Application of retrospective data analysis to clinical protocol design: can the potential benefits of breath-hold techniques for breast radiotherapy be assessed without testing on patients?

Abstract

The advantages, in terms of heart dose sparing, resulting from using a breath-hold technique when treating supine left breast radiotherapy patients are widely accepted, and increasing numbers of radiotherapy departments are implementing breath-hold techniques. However, due to differences in patient setup and treatment planning protocols between radiotherapy departments, it is important to assess the benefits of using a breath-hold technique within each department, before or during implementation. This study investigated the use of retrospective analysis of past patient treatment plans, as a means to identify the potential for breath-hold techniques to benefit patients. In-house “Treatment and Dose Assessor” code was used to complete a bulk retrospective evaluation of dose-volume metrics for 708 supine and 13 prone breast and chest wall radiotherapy treatments, that were planned using the same clinical protocols, which did not utilise a breath hold technique. For supine patients, results showed statistically significant differences between heart doses from left and right breast treatment plans, in the absence of significant differences between lung doses from left and right breast treatment plans, confirming the potential benefit of using a breath-hold technique for supine left breast radiotherapy patients. Fewer than 1% of the right breast treatment plans showed heart doses high enough to suggest a possible benefit from using a breath-hold technique. Approximately 50% of the prone left breast treatment plans included very low heart doses without intervention, and may therefore have shown no noticeable dosimetric benefit from the use of a breath hold. This study demonstrated the extent of information that can be obtained using retrospective data analysis, before or instead of obtaining multiple CT images of patients and completing a process of dual planning and prospective dose evaluation.

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References

  1. 1.

    Darby S, McGale P, Correa C et al (2011) Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10,801 women in 17 randomised trials. Lancet 378:1707–1716

    Article  CAS  Google Scholar 

  2. 2.

    McGale P, Taylor C, Correa C et al (2014) Effect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20-year breast cancer mortality: meta-analysis of individual patient data for 8135 women in 22 randomised trials. Lancet 383:2127–2135

    Article  CAS  PubMed  Google Scholar 

  3. 3.

    Basaula D, Quinn A, Walker A (2017) Risks and benefits of reducing target volume margins in breast tangent radiotherapy. Aust Phys Eng Sci Med 40(2):305–315

    Article  Google Scholar 

  4. 4.

    Pham TT, Ward R, Latty D (2016) Leftsided breast cancer locoregional radiotherapy with deep inspiration breathhold: does volumetricmodulated arc radiotherapy reduce heart dose further compared with tangential intensitymodulated radiotherapy? J Med Imaging Radiat Oncol 60(4):545–553

    Article  PubMed  Google Scholar 

  5. 5.

    Dean J, Hansen CJ, Westhuyzen J (2016) Tangential intensity modulated radiation therapy (IMRT) to the intact breast. J Med Radiat Sci 63(4):217–223

    Article  PubMed  PubMed Central  Google Scholar 

  6. 6.

    Welsh B, Chao M, Foroudi F (2017) Reducing cardiac doses: a novel multileaf collimator modification technique to reduce left anterior descending coronary artery dose in patients with leftsided breast cancer. J Med Radiat Sci 64(2):114–119

    Article  PubMed  Google Scholar 

  7. 7.

    Kairn T, Crowe SB, Langton CM, Trapp JV (2016) Bulk evaluation and comparison of radiotherapy treatment plans for breast cancer. Aust Phys Eng Sci Med 39(3):633644

    Google Scholar 

  8. 8.

    Darby SC, McGale P, Taylor CW, Peto R (2005) Lancet Oncol 6:557–565

    Article  PubMed  Google Scholar 

  9. 9.

    Darby SC, Ewertz M, McGale P (2013) Risk of ischemic heart disease in women after radiotherapy for breast cancer. N Engl J Med 368:987–998

    Article  CAS  PubMed  Google Scholar 

  10. 10.

    Sixel KE, Aznar MC, Ung YC (2001) Deep inspiration breath hold to reduce irradiated heart volume in breast cancer patients. Int J Radiat Oncol Biol Phys 49:199–204

    Article  CAS  PubMed  Google Scholar 

  11. 11.

