Clinical investigation
Breast
Choosing observers for evaluation of aesthetic results in breast cancer conservative treatment

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Purpose

The subjective evaluation of aesthetic results in conservative breast cancer treatment has largely been used without questioning the observer's skills. The aim of this study was to evaluate interobserver agreement of the aesthetic results of breast cancer conservative treatment in three groups of observers with different levels of experience.

Methods and materials

Photographs were taken of 55 women who had undergone conservative unilateral breast cancer treatment and 5 control women with no breast disease. The images were then distributed to 13 observers who were divided into three groups according to their experience in breast cancer treatment: experienced, medium experienced, and inexperienced. They were first asked to distinguish the patients from the controls and for the patients to identify the operated side. Subsequently, they were asked to classify the aesthetic result as excellent, good, fair, or poor. The accuracy in identifying controls, patients, and side of treatment was calculated individually for all observers. The interobserver agreement for the aesthetic result was calculated using observed agreement and multiple κ statistic (κ) in each of the three groups.

Results

Inexperienced observers performed significantly worse than experienced observers in identifying controls, patients, and the side of treatment. Agreement of the aesthetic result was significantly greater in the group of experienced observers (κ = 0.59) than in the medium experienced (κ = 0.35) and inexperienced (κ = 0.33) observers.

Conclusion

Previous experience in breast cancer conservative treatment should be considered a prerequisite for the evaluation of the aesthetic results.

Introduction

Conservative treatment of breast cancer has a proven value for local disease control, as reported in randomized trials (1, 2). The quality of the aesthetic results remains an additional goal that still has to be formally evaluated (3). The methods of evaluating breast cancer conservative treatment are traditionally considered to be subjective (4, 5, 6, 7) or objective (8, 9). For subjective evaluations, observers are usually selected from the local medical staff for practical reasons, and the criteria used for this selection frequently are not described (10, 11, 12). It is possible that previous experience in breast cancer conservative treatment will influence the evaluation of the aesthetic results, because this may enable the distinction between the general aesthetic features valued by society and those related to the surgical procedure itself. To address this issue, we asked three groups of observers with different levels of experience to evaluate the aesthetic results of patients who had undergone unilateral breast cancer conservative treatment to assess the interobserver agreement in each group.

Section snippets

Methods and materials

Photographs were taken of 55 breast cancer patients who had undergone unilateral conservative breast surgery and radiotherapy. The treatment had been completed at least 1 year before the onset of the study. All patients provided written informed consent to participate. A digital camera with a resolution of 4 mega pixels was used, having as background a blue panel of 0, 128, 255. Photographs were taken in four positions with the patient standing on floor marks: face, arms down; face, arms up;

Results

In the identification of the treated cases, the accuracy was >95% in all experienced observers, in all but one of the medium experienced observers, and in only one of the inexperienced group (Table 1). The proportion varied between 96.7% and 98.3% in the experienced group, between 83.3% and 100% in the medium experienced group, and between 83.3% and 96.7% in the inexperienced group. Similar results were obtained for the identification of the treated side (Table 1).

The overall observed agreement

Discussion

The subjective evaluation of the aesthetic results in breast cancer patients after conservative treatment is usually reported as performed globally by individuals with varying levels of expertise (13, 14, 15, 16). Very few studies have compared the agreement of the aesthetic results in groups of observers with different levels of experience (3, 17).

Christie et al. (3), in a study of 47 conservative breast cancer patients, evaluated the interobserver agreement in the aesthetic assessment as

Acknowledgments

We thank Prof. Ayres-de-Campos for his help in the preparation of the manuscript and the following for their participation as observers in this study: Drs. Matos Lima, Pinto-Sousa, António Gouveia, John Preto, Susy Costa, Sandra Ferreira, Eduardo Costa, Francisco Santos, Carla Morgado, Ricardo Seromenho, Susana Silva, and Sandra Sousa.

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