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For radiotherapy to the left breast or chest wall, you take a deep breath and hold it for about 20 to 30 seconds during each part of the treatment. Filling the lungs moves the heart away from the treated area, so it gets less radiation. You practise first, and the planning scan is done holding your breath. If breath-holding does not suit you, treatment while breathing normally is still safe.
NICE NG101 1.13.2 [2018] recommends a deep inspiratory breath-hold technique for people with left-sided breast cancer to reduce heart dose; the RCR UK consensus (2016) supported, unanimously, that every department have a breath-hold technique available and, very strongly, a mean heart dose under 2 Gy for more than 90% of left-sided patients not having internal mammary chain treatment. The rationale is dose: the Darby case-control study found major coronary events rose by 7.4% per gray of mean heart dose with no threshold.
The ESTRO-ACROP implementation guideline (2023, ungraded expert consensus) sets out the practice: coach the patient before the planning CT, aim for a comfortable rather than maximal breath-hold (about 20 to 30 seconds is achievable for more than 90% of breast patients), plan on a CT taken in breath-hold with the same monitoring equipment used on the treatment machine, verify both patient position and breath-hold level with imaging, ideally daily, and be able to re-image and re-plan if the breathing pattern changes. It does not recommend a routine extra free-breathing planning CT beyond the implementation stage, because of the added dose.
Voluntary breath-hold without equipment was as reproducible and heart-sparing as a spirometry device (ABC) in the HeartSpare randomised crossover study, quicker and preferred by patients and radiographers; in larger-breasted women it gave lower heart and coronary artery doses than prone free-breathing (HeartSpare IB). Surface tracking with visual feedback is common; one small randomised trial of chest-surface versus abdominal-block feedback found no difference in accuracy.
Why: Holding a deep breath moves the heart away from the treated area and lowers the heart dose, and heart damage from radiotherapy rises with every unit of dose it receives.
“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]
Why: People who have practised hold their breath more steadily, and steady breath-holds make the planning scan and every treatment line up.
“It is advisable to train patients in the BH procedure before computed tomography (CT), to familiarise them with the equipment and to inform them how the staff will communicate during the procedure.”
ESTRO (Radiotherapy and Oncology; Aznar et al.) 2023 · Expert consensus (not graded)
Why: Practice at home makes the planning appointment shorter and the breath-hold more even.
“Information presented as flyers, videos or slide-presentations may be useful material that the patient can keep and use to practice BH at home if necessary”
ESTRO (Radiotherapy and Oncology; Aznar et al.) 2023 · Expert consensus (not graded)
Why: Most people can hold a breath this long, and a breath that is too deep is hard to repeat the same way every day.
“Most patients are able to hold their breath for 25–30 seconds: reports suggest that > 90% of breast cancer patients can achieve DIBH”
ESTRO (Radiotherapy and Oncology; Aznar et al.) 2023 · Expert consensus (not graded)
Why: Language, distress or difficulty following instructions can make breath-hold the wrong choice, and no one should feel they have failed.
“The staff should reassure the patient that free-breathing (FB) is a safe option for treatment as well.”
ESTRO (Radiotherapy and Oncology; Aznar et al.) 2023 · Expert consensus (not graded)
Why: The plan must be made on the body in the same shape it will be in during treatment.
“The planning CT should be performed in DIBH and additional DIBH skin marks (non-permanent) can be added as needed.”
ESTRO (Radiotherapy and Oncology; Aznar et al.) 2023 · Expert consensus (not graded)
Why: Changing the equipment or the depth of breath between planning and treatment would put the heart and the breast in different places.
“To maximise reproducibility and reduce the risk of introducing a systematic error, all relevant imaging for treatment planning should be performed in BH, and at the same BH level as used throughout the treatment course.”
ESTRO (Radiotherapy and Oncology; Aznar et al.) 2023 · Expert consensus (not graded)
Why: The monitor watches the skin or the airflow, not the heart or the breast; images show that the inside of the chest is where the plan expects it.
