Abstract
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 K statistic (K) 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 (kappa = 0.59) than in the medium experienced (kappa = 0.35) and inexperienced (kappa= 0.33) observers. Conclusion: Previous experience in breast cancer conservative treatment should be considered a prerequisite for the evaluation of the aesthetic results. (C) 2005 Elsevier Inc.

Abstract
Twelve expert observers from nine different countries convened in a workshop to evaluate the validity of the Breast Cancer Conservative Treatment. Cosmetic results (BCCT.core) software, an objective method for the aesthetic evaluation of breast cancer conservative treatment. Experts were initially asked to subjectively classify the aesthetic results of 30 photographed cases submitted to breast cancer conservative treatment according to the four-point Harris scale. It was pre-established that if at least two-thirds [Cardoso MJ, Cardoso J, Santos AC, Barros H, Oliveira MC. Interobserver agreement and consensus over the esthetic evaluation of conservative treatment for breast cancer. Breast 2005] of participants provided the same classification this would be considered a consensual evaluation for that case. For cases where such agreement was not reached, consensus was obtained using a nominal group technique. Experts then individually performed objective evaluation of the same set of photographs using the BCCT.core software. This provides an automatic rating of aesthetic results, once scale and reference points in the photograph have been chosen. Agreement between observers, between each observer and the consensus, for computer evaluation obtained by the different participants and between software and consensus was calculated using multiple kappa (k) and weighted kappa (wk) statistics. In the subjective assessment, first-round consensus was achived in 17 (57%) cases. Overall interobserver agreement was fair to moderate (k = 0.40, wk = 0.57). In the objective assessment there was a higher level of concordance between participants (k = 0.86, wk = 0.90). Agreement between software and consensus classification was fair (k = 0.34, wk = 0.53), but was higher in the 17 cases that reached first-round consensus (k = 0.60, wk = 0.73). Merging the two middle classes of the Harris scale, to form a three-point scale, led to an improvement of all non-weighted measures of agreement. These results show that the BCCT.core software provides consistent evaluation of cosmesis. It has the potential to become a gold standard method for assessment of breast cosmesis in clinical trials, as it can be used simultaneously by a panel of observers from different parts of the world to provide more reliable assessments than has been possible previously.

Abstract
Twenty-four experts from 13 different countries were asked to evaluate photographs taken of 60 women following conservative breast cancer treatment. The esthetic result of each case was classified as poor, fair, good or excellent. Agreement was evaluated using the kappa (k) and weighted kappa (wk) statistics, for all observers, mate and female participants, those younger and older than 50 years, those seeing more than 250 cases a year, and those with previous publications in this area. Consensus was obtained by way of a modified Delphi approach, when more than 50% of participants provided the same classification. In a second round, consensual cases were disclosed and a revised opinion was asked in non-consensual ones. Agreement between all participants was fair (k = 0.24, wk = 0.37) and remained within the same range (k = 0.20-0.31, wk = 0.31-0.45) in the subgroups analyzed. First round consensus was obtained in 46 out of 60 cases (77%) and in the second round in 59 out of 60 cases (98%). Evaluation of the esthetic results of conservative treatment for breast cancer is only fairly reproducible when performed by experts working in different geographical areas. Consensus is obtainable if a relatively low threshold of agreement is considered acceptable.

Abstract
During the Turning Subjective Into Objective seminar held in Lisbon in May 2011, experts in the topic gathered to discuss the unsolved problems of aesthetic evaluation of breast-conserving treatment (BCT). The purpose of this study is to review the main methodological issues related to the aesthetic evaluation of BCT, to discuss currently used methods of evaluation and the lack of a gold standard, and to write a set of recommendations that can be used as guidance for the aesthetic evaluation of BCT.

Abstract
The breast cancer conservative treatment. cosmetic results (BCCT. core) is a new software tool created for the automatic and objective evaluation of the aesthetic result of BCCT. It makes use of a face-only photographic view of each patient and might thus have been considered insufficient for an accurate evaluation, as others have used multiple views of each patient. The purpose of this work is to compare the performance of the BCCT. core (using face-only views) with a subjective expert analysis using both the face-only and four-view assessment. Photographs in four-views of 150 patients, were evaluated by a panel of experts and a consensus classification was obtained. The agreement between the consensus and the BCCT. core (face-only view) was calculated using the kappa (k) and weighted kappa (wk) statistics. Face-only views, of the same 150 patients, were subsequently sorted out in a different order and sent for individual evaluation by three specialists from the previous panel of experts. The individual agreement between the face-only view and the four-view evaluation by each of the three experts and the consensus was calculated using the same methods. Obtained results were compared to the BCCT. core performance. The software obtained a moderate agreement with the consensus (k = 0.57; wk = 0.68). The highest value of agreement, from the three experts, between the four-view evaluation and the consensus was identical to the software agreement (k = 0.55; wk = 0.67). In the face-only view experiment, the highest value of agreement between the experts and the consensus was only fair (k = 0.37; wk = 0.54). Performance of the software was thus considered equal to that obtained by experts using a four-view evaluation.

Abstract
Breast cancer conservative treatment (BCCT), due to its proven oncological safety, is considered, when feasible, the gold standard of breast cancer treatment. However, aesthetic results are heterogeneous and difficult to evaluate in a standardized way, due to the lack of reproducibility of the subjective methods usually applied. The objective assessment methods, considered in the past as being less capable of evaluating all aspects of BCCT, are nowadays being preferred to overcome the drawbacks of the subjective evaluation. A computer-aided medical system was recently developed to objectively and automatically evaluate the aesthetic result of BCCT. In this system, the detection of the breast contour on the patient's digital photograph is a necessary step to extract the features subsequently used in the evaluation process. In this paper an algorithm based on the shortest path oil a graph is proposed to detect automatically the breast contour. The proposed method extends an existing semi-automatic algorithm for the same purpose. A comprehensive comparison with manually-drawn contours reveals the strength of the proposed method.