If you need radiation for breast cancer ask your radiation oncologist, before starting treatment, if they can treat you with a technique that may be able to significantly lower the amount of radiation dose to your lung and/or heart. This technique is called “deep inspiration breath holding,” and requires that you are able to hold your breath for between 20-30 seconds during treatments. This is particularly important for left-sided breast cancers.
Numerous studies have described the advantages of using this technique over the standard “free breathing” technique:
- One study reported that the breath hold technique reduced high radiation doses to the lung by up to 91% and reduced the average dose to the lung by 48% (reference). See FIGURE 3 for an example from one of my patients who also had relative reductions in lung doses by up to 50%.
- Another study found that when radiating left sided breast cancers using the breath hold technique, doses to the heart were reduced by up to 50% (reference). See FIGURES 1 and 2. It’s this reduced heart dose that most impresses me. A recent study reported that for every 1 Gy of radiation (a unit of radiation dose) increase in the mean dose to the heart there is a 7.4% increased risk of eventually developing a major cardiac event (such as a heart attack). This tells us that even small radiation dose reductions can make a BIG difference to your heart.
FIGURE ONE: This image demonstrates the two techniques (standard “free breathing” and deep inspiration “breath hold”.) The yellow arrow represents a typical radiation beam that is used to treat the breast. As you can see, the radiation beam in the “free breathing” image (top) goes through the heart (labeled, “H”.) However, the radiation beam used in the “breath hold” image (below) misses the heart. By expanding the lungs during a deep inspiration breath hold, the chest wall expands outward and the heart drops and falls out of the radiation field.
Watch My Fox 5 News Segment On The Breath-Holding Technique (October 8, 2014)
This is information is not new (it has been in use for over 10 years), but outside of academic teaching hospitals it is rarely used.
There are a few reasons why breath hold radiation therapy is not more widespread:
- Not all patients can hold their breath consistently for the required time (20-30 seconds per radiation field.)
- Technically, ensuring an accurate set up is more challenging and requires ‘coaching’ the patient on how to do the breathing technique. (Yes, it’s more challenging for the patient and the staff…but if it is possible to do in their office, it would be great to see more radiation oncologists giving their patients this option.)
- Radiation offices that do not have the necessary technologies (i.e. on-board imaging, active breathing control devices, surface motion tracking technologies, etc.) may either not be able to perform this technique or the radiation oncologist may not be comfortable doing it.
- Since it takes longer to treat each patient, busier radiation oncology centers may not have the time to do this technique.
Not everyone who needs radiation for breast cancer will benefit from treatment with the breath hold technique.
FIGURE TWO: This graph shows the significant reduction in radiation dose to the left anterior descending artery (LAD), a major cardiac blood vessel, when using the deep inspiration “breath hold” technique (purple graph line) versus the standard “free breathing” technique (blue graph line.)
In some patients, the radiation treatment plans will not show a significant difference in the doses to the heart or lungs regardless of the technique used. Your radiation oncologist will review both plans and determine if there is an advantage of one over the other. Even if the breath hold plan looks superior, there will be some individuals who simply can’t hold their breath for 20-30 seconds (making breath hold treatments impossible.) Additionally, if after breath hold coaching by our staff, you are not able to accurately inflate your lungs the same amount for each treatment, we will not be able to do the breath hold technique.
Is There A Benefit For Using A Breath Hold Technique For Right-Sided Breast Cancer Radiation?
Most of the time, yes, there will be lower doses of radiation to the right lung (see FIGURE 3.) Although the small reductions in right lung dose may not be clinically significant, decreasing dose to healthy tissues is compelling. The radiation dose to the heart (during right breast radiation) is typically very small regardless of the technique used. Therefore, the main reason to consider breath holding for right breast radiation treatment is to better protect the right lung.
FIGURE 3 shows the significant reduction in right lung radiation dose (in units of Gray or Gy) with the deep inspiration “breath hold” technique versus standard “free breathing.”
The Bottom Line:
Ask your radiation oncologist if deep inspiration breath holding makes sense for your situation and whether they are able and comfortable performing this technique. Unless you ask about it you may never know if you could have received it. This is your life, so don’t be concerned about hurting anyone’s feelings by asking for a referral or second opinion to a radiation oncology center that has experience using this technique.
