A straightforward breathing technique could save the lives of more women with cancer in the left breast, according to one of the largest studies of its kind conducted by GenesisCare.
Spirometry-monitored Deep Inspiration Breath-Hold (DIBH) is a simple technique whereby a patient is required to take a deep breath to lift their chest cavity away from their heart while radiotherapy is delivered directly at their tumour. The technique reduces harmful radiation doses to vital organs and critical tissue and, because the heart is situated on the left side of the body, DIBH is particularly pertinent for women with left-sided breast cancer. Cancer survival rates are improving and people are living longer, which means cardiac deformities caused by radiation treatment are more of an issue than they were historically.
To perform the technique, patients are required to hold their breath for several short periods whilst the radiotherapy is administered. One particular type of DIBH – spirometry-monitored DIBH – is believed to give more accurate results because it allows the patient to see how deeply they are holding their breath via a monitor, making the technique more reproducible.
To test the benefits of using this technique, GenesisCare undertook one of the largest studies of its kind. The organisation compared spirometry-monitored DIBH plans with conventional free-breathing plans to assess the difference in the radiation dose received in the heart in 296 patients receiving radiotherapy for left-sided breast cancer between February 2013 and September 2014.
The results showed that the use of spirometry-monitored DIBH radiotherapy significantly reduces radiation to the heart and surrounding critical organ tissue in the chest.
In 2012, there were 37,132 breast cancer patients in the UK; potentially, around half of these could have been eligible for DIBH (approximately 18,500). Based on these numbers, spirometry-monitored DIBH might have prevented as many as 11 deaths and 24 major coronary events. The benefits for DIBH are even greater in individuals who have at least one cardiac disease risk factor when treated (e.g. high blood pressure or smoking), making DIBH an even safer choice for them.
This major research, which was peer reviewed at the 3rd ESTRO Forum in Barcelona, in April 2015, confirms findings from an interim study conducted by GenesisCare in 2014, which also showed that the heart received less radiation with DIBH.
Karol Sikora, Chief Medical Officer at GenesisCare, explained the relevance of the research for the future of cancer treatment: “The importance of considering the longer-term effects of radiotherapy at the point of treatment is absolutely crucial. Clearly we want to avoid treating someone for cancer and then for them to potentially die of a heart condition which may have been caused by their cancer treatment. If you have left-sided breast cancer, DIBH is the treatment you should choose where possible, for both short and long-term benefit.”
Karol continued: “The future of radiotherapy treatment is going to be focused on using simple techniques like this to reduce dosage of radiation to critical tissue, for instance the heart, spinal cord or bladder. The next two decades will see us paying more attention to the longer-term effects of cancer treatments and developing techniques to reduce complications for patients and this research marks the start of that revolution.”
It has been reported that up to 88 per cent of cardiac deformities present within the first five years of receiving non-DIBH radiotherapy for left-sided breast cancer. Matt Hickey, GenesisCare’s Director of Clinical Strategy explains the impact of the research for patients: “Although most women with left-sided breast cancer can benefit from DIBH, younger women, for example those between 40 and 60 years old, are more likely to present with side-effects than older women in their 70s or 80s. As such, we believe these findings are particularly pertinent for younger people with breast cancer. Incidentally, the average age of our patients with breast cancer is 52 – which sit within the age bracket that will most benefit from this treatment.”
Matt continued: "This innovative yet simple to administer treatment which is not yet widely available on the NHS, has been shown to deliver tangible benefits to left-sided breast cancer patients and prevent side effects that can manifest quickly – sometimes within just two years. Ultimately the best treatment pathways need to be provided to patients to help prevent other serious issues and even death occurring further down the line."
DIBH has been used to help treat many patients at GenesisCare including event manager and mum of one, Claire White. Claire was diagnosed with early stage breast cancer in her left breast in July 2014, just four months after returning to work from maternity leave. Unfortunately, the cancer had also spread to some lymph nodes, but these were successfully removed during surgery. Claire first learnt about Deep Inspiration Breath Hold (DIBH) towards the end of her chemotherapy treatment.
