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Research Paper I
Sunhee Lee, Simran Rai, Janice Chuang
Dos 731
June 6, 2022
Introduction

The adjuvant use of radiotherapy in breast conserving therapy has resulted in excellent
long term local control for early-stage breast cancer.1This approach has led to greater cosmetic
outcomes with similar levels of long-term survival compared to mastectomies. Following
lumpectomy, the whole breast is typically treated with 3D-CRT consisting of lateral and medial
tangent beams. This is often followed by a boost to the surgical cavity. The goal of this treatment
is to deliver a homogenous dose to the breast and surgical cavity while diminishing the dose to
organs at risk (OAR).

The goal of consistent dose coverage for a treatment planner is crucial but can be difficult
at times. In general, it is seen as desirable to deliver a homogenous dose distribution to breast
tissue without excessive hot spots. This is in part because excessive areas of high dose have been
linked to poorer cosmetic outcomes.2 This objective becomes increasingly difficult to balance
with target coverage as a patient has an increased tangential separation. This is in part because
the greater monitor units needed to deliver dose to the entire breast create much larger high dose
areas that in many cases cannot be eliminated with lower energies.3 Conversely, when higher
energies such as 10 MV are used in these cases, a loss of dose in the peripheral region of the
breast is often reported.4 This is due to the skin-sparing effect seen in higher energy photon
beams. The availability of energies that can provide adequate target coverage along with a low
area of hot spots is one such limitation of conventional breast planning.

Flattening Filter Free (FFF) beams have been shown to display favorable beam
characteristics that would suggest a greater likelihood of target coverage closer to the surface of
the patient. The unique beam characteristics of flattening filters may allow for a homogenous
dose of the whole breast while maintaining dose near the surface. This is because 6MV and 10
MV FFF beams have a greater surface dose than their flattened counterpart.5 Additionally, for 10
MV FFF beams the depth of electron equilibrium is shallower than a 10 MV flattened beam in
field sizes larger than 10x10 cm. Flattening Filter Free beams have also been shown to decrease
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treatment times adding to its benefits.6 It can be reasoned that a FFF beam when modulated
correctly can provide homogenous dose distribution within the breast while maintaining a
favorable dose closer to the skin surface.

Despite some clinical practices, adequate dose coverage near the skin is still favorable.
Although dose in this peripheral region of the breast is left out when target coverage is evaluated,
many radiation oncologists do in fact include it in their target volume.7 Furthermore, this area
becomes of particular importance in instances where the surgical cavity is near the medial or
lateral surface since the cavity is the most common area of local recurrence. The minimum dose
seen in superficial cavities can suffer when higher energies are incorporated into the plan. This
leaves a need for a more seamless planning method that maintains target volume coverage near
the surface.

An investigation into the alternative options to mixed energy planning in whole breast
irradiation is needed. Whole breast tangential setups in patients with a separation >21 cm
typically require mixed energy beams for adequate coverage of breast tissue. The problem is that
these higher energies can lead to a loss of peripheral dose in the outer region of breast tissue
which is of concern for patients with a medial or lateral lumpectomy cavity when receiving
whole breast radiation. The ability of FFF beams to provide increased superficial dose may be
able to address this issue. The purpose of this study is to determine if 10MV FFF beams can
increase peripheral dose coverage in outer region of breast tissue and the lumpectomy cavity
compared to mixed energy treatment techniques for patient receiving whole breast irradiation.
There is limited research on the clinical implications of using FFF beams to increase the relative
dose near the surface. Researchers tested the hypotheses that FFF treatments would increase
volume of the whole breast receiving 95 percent of the prescription dose and minimum cavity
dose, for breast patients by 5 percent compared to mixed energy treatment techniques.
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References

1. Wrubel E, Natwick R, Wright P.G. Breast conserving therapy is associated with

improved survival compared with mastectomy for early-stage breast cancer: A propensity
score matched comparison using the national cancer database. J Ann Surg Oncol.
2020;28(2): 914–919. https://doi.org/10.1245/s10434-020-08829-4
2. Vargas L, Solé S, Solé CV. Cosmesis after early stage breast cancer treatment with
surgery and radiation therapy: experience of patients treated in a Chilean radiotherapy
center. Ecancermedicalscience. 2018;12(1):819-826.
https://doi.org/10.3332/ecancer.2018.819