“For treatment delivery, image verification must encompass patient position (similar to treatments in FB) and verification of the BH level.”
ESTRO (Radiotherapy and Oncology; Aznar et al.) 2023 · Expert consensus (not graded)
Why: A breath-hold can drift over a course of treatment; daily checks catch it before it moves dose onto the heart.
“Daily imaging for the verification of the position of the target in BH as well as verification of the BH level (if necessary to ensure consistency in OAR sparing).”
ESTRO (Radiotherapy and Oncology; Aznar et al.) 2023 · Expert consensus (not graded)
Why: A target makes it clear when breath-hold, or another heart-sparing method, is needed for a particular patient.
“In left-breast-affected patients undergoing radiotherapy not including the IMC, >90% of patients should be treated to a mean heart dose of <2 Gray (Gy).”
The Royal College of Radiologists 2016 · Very strongly supported (90 to 99% of centres)
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.
A breath-hold technique for every person having left breast or chest wall radiotherapy (NICE NG101 1.13.2 [2018]; RCR 2016, unanimous that every department have one), with coaching before the planning CT, a comfortable breath-hold of about 20 to 30 seconds, planning and treatment with the same monitoring system at the same breath-hold level, and image verification of position and breath-hold level, daily where feasible (ESTRO-ACROP 2023, expert consensus). The guidelines agree on the technique; they differ in scope. NICE limits its recommendation to left-sided cancer, having found no evidence for right-sided; the RCR also asks for breath-hold to be available for internal mammary chain radiotherapy, and recommends it particularly for lower-half left breast tumours. No guideline read prefers one monitoring system over another; voluntary breath-hold without equipment was equivalent to a spirometry device in a randomised crossover study and quicker to deliver.
NICE 2018 · The Royal College of Radiologists 2016 · ESTRO (Radiotherapy and Oncology; Aznar et al.) 2023 · Radiotherapy and Oncology (Bartlett et al.) 2013
Where it differs: The patient holds their breath to a level checked against skin marks, a laser or surface imaging, with no spirometer or valve.
Evidence: HeartSpare (23 patients, randomised crossover): voluntary DIBH and the Active Breathing Coordinator were comparable in positional reproducibility and normal-tissue sparing; voluntary was preferred by patients and radiographers, took less time and is cheaper. ESTRO-ACROP 2023 says voluntary approaches have been shown suitable for 3D-CRT breast treatments.
Radiotherapy and Oncology (Bartlett et al.) 2013 · ESTRO (Radiotherapy and Oncology; Aznar et al.) 2023
Where it differs: The patient breathes through a mouthpiece with a nose clip; a valve holds the breath at a set lung volume and can interlock with the beam.
Evidence: Comparable heart sparing and reproducibility to voluntary breath-hold in HeartSpare, with longer set-up times and lower patient preference. No trial showing a clinical advantage was found.
Where it differs: An optical surface system or a marker block tracks the chest or abdomen, and the patient watches their own breath-hold on a screen or in goggles.
Evidence: BRAVEHeart (26 analysable patients, randomised): no difference in treatment accuracy, satisfaction or appointment length between chest-surface and abdominal-block feedback, though the chest surface correlated better with the chest wall (median 0.69 against 0.17). ESTRO-ACROP 2023 notes that visual coaching can decrease breath-hold to breath-hold variability in breast cancer patients.
Advances in Radiation Oncology (Byrne et al.) 2024 · ESTRO (Radiotherapy and Oncology; Aznar et al.) 2023
Where it differs: The patient lies face down so the breast falls away from the chest wall, without holding their breath; used in some centres for larger breasts.
Evidence: HeartSpare stage IB (34 larger-breasted women, randomised crossover): supine voluntary breath-hold gave lower mean heart and coronary artery doses and better positional reproducibility than prone free-breathing. ESTRO-ACROP 2023 (positioning) says prone can be considered for larger breasts or where more lung sparing is needed, if equipment and expertise are available.