At the start of her radiotherapy treatment, Claire had an initial CT scan that mapped out exactly where the radiation dose would be administered. She was then walked through, the breath hold technique, step by step: “I was provided with goggles to wear which displayed my breathing which really helped; a target line is set which you can see in the goggles so when you inhale a breath you can see the particular target zone, and you can then see the seconds counting down.”
Once the treatment was underway, Claire felt really empowered because she felt she had some control in helping herself to get the best outcome from the radiotherapy treatment. She commented: “I was so pleased that I was able to accomplish the technique and continue to do it every day as part of the treatment.
Steve Bird, GenesisCare Chief Executive, said: “Demonstrating that the treatments we deliver really do make a difference to our patients is vital and therefore research and development is central to Cancer Partners UK. Transparency in what we do and how we do it will be absolutely vital moving forward; we want to work with all healthcare sectors to deliver the best available treatment for patients with cancer and ensure the whole sector benefits from sharing intelligence to driving improvements. As such, Cancer Partners UK want to share its research intelligence and treatment data with as wide an audience as possible. We are going to submit our quality data to the national statistics data used by the National Cancer Intelligence Network (NCIN) and, to our knowledge; we are the first independent healthcare group to provide this kind of intelligence.”
Looking to the future, GenesisCare is continuing to invest in research and development and will be monitoring the outcomes from patients who have received spirometry-monitored DIBH to ensure that any theoretical benefits are observed in reality.
GenesisCare has produced various materials including a whitepaper to break down the results of the study including and a video to explain how the treatment works. The organisation has also shared some patient experiences which can be viewed online here. GenesisCare offers DIBH at its eight radiotherapy and treatment centres across the UK. Since being fully adopted by GenesisCare in 2013 the technique has been used to treat 90 per cent of all eligible left-breast cancer patients. For more information, visit www.cancerpartnersuk.org.
GenesisCare provides the highest levels of patient-focused care across a network of purpose-built cancer centres, located in Birmingham, Guildford, Hertfordshire, Milton Keynes, Nottingham, Oxford, Portsmouth and Southampton.
Services at each centre are varied. However core principles are applied throughout in offering high quality, patient-led care. All centres provide sophisticated radiotherapy treatments which include daily image guided radiotherapy (IGRT), and intensity modulated radiotherapy (IMRT) and deep inspiration breath-hold (DIBH) techniques.
About the research
GenesisCare conducted a study of 296 DIBH patients during February 2012 and September 2014. The largest study of its kind compared the cardiac dose received in DIBH plans with conventional free-breathing plans for the 296 patients receiving radiotherapy for left-sided breast cancer.
The results showed that the use of spirometry-monitored DIBH radiotherapy saw a median reduction in the mean heart dose of 0.62Gy and a .72Gy in the Left Anterior Descending (LAD) coronary artery.
In the UK, in 2012, 37,132 patients were treated with radiotherapy. Potentially, around half of these could have been eligible for DIBH. The study shows that, according to the latest cardiac risk tables, this technique could prevent 11 deaths and 24 major coronary events per year.
These benefits are further improved, by an average of 25%, in patients who have at least one cardiac risk factor when treated, making DIBH an even safer choice in this population.
DIBH involves a patient learning to hold their breath for a matter of seconds while each radiation dose is administered. This simple action lifts the chest cavity away from the heart and the expanded lungs move the heart deeper into the body. The space in the chest cavity this leaves allows the radiation beam to treat the tumour in the breast whilst avoiding or reducing the dose to vital organs such as the heart.
To ensure each deep breath is consistent, a spirometry-monitored DIBH technique is used. This involves the patient wearing a mouthpiece, similar to a snorkel and goggles similar to those used with a games console, which display the patients breathing pattern and a simple green and red light system which helps the patient know when to take a breath, how much breath to take in and when to release it. If at any time the patient loses control of their breath, the system automatically cuts out and the treatment stops.
The majority of patients who have used the system have reported that it is easy to master and that they are comfortable using it.
Click here to view a video which explains the technique and how it is administered. For more patient case studies, information, interviews with the team at GenesisCare or images, please contact email@example.com or by calling 02393 277 000.