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We compared overall survival (OS), breast cancer specific survival (BCSS) and second primary malignancies (SPM) in early-stage breast cancer patients treated with postoperative radiotherapy (PORT) versus those treated neoadjuvant radiotherapy (NART) and intraoperative radiotherapy (IORT) after propensity score matching by 1:1.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>A total of 457,166 patients were included in this study. After matching, the 20-year OS of 1441 patients in NART cohort was lower than that in PORT cohort (p\u2009&lt;\u20090.01), particularly in hormone receptor positive patients (p\u2009&lt;\u20090.01). NART were dependent prognostic factors for 20-year OS [Hazard Ratio (HR):1.21, 95%CI: 1.06\u20131.38, p\u2009&lt;\u20090.01). No significant difference in BCSS was observed between NART and PORT treatments. Additionally, patients undergoing NART had a lower risk of all SPM (p\u2009=\u20090.01) and second solid cancers (p\u2009=\u20090.02) but a comparable risk of second hematological malignancies (p\u2009=\u20090.55) than patients administered PORT. HR-positive was a risk factor for SPM. No OS, BCSS or SPM risk difference were significantly observed in the 2096 pairs of IORT and PORT groups.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Compared to PORT, NART and IORT don\u2019t offer survival advantages for early-stage breast cancer patients. Altering the sequence of radiotherapy requires careful evaluation.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1177\/00368504261420988","type":"journal-article","created":{"date-parts":[[2026,1,30]],"date-time":"2026-01-30T17:48:05Z","timestamp":1769795285000},"update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":0,"title":["Optimizing radiotherapy for early-stage breast cancer: A comparative SEER-based analysis of neoadjuvant, intraoperative, and postoperative approaches"],"prefix":"10.1177","volume":"109","author":[{"given":"Lingrui","family":"Li","sequence":"first","affiliation":[{"name":"Chinese Academy of Medical Sciences and Peking Union Medical College"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Xiangyi","family":"Kong","sequence":"additional","affiliation":[{"name":"Chinese Academy of Medical Sciences and Peking Union Medical College"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Zhuang","family":"Xiong","sequence":"additional","affiliation":[{"name":"The Third Medical Center, Chinese PLA General Hospital"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Xiangyu","family":"Wang","sequence":"additional","affiliation":[{"name":"Chinese Academy of Medical Sciences and Peking Union Medical College"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Wenxiang","family":"Zhang","sequence":"additional","affiliation":[{"name":"Chinese Academy of Medical Sciences and Peking Union Medical College"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yi","family":"Fang","sequence":"additional","affiliation":[{"name":"Chinese Academy of Medical Sciences and Peking Union Medical College"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Zhongzhao","family":"Wang","sequence":"additional","affiliation":[{"name":"Chinese Academy of Medical Sciences and Peking Union Medical College"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3224-3993","authenticated-orcid":false,"given":"Jing","family":"Wang","sequence":"additional","affiliation":[{"name":"Chinese Academy of Medical Sciences and Peking Union Medical College"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"179","published-online":{"date-parts":[[2026,1,30]]},"reference":[{"key":"e_1_3_3_2_2","doi-asserted-by":"publisher","DOI":"10.3322\/caac.21834"},{"key":"e_1_3_3_3_2","doi-asserted-by":"publisher","DOI":"10.3322\/caac.21820"},{"key":"e_1_3_3_4_2","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMoa022152"},{"key":"e_1_3_3_5_2","doi-asserted-by":"publisher","DOI":"10.6004\/jnccn.2022.0030"},{"key":"e_1_3_3_6_2","article-title":"Neoadjuvant radiotherapy in the approach of locally advanced breast cancer","volume":"4","author":"Sousa C","year":"2020","unstructured":"Sousa C, Cruz M, Neto A, et al. 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