Purpose: Photographic documentation of breast changes after breast radiotherapy (RT) is a helpful tool to both subjectively and objectively evaluate cosmesis. This study aimed to evaluate cosmesis in breast cancer patients after receiving hypo fractionated whole breast RT (HF-WBRT), norm fractionated (NF-WBRT), intraoperative RT (IORT) or combined WBRT/IORT within prospective studies.
 
Methods: After excluding files with missing or inadequate photos from three prospective clinical trials (KOSIMA, TARGIT-A & TARGIT-E) 205 patients were included in subjective analysis while 185 patients were included in the objective analysis 2 years after RT respectively. Subjective evaluation was done using the Harvard scale. Objective evaluation was done by assessing percentage breast retraction. Based on the treatment received, patients were divided into 5 groups: 1.HF-WBRT 40.05Gy/2.67Gy±Boost, 2.NF- WBRT 50Gy/2Gy±Boost, 3.NF-WBRT 56Gy/2Gy, 4.IORT 20Gy, 5.IORT 20Gy +WBRT 46Gy/2Gy.
 
Results: Subjectively, the rate of acceptable cosmesis was 84% while objectively it was around 56%. At 2 years, there was neither a subjective (p=0.55) nor objective (p=0.88) significant difference in cosmesis between the 5 treatment groups. Regarding possible factors affecting cosmesis at 2 years, there were no differences concerning age, smoking, body mass index, chemotherapy, hormone therapy or type of axillary surgery. Significantly better cosmesis was observed in patients with tumor location in the upper outer quadrant (p < 0.001) and with percentage of excised to total breast volume <10% (p < 0.0294).
 
Conclusions: After two years of follow-up, adjuvant radiotherapy caused only minor cosmetic deterioration based on subjective assessment of photographic documentation. The influence of the treatment method was minimal. Hypo fractionated WBRT and IORT as a single treatment or as a boost were cosmetically similar to norm fractionated WBRT. Tumor location and excised breast volume were the only factors significantly affecting cosmetic outcome