3. Gustafson NR, Burrier T, Butler B, Hunzeker A, Lenards N, Culp L. Correlation of hot

spot to breast separation in patients treated with postlumpectomy tangent 3d-crt using
field-in-field technique and mixed photon energies. J Med Dosim. 2020;45(2):134-139.
https://doi.org/10.1016/j.meddos.2019.08.00488
4. Lief EP, Hunt MA, Hong LX, Amols HI. Radiation therapy of large intact breasts using a
beam spoiler or photons with mixed energies. J Med Dosim. 2007;32(4):246- 253.
https://doi.org/253.10.1016/j.meddos.2007.02.002888888888888888888888888888888
5. Kragl G, Wetterstedt S, Knäusl B, et al. Dosimetric characteristics of 6 and 10MV
unflattened photon beams. Radiotherapy oncol. 2009;93(1):141-146.
https://doi.org/10.1016/j.radonc.2009.06.008 
6. Takakura T, Koubuchi S, Uehara A, et al. Evaluation of beam-on time and number of
breath-holds using a flattening-filter-free beam with the deep inspiration breath-hold
method in left-sided breast cancer. J Med Dosim. 2020;45(4):359-362.
https://doi.org/10.1016/j.meddos2020.05.002

7. Li XA, Tai A, Arthur DW, et al. Variability of target and normal structure delineation for
breast cancer radiotherapy: an rtog multi-Institutional and multiobserver study. Int J
Radiat Oncol Biol Phys. 2009;73(3):944-951.
https://doi.org/10.1016/j.ijrobp.2008.10.034
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Submission Packet
You are required to submit this packet with each submission of your paper. You
will build on each draft and will also build on each submission packet so it will
represent the changes of your paper from start to finish. In this packet, you will
find:
I. Statements
II. Change Matrix
III. AMA Formatting Checklists
The instructions for each section are listed below. Copy and paste the statement
page, change matrix table and AMA formatting checklist table to the first page
of your draft submission. Remember that you should build on each submission.
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Statements
Remember the problem, purpose and hypotheses statements that we worked so
hard on last semester? We will be using them again! They should be stated in
your paper (just as we worked on in your research proposal) but we are also
asking you to spell them out here as a reminder of the foundational basis for your
research.
Purpose Statement: The purpose of this study is to determine if 10MV Flattening Filter Free
(FFF) beams can increase peripheral dose coverage in the outer region of breast tissue and the
lumpectomy cavity compared to mixed energy treatment techniques for patients receiving whole
breast radiation.

Problem Statement: Whole breast tangential set ups in patients with a separation > 21cm
typically require mixed energy beams for adequate coverage of breast tissue. The problem is the
higher energy beams can lead to a loss of peripheral dose in the outer region of breast tissue
which is of concern for patients with a medial or lateral lumpectomy cavity receiving whole-
breast radiation.

Hypotheses:
H1: The first research hypothesis (H1) is that FFF beams for breast radiotherapy will increase
the volume of the whole breast receiving 95% of the prescription dose.

H10: The first null hypothesis (H10) is that FFF beams for breast radiotherapy will not increase
the volume of the whole breast receiving 95% of the prescription dose.

H2: The second research hypothesis (H2) is that FFF beams for breast radiotherapy will increase
minimum cavity dose by 5%.

H20: The second null hypothesis (H20) is that FFF beams for breast radiotherapy will not
increase minimum cavity dose by 5%.
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Change Matrix
A change matrix is required with every milestone document submission.

A detailed change matrix simplifies the review process and indicates to the instructors and advisors that
the author has demonstrated a clear and thorough response to reviewer comments.

Reviewer comments are not intended as an exhaustive list. It is the Learner’s responsibility to correct
any additional errors that are not specifically noted by the reviewer and to address the requirements of
the capstone project. All instances where changes have been made should be clearly noted.

If, after discussion with the group, there are questions about a reviewer’s comments, it is the
responsibility of the group leader to reach out to the instructors and advisor via email for clarification.

If, after discussion with the instructors, the author chooses not to make a requested change, the
author must provide a brief rationale, and describe how they addressed reviewer concerns.

Failures to consider, address, and notate within the Change Matrix will result in the manuscript being
returned to the group without comment.

Copy and paste the instructor’s comment from your draft into the matrix.

You will continuously build on this change matrix so that any/all comments can be reviewed at any given
time in the projects progress.

Title of Capstone: Effects of target volume coverage in superficial medial and lateral breast tissue
using flattening filter free beams.

Group: 10
Reviewer’s recommendation How addressed Page numbers
where change
appears

Example Example p.52

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AMA Referencing Quick Guide Checklist

Correctly using AMA formatting is one of the few aspects in the Capstone project that you have
complete control of whether it is your first outline submission or the final draft. Use this AMA quick
guide checklist to avoid common AMA formatting mistakes and receive the greatest number of points
possible. Not everyone has the ability to be an exceptional scholarly writer and researcher, however,
everyone has the capability of using AMA formatting correctly. Review this guide for EVERY submission
(discussion post, outline, draft) in the research courses and ask yourself the following questions:

Task Submiss Submissio Submissio Submissio Submissio Submissio Submissio

ion n Date: n Date: n Date: n Date: n Date: n Date:
Date:
6/15/20
22

Manuscript
Written in past ☒ ☐ ☐ ☐ ☐ ☐ ☐
tense?
Written in size 12,
☒ ☐ ☐ ☐ ☐ ☐ ☐
Times New Roman
font
Paragraphs include
☒ ☐ ☐ ☐ ☐ ☐ ☐
at least 3
sentences
Page numbers?