Radiotherapy and Oncology (Bartlett et al.) 2015 · ESTRO (Technical Innovations and Patient Support in Radiation Oncology; Mast et al.) 2023
Where it differs: A second planning scan is taken while breathing normally, to compare plans or keep a back-up plan for days the patient cannot hold their breath.
Evidence: ESTRO-ACROP 2023 accepts it while a department is learning the technique but does not recommend it for routine practice beyond implementation, because of the additional radiation; it notes the benefits are limited.
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.
During breath-hold radiotherapy a camera or sensor measures how deep the breath is, but often only the radiographers see the trace. Showing it to the patient, on a screen or in video glasses with a target band to stay inside, made holds steadier and more repeatable in the clinical comparisons OnCo found, though none has yet measured whether it changes side effects.
Breath-hold is usually taught on the day of the planning scan. Two hospital series found that teaching it at least five days earlier, with practice at home, went with lower heart doses and shorter set-up times, and a survey of American radiation oncologists found interpreters were present at fewer than one in three first treatments for people who do not speak English.
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Use a deep inspiratory breath-hold technique for people with left-sided breast cancer | [2018] (NICE does not grade) | NICE 2018 |
| All UK radiotherapy departments should have a breath-hold technique available “All UK radiotherapy departments should have a breath-hold technique available.” | Unanimous support | The Royal College of Radiologists 2016 |
| Breath-hold techniques recommended for those with lower-half left breast tumours “Breath-hold techniques are recommended for those with lower-half left breast tumours.” | Consensus statement (no vote shown for this sentence) | The Royal College of Radiologists 2016 |
| More than 90% of left-sided patients without internal mammary chain treatment to a mean heart dose under 2 Gy | Very strongly supported | The Royal College of Radiologists 2016 |
| Every centre should have a breath-hold technique for internal mammary chain radiotherapy “Every centre should have a breath-hold technique available for patients undergoing IMC radiotherapy.” | Consensus statement | The Royal College of Radiologists 2016 |
| An additional free-breathing planning CT adds dose for limited benefit “However, the benefits of the acquisition of an additional FB CT scan are limited and add an increased imaging dose.” | Expert consensus (not graded) | ESTRO (Radiotherapy and Oncology; Aznar et al.) 2023 |
| Rates of major coronary events rise with mean heart dose, by 7.4% per gray “Rates of major coronary events increased linearly with the mean dose to the heart by 7.4% per gray (95% confidence interval, 2.9 to 14.5; P<0.001), with no apparent threshold.” | Population-based case-control study | New England Journal of Medicine (Darby et al.) 2013 |
Shares Deep-breath-hold radiotherapy for every suitable person with left-sided breast cancer, Surface-guided radiotherapy (SGRT), Breast cancer (all types).
Shares Breath-hold coaching and home practice a week before the planning scan, in the patient's own language, Radiotherapy, Breast cancer (all types).
Shares Let the patient see their own breath-hold on a screen or in video glasses, Deep-breath-hold radiotherapy for every suitable person with left-sided breast cancer, Respiratory motion management (4D-CT, gating, breath-hold, tracking), In-room imaging for radiotherapy (cone-beam CT, ExacTrac, CT-on-rails, HyperSight).
Shares Deep inspiration breath-hold (DIBH), Surface-guided radiotherapy (SGRT), Respiratory motion management (4D-CT, gating, breath-hold, tracking).
Shares In-room imaging for radiotherapy (cone-beam CT, ExacTrac, CT-on-rails, HyperSight), Radiotherapy, IMRT / IGRT (modern external beam).
Shares Surface-guided radiotherapy (SGRT), Respiratory motion management (4D-CT, gating, breath-hold, tracking), In-room imaging for radiotherapy (cone-beam CT, ExacTrac, CT-on-rails, HyperSight).
Shares Respiratory motion management (4D-CT, gating, breath-hold, tracking), IMRT / IGRT (modern external beam).
Shares Deep inspiration breath-hold (DIBH), Respiratory motion management (4D-CT, gating, breath-hold, tracking).