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For breast or chest wall radiotherapy you usually lie on your back on a sloping board with both arms above your head, in the same position every day. Skin marks or a camera that maps your skin help line you up, and X-ray images, ideally daily, check your position before treatment. If lifting both arms is too hard, one arm up is an option; some departments treat larger breasts lying face down.
The ESTRO-ACROP guideline (2023) is the only international guideline on breast set-up. Its recommendations: supine as the standard position for most treatments (it works with surface guidance); prone considered for larger breasts or more lung sparing where the equipment, expertise and patient tolerance allow; both arms up as more stable (one randomised study), one arm up for those who cannot tolerate it; flat or inclined boards both acceptable if collision risk is managed. There is insufficient evidence for any breast immobilisation device; bras or thermoplastic moulds may help selected patients with large or pendulous breasts, with skin dose evaluated locally.
Without surface-guided imaging, skin marks are required; the options (permanent tattoo, temporary marks) should be discussed with the patient, and the guideline notes that temporary marks may affect wellbeing less. For verification it recommends daily 2D-2D or 3D online imaging where available, matching on the bony anatomy under the treated volume and the breast tissue or contour, and warns against using surface guidance as the only verification without local validation, especially for partial-breast or boost treatment. Most of its statements rest on small studies; several are labelled considerations because the evidence could not support a recommendation. Breath-hold for left-sided treatment is a separate protocol.
Why: Lying on the back is the simplest position to repeat each day and lets surface cameras see the breast.
“Based on the literature and the current equipment we recommend the supine position as the standard for most treatments, see the recommendations when prone positioning is advised below.”
ESTRO (Technical Innovations and Patient Support in Radiation Oncology; Mast et al.) 2023 · Recommendation
Why: Lying face down lets a large breast fall away from the chest, which can even out the dose and spare the lung and skin folds.
“For patients with larger breasts or patients that require a higher degree of lung sparing, prone may be considered if the equipment and expertise are available, and the patient can tolerate the position.”
ESTRO (Technical Innovations and Patient Support in Radiation Oncology; Mast et al.) 2023 · Recommendation
Why: Both arms up is steadier from day to day, but after surgery some people cannot lift both arms for long.
“Both arms up are considered more stable from one randomised study, in this study significantly lower translational displacements were found.”
ESTRO (Technical Innovations and Patient Support in Radiation Oncology; Mast et al.) 2023 · Recommendation
Why: A board that clicks into the same place on the couch every day makes the position easier to repeat.
“While lacking formal evidence, anecdotally the authors strongly advise the use of positioning aids, e.g., supine breast boards, which can be indexed to both the treatment couch and skin reference marks for efficient and accurate patient positioning.”
ESTRO (Technical Innovations and Patient Support in Radiation Oncology; Mast et al.) 2023 · Consideration (no formal evidence)
Why: No device has been shown to help most people, and anything resting on the breast can raise the skin dose and make skin reactions worse.
“There is currently insufficient evidence to support the widespread adoption of any specific type of immobilisation device of the breast.”
ESTRO (Technical Innovations and Patient Support in Radiation Oncology; Mast et al.) 2023 · Recommendation
Why: Marks are needed to line the body up before imaging; permanent tattoos stay for life, and some people find them a lasting reminder of their cancer.
“The available options for skin marking should be discussed taking into account long-term patient experience and patient preference.”
ESTRO (Technical Innovations and Patient Support in Radiation Oncology; Mast et al.) 2023 · Recommendation
Why: Daily images before treatment catch a shift in position and allow it to be corrected before the radiation is given.
“Where available, 2D-2D or 3D imaging daily is recommended for online position verification.”
ESTRO (Technical Innovations and Patient Support in Radiation Oncology; Mast et al.) 2023 · Recommendation
Why: A single flat image cannot see a shift towards or away from the camera.
“If 2D-2D or 3D position verification is not available, the limitations of 2D position verification (online or offline) in visualising out-of-plane setup errors should be considered and appropriate target volume margins employed.”
ESTRO (Technical Innovations and Patient Support in Radiation Oncology; Mast et al.) 2023 · Recommendation
Why: The breast can move and change shape relative to the ribs, so matching on bone alone can miss it.
“Image-matching should evaluate bony anatomy directly underlying the treated volume as well as breast tissue or external breast contour.”
ESTRO (Technical Innovations and Patient Support in Radiation Oncology; Mast et al.) 2023 · Recommendation
Why: Cameras see the skin, not the surgical bed inside the breast, which is what a partial-breast or boost treatment aims at.
“SGRT should not be used as a sole means of position verification without centres first conducting a local study to validate consistent agreement with the pre-existing IGRT modality.”