**The default font

for page numbers
is Calibri, size 11 ☒ ☐ ☐ ☐ ☐ ☐ ☐
even after you
have changed the
font in your paper
so make sure to
check
Spell out ☒ ☐ ☐ ☐ ☐ ☐ ☐
abbreviation at
first use if not
recognized by
AMA

***Remember
that you may
add/subtract
content with each
draft so something
that once spelled
out might be
removed and need
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to spelled out
again
Spell out numbers
and abbreviations
that begin a
sentence?

**If an
☒ ☐ ☐ ☐ ☐ ☐
abbreviation must ☐
be spelled out to
begin a sentence,
do not include the
abbreviation in
parentheses after
words unless this
is the first use.
Numeric values
when referring to
☒ ☐ ☐ ☐ ☐ ☐ ☐
numbers in
sentence (“3”, not
“three”)
Reference
superscripts after ☒ ☐ ☐ ☐ ☐ ☐ ☐
each sentence I
used a reference?
OAR is properly
defined as organS
at risk.

**This is a
common mistake, ☒ ☐ ☐ ☐ ☐ ☐ ☐
even in journal
publications. By
saying OARs, you
are implying
organs at risks
which doesn’t
make sense
If I directly cited an
author, did I
immediately
include the ☒ ☐ ☐ ☐ ☐ ☐ ☐
reference
superscript
following the
author’s name?
Tables and figures
are referenced in-
text directly ☒ ☐ ☐ ☐ ☐ ☐ ☐
following the
sentence (….
(Figure 1).
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0

All terms must be

spelled out in the
abstract and
manuscript at first
use
☐ ☐ ☐ ☐ ☐ ☐ ☐
**So if you refer to
and spell out
VMAT in the
abstract, you must
also define the
term again in the
manuscript
Scholarly writing is
appropriate

**Do not use ☒ ☐ ☐ ☐ ☐ ☐ ☐

terms such as max,
cord, rad onc,
simmed etc. Spell
out these terms
and avoid slang
All reference of
our profession
should be written
as “medical
dosimetrist” not
☒ ☐ ☐ ☐ ☐ ☐ ☐
just “dosimetrist.”

**Remember that
there are other
types of
dosimetrists
Is my paper
formatted
according the ☐ ☐
☒ ☐ ☐ ☐ ☐
instructions? Case
study vs. Research
Paper

Reference Page
Page break
before this ☒ ☐ ☐ ☐ ☐ ☐ ☐
section?
Capitalize the
first letter of
☒ ☐ ☐ ☐ ☐ ☐ ☐
the first word
in the title only
Abbreviate
and italicize ☒ ☐ ☐ ☐ ☐ ☐ ☐
the journal?
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Year, volume,
issue and page
number
written
without any
spaces?

**If you didn’t

find one listed,
consider ☒ ☐ ☐ ☐ ☐ ☐ ☐
completing
another
literature
search review.
If you cannot
find one, reach
out to
instructor for
help
Doi?

**Remember
that most
publications
have doi
numbers now
so if you do
☒ ☐ ☐ ☐ ☐ ☐ ☐
not locate one
on the original
article,
complete
another
literature
search to find
it.
Format dois
like this:
http://doi.org..
.
☐
☒ ☐ ☐ ☐ ☐ ☐
**Remember
this has
changed from
last semester
Listed in
chronological ☒ ☐ ☐ ☐ ☐ ☐ ☐
order as they
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are referenced
in text
Figures and Tables
Page break
before each ☐ ☐ ☐ ☐ ☐ ☐ ☐
section?
Each heading
is bolded and
☐ ☐ ☐ ☐ ☐ ☐ ☐
centered for
each section
If 2 figures are
related, they
are to be ☐ ☐ ☐ ☐ ☐ ☐ ☐
labeled as A
and B.
Captions are
written in
complete
sentences and ☐ ☐ ☐ ☐ ☐ ☐ ☐
single spaced
starting with
“Figure 1”
Figure
captions
☐ ☐ ☐ ☐ ☐ ☐ ☐
appear after
the figure
Table captions
appear before ☐ ☐ ☐ ☐ ☐ ☐ ☐
the figure
All patient
identifying
information is
☐ ☐ ☐ ☐ ☐ ☐ ☐
blocked and
fused with the
original image
All table axis,
labels and
legends are in
☐ ☐ ☐ ☐ ☐ ☐ ☐
Times New
Roman, size 12
font
Any DVHs
include
structure ☐ ☐ ☐ ☐ ☐ ☐ ☐
labels directly
on the DVH
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Vertical lines
are removed ☐ ☐ ☐ ☐ ☐ ☐ ☐
from tables
Single line
spacing used
for figure and ☐ ☐ ☐ ☐ ☐ ☐ ☐
table
descriptions