Research Proposal Group 7 (Ryann Edwards and Milica Ilic)

Working Title

A comparison of free breathing (FB) and deep inspiration breath hold (DIBH) simulation scan
sequence due to CBCT OAR shifts for breast radiotherapy.

Problem Statement

The problem is that the delineated OAR from the FB simulation scans do not line up accurately
to the cone beam CT (CBCT) scans on the first day of treatment.

Purpose Statement

The purpose of this retrospective study is to compare FB and DIBH CT simulation scans and
evaluate OAR shifts to determine if the cause of the shifted CBCT OAR on first day treatment is
due to the sequence of the scans.

Hypotheses Statements
H1A: The first research hypothesis (H1A) is that there will be a reduction of ≥ 10% in shifts to the
heart when changing the sequence of simulation scans to FB followed by DIBH.

H10: The first null hypothesis (H10) is that there will not be a reduction of ≥ 10% in shifts to the
heart when changing the sequence of simulation scans to FB followed by DIBH.

H2A: The second research hypothesis (H2A) is that there will be a reduction of ≥10% in shifts to
the lungs when changing the sequence of simulation scans to FB followed by DIBH.

H20: The second null research hypothesis (H20) is that there will not be a reduction of ≥ 10% in
shifts to the lungs when changing the sequence of simulation scans to FB followed by DIBH.

H3A: The third research hypothesis (H3A) is that there will be a reduction of ≥ 10% in shifts to
the liver when changing the sequence of simulation scans to FB followed by DIBH.

H30: The third null hypothesis (H3A) is that there will not be a reduction of ≥10% in shifts to the
liver when changing the sequence of simulation scans to FB followed by DIBH.

Summary

Breast radiotherapy has proven to have both local control and survival benefits for breast
cancer patients. The heart is one of the major organs at risk (OAR) for breast radiotherapy,
especially in the case of left side-breast radiotherapy. Radiation exposure to the heart is the most
well-known risk factors for developing coronary artery disease and cardiac mortality.1,2 The risk
of heart disease and coronary events is estimated to increase 4-7% for every 1 Gy in mean heart
dose.1 Studies have shown that there has been a 50% relative reduction in the mean heart dose
and left anterior descending artery between a free breathing (FB) and breath hold (BH) plans.3

Throughout previous years, medical advancements in radiation oncology have been

ongoing. Limiting patient movement has been a consistent priority to ensure patients are not
shifting and are receiving the correct prescribed dose to the corresponding area of the body
during the treatment process. One factor that plays a role in patient movement is the patient’s
respiration. Some of the medical advancements have included the use of deep inspiration breath
hold (DIBH) techniques.1 During a computed tomography (CT) simulation scan, patients will
either be in a FB state or in a BH state.1 DIBH is a technique in which the patient takes a deep
breath and then holds it for a period during the CT simulation. This is based on the observation
that during inspiration, the diaphragm flattens, and the lungs expand, pulling the heart away from
the chest wall (CW). This has been beneficial for many patients who receive breast
radiotherapy.1

DIBH techniques include two different commonly used methods, voluntary DIBH
(vDIBH) and moderate DIBH.1 Patients that undergo vDIBH are instructed to hold their breath at
certain points in the breathing cycle. Depending on the type of machine available at clinics, this
often includes gating patient respirations by placing a device on the patient’s chest to measure
vertical displacement. Treatment is stopped when the patient is not at a desirable volume
threshold. Moderate DIBH includes having patients connected to active breathing control (ABC)
devices to allow for monitoring of airflow and ensure that patients remain at a desired breath
hold volume.1

Because of the possible benefits patients may receive by using the DIBH method,
physicians will often have both an FB and DIBH CT simulation completed for evaluation prior
to beginning the treatment planning process. However, when it comes to DIBH, not every patient
can follow through without complications and overexertion. This is why many physicians often
elect for both simulation scans to be completed. The patient is likely to feel an immense amount
of pressure during the DIBH procedure, which deteriorates the success of the DIBH technique.4
The session can take around 20-30 minutes, which can make the patients uncomfortable and
increase their stress and anxiety as a result.4 A study by Kron and Bressel et al5 found that the
mean anxiety score for 30 breast cancer patients about performing a DIBH for CT simulation
was 4.3 out of 10, with 13% of them feeling ‘quite a bit’ or ‘very much’ worried they would not
hold their breath correctly. The sensitivity to an individual’s respiratory rate can be directly
affected by various factors and stressors, especially emotional stressors.6 Thus, patients need to
be properly coached in the process of the DIBH CT scan and allow for time for the patient to
adapt to their clinical setting.

Protocols for the sequence of FB and DIBH simulation scans may not be established at Commented [NL1]: Is this replacing the paragraph
above? IF so - go ahead and delete the prior and move this.
all clinical sites and often physician preference. The FB scan may be altered due to emotional Right now we have two competing paragraphs which is
confusing.
stressors and overexertion of the patient when completed after the DIBH scan. However, the
OARs are delineated on the FB simulation scan. The problem is that the delineated OAR from
the FB simulation scans do not line up accurately to the CBCT scans on the first day of
treatment. Therefore, the purpose of this retrospective study is to compare FB and DIBH CT
simulation scans and evaluate OAR shifts to determine if the cause of the shifted CBCT OAR on
first day of treatment is due to the sequence of the scans. Researchers tested hypotheses that
there will be a reduction of ≥10% in shifts to the heart (H1A), lungs (H2A), and liver (H3A)
when changing the sequence of simulation scans to FB followed by DIBH.
 References

1. Bergom C, Currey A, Desai N, Tai A, Strauss JB. Deep inspiration breath hold:
techniques and advantages for cardiac sparing during breast cancer irradiation. Front.
Oncol. 2018; 8(87). doi: 10.3389/fonc.2018.00087
2. 2. Kim A, Kalet AM, Cao N, et al. Effects of preparatory coaching and home practice for
deep inspiration breath hold on cardiac dose for left breast radiation therapy. Clin Oncol.
2018; 29(9):571-577. https://doi.org/10.1016/j.clon.2018.04.009
3. 3. Reitz D, Walter, F, Schönecker S, et al. Stability and reproducibility of 6013 deep
inspiration breath-holds in left-sided breast cancer. Radiat Oncol. 2020; 15:121.
https://doi.org/10.1186/s13014-020-01572-w
4. 4. Oonsiri P, Wisetrinthong M, Chitnok M, Saksornichai K, Suriyapee S. An effective
patient training for deep inspiration breath hold technique of left-sided breast on
computed tomography simulation procedure at King Chulalong Memorial Hospital.
Radiat Oncol J. 2019; 37(3):201-206. doi: 10.3857/roj.2019.00290
5. 5. Kron T, Bressel M, Lonski P, et al. TROG 14.04: multicentre study of feasibility and
impact on anxiety of DIBH in breast cancer patients. Clin Oncol. 2022; 34(9):e410-e419.
https://doi.org/10.1016/j.clon.2022.05.020
6. 6. Nicolò A, Massaroni C, Schena E, Sacchetti M. The importance of respiratory rate
monitoring: from healthcare to sport and exercise. Sensors. 2020; 20(21):6396.
https://doi.org/10.3390/s20216396