ESTRO (Technical Innovations and Patient Support in Radiation Oncology; Mast et al.) 2023 · Recommendation
Why: Holding a deep breath moves the heart away from the treated area.
“Use a deep inspiratory breath-hold radiotherapy technique for people with left-sided breast cancer to reduce the dose to the heart.”
NICE 2018 · [2018]
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
Supine on an indexed breast board with both arms up where tolerated, no routine breast immobilisation device, skin marks (permanent or temporary, chosen with the patient) unless surface guidance replaces them, and daily online 2D-2D or 3D imaging matched on bone and breast tissue, with surface guidance used alone only after local validation (ESTRO-ACROP 2023). Prone treatment is an option for larger breasts or extra lung sparing where expertise exists; for left-sided cancer the heart is better spared by supine breath-hold (HeartSpare IB, in the breath-hold protocol). ESTRO-ACROP is the only guideline read on this subject, so there is no second guideline to set beside it; its authors say most of the underlying studies are small and old.
ESTRO (Technical Innovations and Patient Support in Radiation Oncology; Mast et al.) 2023 · ESTRO (Radiotherapy and Oncology; Aznar et al.) 2023
Where it differs: The patient lies face down on a dedicated board with the treated breast hanging through an opening.
Evidence: ESTRO-ACROP: improves dose homogeneity and can reduce lung and skin-fold dose, but is harder to implement and needs a dedicated team; most supine-prone comparisons are more than 10 years old; no predictor tells which patients do better prone.
ESTRO (Technical Innovations and Patient Support in Radiation Oncology; Mast et al.) 2023
Where it differs: Only the arm on the treated side is raised, the other resting at the side or across the waist.
Evidence: Cohort studies report it as more comfortable; one randomised study found both arms up more stable. ESTRO-ACROP allows one arm up for patients who cannot tolerate both.
ESTRO (Technical Innovations and Patient Support in Radiation Oncology; Mast et al.) 2023
Where it differs: Set-up marks are drawn or applied semi-permanently and renewed during the course, so no lifelong tattoo remains.
Evidence: ESTRO-ACROP cites a randomised study (176 against 166 patients) that found no significant difference in random or systematic set-up error between tattoos and non-permanent marks on weekly portal imaging, and a qualitative study (SuPPORT 4 All) reporting that permanent tattoos may affect wellbeing. It lists temporary marks as a consideration.
ESTRO (Technical Innovations and Patient Support in Radiation Oncology; Mast et al.) 2023
Where it differs: An optical surface imaging system positions the patient against their planning surface, with no tattoos or marks.
Evidence: ESTRO-ACROP: SGRT may improve set-up accuracy and allow marks to be omitted, but must be validated in the department's own workflow, and should not replace X-ray verification without local validation.
ESTRO (Technical Innovations and Patient Support in Radiation Oncology; Mast et al.) 2023
Where it differs: A fabric bra or moulded shell holds a large or pendulous breast in a fixed shape.
Evidence: ESTRO-ACROP: may benefit selected patients; in one free-breathing study a bra reduced mean heart dose from 4.9 to 1.4 Gy but phantom measurements found skin dose about 1.5 times higher with it; the effect on skin toxicity must be evaluated locally.
ESTRO (Technical Innovations and Patient Support in Radiation Oncology; Mast et al.) 2023
Most people having breast radiotherapy are given small permanent ink dots to line them up on the couch. In a United Kingdom survey of 204 people afterwards, half rated the impact of those tattoos as negative, and surface cameras or ultraviolet ink line people up as accurately without leaving a visible mark.
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Supine as the standard position for most treatments | Recommendation | ESTRO (Technical Innovations and Patient Support in Radiation Oncology; Mast et al.) 2023 |
| Without surface guided imaging, skin marking is required “In the absence of surface guided imaging, the use of skin marking is required.” | Recommendation (summary table) | ESTRO (Technical Innovations and Patient Support in Radiation Oncology; Mast et al.) 2023 |
| Temporary skin marks may be an alternative to permanent tattoos with less impact on wellbeing “Temporary skin marks may be an alternative to permanent tattoos with a lesser impact on patient well-being” | Consideration | ESTRO (Technical Innovations and Patient Support in Radiation Oncology; Mast et al.) 2023 |
| Daily 2D-2D or 3D online position verification where available | Recommendation | ESTRO (Technical Innovations and Patient Support in Radiation Oncology; Mast et al.) 2023 |
| SGRT should not replace standard image guidance without local validation, with particular caution for partial-breast and integrated-boost treatment “SGRT should not replace standard image-guidance without local validation and particular caution to partial-breast/integrated-boost treatments.” | Recommendation (summary table) | ESTRO (Technical Innovations and Patient Support in Radiation Oncology; Mast et al.) 2023 |
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