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Radiation therapy (RT) has been widely used for breast cancer (BC) treatments. However, for left sided breast radiotherapy cardiac complication is of concern, because earlier studies did not show an increase in overall survival in breast cancer patients treated with RT because of the increase in non-breast cancer mortality, in particular cardiovascular events. Additional systemic treatment may even enhance this effect. Deep inspiration breath-hold (DIBH) technique can reduce the cardiac dose by increasing the distance between the heart and the breast or chest wall.

Overall, 350 patients (ages 30-83) with left-sided BC were enrolled on a prospective quality assurance study from 2016-2019. We treated 150 patients with free breathing (FB) and 200 with DIBH. For treatment application the Catalyst/Sentinel system (C-RAD AB, Uppsala, Sweden) was used and gating control was performed by an audio-visual patient feedback system. CT and surface data were acquired in FB and DIBH. FB patients were significantly older (median: 58 vs. 48.5 years), more likely to have pre-existing heart (11% vs. 1%) and lung disease (13% vs. 4%), and less likely to receive chemotherapy (42% vs. 66%). Treatments were prescribed with 50 Gy in 25-28 fractions. Opposing tangent fields with electronic compensator techniques (field-in-field) were used to improve dose homogeneity. The separation between the heart and the chest wall was standardizedly measured at the 7th thoracic vertebrae and 11 cm anterior to the vertebral body on the scan for each patient.

The overall treatment time, including patient setup and alignment as well as beam on time, ranged from 7-15 minutes for each fraction. The average time for each treatment field is 11 seconds (ranged for 9.5-15 seconds). The separation between the heart and chest wall for DIBH scans is 6.5 cm (range 5.1-7.8 cm). This is significantly larger than the separation in the FB scans, which is 2.72 cm (range 2-4.25 cm). The maximum dose to the heart is significantly lower for the DIBH scans than the FB scans, 11.0 Gy (range 6.8-21 Gy) vs 35.6 Gy (range 12.8-45.5 Gy). The mean dose to the heart is lower, 0.93 vs. 2.06 Gy.

DIBH can significantly benefit the left breast and chest wall patients by separating the heart from the radiation fields. Daily real-time surfacing imaging facilitates patients’ setup and ensures accurate and reproducible positioning for DIBH treatments without additional radiation dose. Patient compliance was good, and treatment durations are clinically acceptable. DIBH with real-time surface monitoring appears to be a viable option to potentially reduce heart dose for left breast cancers patients, and thus may reduce the potential long-term cardiovascular complications.