title: The UK HeartSpare Study: randomised evaluation of voluntary deep-inspiratory breath-hold in women undergoing breast radiotherapy.
abstract: OBJECTIVE
  To determine whether voluntary deep-inspiratory breath-hold (v_DIBH) and deep-inspiratory breath-hold with the active breathing coordinator™ (ABC_DIBH) in patients undergoing left breast radiotherapy are comparable in terms of normal-tissue sparing, positional reproducibility and feasibility of delivery.
  
  
  METHODS
  Following surgery for early breast cancer, patients underwent planning-CT scans in v_DIBH and ABC_DIBH. Patients were randomised to receive one technique for fractions 1-7 and the second technique for fractions 8-15 (40 Gy/15 fractions total). Daily electronic portal imaging (EPI) was performed and matched to digitally-reconstructed radiographs. Cone-beam CT (CBCT) images were acquired for 6/15 fractions and matched to planning-CT data. Population systematic (Σ) and random errors (σ) were estimated. Heart, left-anterior-descending coronary artery, and lung doses were calculated. Patient comfort, radiographer satisfaction and scanning/treatment times were recorded. Within-patient comparisons between the two techniques used the paired t-test or Wilcoxon signed-rank test.
  
  
  RESULTS
  Twenty-three patients were recruited. All completed treatment with both techniques. EPI-derived Σ were ≤ 1.8mm (v_DIBH) and ≤ 2.0mm (ABC_DIBH) and σ ≤ 2.5mm (v_DIBH) and ≤ 2.2mm (ABC_DIBH) (all p non-significant). CBCT-derived Σ were ≤ 3.9 mm (v_DIBH) and ≤ 4.9 mm (ABC_DIBH) and σ ≤ 4.1mm (v_DIBH) and ≤ 3.8mm (ABC_DIBH). There was no significant difference between techniques in terms of normal-tissue doses (all p non-significant). Patients and radiographers preferred v_DIBH (p=0.007, p=0.03, respectively). Scanning/treatment setup times were shorter for v_DIBH (p=0.02, p=0.04, respectively).
  
  
  CONCLUSIONS
  v_DIBH and ABC_DIBH are comparable in terms of positional reproducibility and normal tissue sparing. v_DIBH is preferred by patients and radiographers, takes less time to deliver, and is cheaper than ABC_DIBH.
authors.affiliation: Department of Academic Radiotherapy, Royal Marsden NHS Foundation Trust, Sutton, UK. Electronic address: frederick.bartlett@rmh.nhs.uk.
authors.forename: Frederick R
authors.initials: FR
authors.lastname: Bartlett
authors.forename: Ruth M
authors.initials: RM
authors.lastname: Colgan
authors.forename: Karen
authors.initials: K
authors.lastname: Carr
authors.forename: Ellen M
authors.initials: EM
authors.lastname: Donovan
authors.forename: Helen A
authors.initials: HA
authors.lastname: McNair
authors.forename: Imogen
authors.initials: I
authors.lastname: Locke
authors.forename: Philip M
authors.initials: PM
authors.lastname: Evans
authors.forename: Joanne S
authors.initials: JS
authors.lastname: Haviland
authors.forename: John R
authors.initials: JR
authors.lastname: Yarnold
authors.forename: Anna M
authors.initials: AM
authors.lastname: Kirby
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001943:Breast Neoplasms / Q000000981:diagnostic imaging* / Q000473:pathology / Q000532:radiotherapy* / Q000601:surgery; D062485:Breath Holding / Q000528:radiation effects*; D054893:Cone-Beam Computed Tomography; D005069:Evaluation Studies as Topic; D005260:Female; D005500:Follow-Up Studies; D006321:Heart / Q000528:radiation effects; D006801:Humans; D015412:Mastectomy, Segmental / Q000379:methods; D008875:Middle Aged; D009361:Neoplasm Invasiveness / Q000473:pathology; D009367:Neoplasm Staging; D058958:Organs at Risk / Q000528:radiation effects; D056888:Patient Positioning; D011879:Radiotherapy Dosage; D011880:Radiotherapy Planning, Computer-Assisted; D018714:Radiotherapy, Adjuvant; D020266:Radiotherapy, Conformal / Q000379:methods; D061089:Radiotherapy, Image-Guided; D012016:Reference Values; D015203:Reproducibility of Results; D018570:Risk Assessment; D018709:Statistics, Nonparametric; D016896:Treatment Outcome; D006113:United Kingdom
keywords: Activated breathing control; Breast cancer; Cardiac dose; Radiotherapy; Voluntary breath-hold