# Deep-breath-hold radiotherapy for every suitable person with left-sided breast cancer

Source: https://onco.cc/ideas/idea-pu-breath-hold-left-breast-routine/  
OnCo record `idea-pu-breath-hold-left-breast-routine` (Idea). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Taking and holding a deep breath during each beam moves the heart away from the treated breast and roughly halves the dose it receives. England's national guideline has recommended it for left-sided breast cancer since 2018, yet surveys in Germany, Austria, Switzerland, Australia and the United States found it applied to a fraction of the people who could have it.

## Summary

Why heart dose matters. In a population-based study of 2,168 women treated between 1958 and 2001 in Sweden and Denmark, the rate of major coronary events rose by 7.4 per cent for every gray of mean dose to the heart (95 per cent confidence interval 2.9 to 14.5), with no threshold below which the risk disappeared, starting within five years and continuing into the third decade. The proportional increase was the same in women with and without cardiac risk factors, so women who already had those factors gained the most in absolute terms from a lower dose.

What breath-hold does. A pooled analysis of 12 comparative studies with 1,019 patients found that breath-hold lowered heart dose, dose to the left anterior descending coronary artery and left lung dose compared with free breathing, without reducing coverage of the breast. A planning study using audio coaching and visual feedback reduced mean heart dose from 3.7 to 1.7 Gy and mean coronary artery dose from 18.1 to 6.4 Gy. The UK HeartSpare study randomised 23 women between a voluntary breath-hold and one held by a device that closes a valve: dose and positional accuracy were the same, patients and radiographers preferred the voluntary version, it was quicker to set up, and it was cheaper. The voluntary technique needs no new machine.

The guideline. NICE recommendation 1.13.2 in NG101 (2018) reads: "Use a deep inspiratory breath-hold radiotherapy technique for people with left-sided breast cancer to reduce the dose to the heart." The committee found no harms and no loss of target coverage, and found no evidence either way for right-sided cancer, so it made no recommendation there.

The measured gap. A 2015 survey of 82 radiotherapy departments in Germany, Austria and German-speaking Switzerland found that 90.2 per cent offered a heart-sparing technique, but 87.7 per cent used one in fewer than half of their breast cancer patients, and fewer than half (46.3 per cent) had written internal guidance. A survey of 50 of Australia's 69 radiotherapy centres in the same year concluded there may be less uptake of breath-hold there than in the international literature. A 2022 survey of 53 United States radiation oncologists found 90 per cent offered breath-hold and 74 per cent of those used it for at least a quarter of their breast patients; 32 per cent said they would be less likely to use it for a patient who did not speak English. No source OnCo found measures breath-hold use across the NHS.

What a reader can do: anyone having radiotherapy to the left breast or chest wall can ask whether breath-hold is planned for them and, if not, why not.

## Fields

- Kind: Idea
- Last checked: 2026-10-20
- Tags: protocol-upgrade; upgrade:proven-unevenly-used; evidence:strong; precision; breast
- Hypothesis: Making breath-hold the written default for left-sided breast and chest-wall radiotherapy, with exceptions recorded, raises its use to more than 90 per cent of eligible patients within a year and lowers average mean heart dose across the department, without lengthening appointments.
- Rationale: Heart dose carries a measured, dose-proportional risk with no threshold. Voluntary breath-hold reduces that dose using equipment most departments already have, a national guideline has recommended it since 2018, and the surveys that measure its use find it applied to a minority of eligible patients in several high-income countries.
- Proposed test: A department-level audit of breath-hold use and mean heart dose across a regional network before and after a written default with exception reporting, followed by linkage to cardiac events through hospital records at ten years.
- Maturity: being-tested-at-scale
- Actor: clinic

## Sources

- Darby et al., Risk of ischemic heart disease in women after radiotherapy for breast cancer (New England Journal of Medicine 2013): https://doi.org/10.1056/NEJMoa1209825
- NICE guideline NG101, Early and locally advanced breast cancer: recommendations 1.13.2 (breath-hold, 2018) and 1.13.13 (26 Gy in 5 fractions, 2023): https://www.nice.org.uk/guidance/ng101/chapter/Recommendations
- Lai et al., Meta-analysis of deep inspiration breath hold versus free breathing in postoperative radiotherapy for left-side breast cancer (Breast Cancer 2020): https://doi.org/10.1007/s12282-019-01023-9
- Vikström et al., Cardiac and pulmonary dose reduction for tangentially irradiated breast cancer, utilizing deep inspiration breath-hold with audio-visual guidance (Acta Oncologica 2011): https://doi.org/10.3109/0284186x.2010.512923
- Bartlett et al., The UK HeartSpare Study: randomised evaluation of voluntary deep-inspiratory breath-hold in women undergoing breast radiotherapy (Radiotherapy and Oncology 2013): https://doi.org/10.1016/j.radonc.2013.04.021
- Duma et al., Heart-sparing radiotherapy in patients with breast cancer: a pattern of practice survey in the German-speaking countries (Medical Dosimetry 2017): https://doi.org/10.1016/j.meddos.2017.03.002
- Dundas et al., Australian survey on current practices for breast radiotherapy (Journal of Medical Imaging and Radiation Oncology 2015): https://doi.org/10.1111/1754-9485.12348
- Shukla et al., Disparities in radiation therapy: practice patterns analysis of deep inspiratory breath hold use in non-English speakers (International Journal of Radiation Oncology, Biology, Physics 2022): https://doi.org/10.1016/j.ijrobp.2021.12.171

## Connected records

- ideas: [Breath-hold coaching and home practice a week before the planning scan, in the patient's own language](https://onco.cc/ideas/idea-pu-breath-hold-coaching-before-planning/), [Let the patient see their own breath-hold on a screen or in video glasses](https://onco.cc/ideas/idea-pu-breath-hold-visual-feedback/), [Radiotherapy set-up without permanent ink tattoos, using surface guidance or invisible ink](https://onco.cc/ideas/idea-pu-tattoo-free-set-up/)
- cancers: [Breast cancer (all types)](https://onco.cc/cancers/breast-cancer/), [HER2-positive breast cancer](https://onco.cc/cancers/breast-her2-positive/), [HR-positive / HER2-negative breast cancer](https://onco.cc/cancers/breast-hr-positive/)
- fronts: [Radiation Therapy](https://onco.cc/fronts/radiation/)
- technologies: [Heart function after anthracyclines, trastuzumab and chest radiotherapy](https://onco.cc/technologies/cardiotoxicity-surveillance-recovery/), [Respiratory gating and tumour tracking systems (RPM, ABC, Calypso, Synchrony)](https://onco.cc/technologies/respiratory-gating-tumour-tracking-systems/), [Respiratory motion management (4D-CT, gating, breath-hold, tracking)](https://onco.cc/technologies/respiratory-motion-management/), [Surface-guided radiotherapy (SGRT)](https://onco.cc/technologies/surface-guided-radiotherapy/)
- institutions: [National Institute for Health and Care Excellence](https://onco.cc/institutions/nice/)
- terms: [Deep inspiration breath-hold (DIBH)](https://onco.cc/terms/deep-inspiration-breath-hold/), [Late effects and survivorship toxicity](https://onco.cc/terms/late-effects/)
- bottlenecks: [Knowledge reaches practice too slowly](https://onco.cc/bottlenecks/b-knowledge-diffusion/), [Survivorship and late effects are neglected](https://onco.cc/bottlenecks/b-survivorship/), [Toxicity and quality of life are undervalued](https://onco.cc/bottlenecks/b-toxicity-qol/)

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