factors significant for LE were tumour size > 3cm [HR 9], breast volume receiving 107% [HR 6] and co-morbidity [HR 3]. PROM revealed that 69% had poor body image, 35% had breast pain and 47% were sexually active. Arm score had a correlation with positive nodal status (HR 4.3), and breast score with large breast volume (HR 5.4) and premenopausal status (HR 7.3).

Conclusion: Our data reveals that 75% of our population have large breast, the presence of high-risk features in 50% women, which resulted in a high incidence of adverse global cosmesis, (56%), LE and PROM (poor body image, breast pain and low sexually activity).