    Borst GR, Sonke JJ, den Hollander S (2010) Clinical results of image-guided deep inspiration breath hold breast irradiation. Int J Radiat Oncol Biol Phys 78:1345–1351

    Article  PubMed  Google Scholar 

  12. 12.

    Mulliez T, Veldeman L, Speleers B (2015) Heart dose reduction by prone deep inspiration breath hold in left-sided breast irradiation. Radiother Oncol 114(1):79–84

    Article  PubMed  Google Scholar 

  13. 13.

    Bartlett FR, Colgan RM, Carr K (2013) The UK HeartSpare Study: randomised evaluation of voluntary deep-inspiratory breath-hold in women undergoing breast radiotherapy. Radiother Oncol 108(2):242–247

    Article  PubMed  Google Scholar 

  14. 14.

    Latty D, Stuart KE, Wang W, Ahern V (2015) Review of deep inspiration breathhold techniques for the treatment of breast cancer. J Med Radiat Sci 62(1):74–81

    Article  PubMed  PubMed Central  Google Scholar 

  15. 15.

    van der Laan HP, Hurkmans CW, Kuten A, Westenberg HA (2010) Current technological clinical practice in breast radiotherapy; results of a survey in EORTC-Radiation Oncology Group affiliated institutions. Radiother Oncol 94(3):280–285

    Article  PubMed  Google Scholar 

  16. 16.

    Dundas KL, Pogson EM, Batumalai V et al (2015) Australian survey on current practices for breast radiotherapy. J Med Imaging Radiat Oncol 59(1):736–742

    Article  PubMed  Google Scholar 

  17. 17.

    Batumalai V, Holloway LC, Kumar S, Dundas K, Jameson MG, Vinod SK, Delaney GP (2017) Survey of imageguided radiotherapy use in Australia. J Med Imaging Radiat Oncol 61(3):394–401

    Article  PubMed  Google Scholar 

  18. 18.

    Rice L, Harris S, Green MM, Price PM (2015) Deep inspiration breath-hold (DIBH) technique applied in right breast radiotherapy to minimize liver radiation. BJR Case Rep 1(2):20150038

    CAS  PubMed  PubMed Central  Google Scholar 

  19. 19.

    Frazier RC, Vicini FA, Sharpe MB (2004) Impact of breathing motion on whole breast radiotherapy: a dosimetric analysis using active breathing control. Int J Radiat Oncol Biol Phys 58(4):1041–1047

    Article  PubMed  Google Scholar 

  20. 20.

    Bartlett FR, Donovan EM, McNair HA (2017) The UK HeartSpare Study (Stage II): multicentre evaluation of a voluntary breath-hold technique in patients receiving breast radiotherapy. Clin Oncol 29(3):e51–e56

    Article  CAS  Google Scholar 

  21. 21.

    Ramella S, Trodella L, Ippolito E (2012) Whole-breast irradiation: a subgroup analysis of criteria to stratify for prone position treatment. Med Dosim 37(2):186–191

    Article  PubMed  Google Scholar 

  22. 22.

    Stillie AL, Kron T, Herschtal A (2011) Does inverseplanned intensitymodulated radiation therapy have a role in the treatment of patients with leftsided breast cancer? J Med Imaging Radiat Oncol 55(3):311–319

    Article  PubMed  Google Scholar 

  23. 23.

    Kairn T (2018) Patient rotation during linac-based photon and electron radiotherapy. J Med Imaging Radiat Oncol 62:548–552

    Article  Google Scholar 

  24. 24.

    Crowe SB, Kairn T, Middlebrook N (2013) Retrospective evaluation of dosimetric quality for prostate carcinomas treated with 3D conformal, intensity modulated and volumetric modulated arc radiotherapy. J Med Radiat Sci 60(4):131–138

    Article  PubMed  PubMed Central  Google Scholar 

  25. 25.

    Kairn T, Crowe SB (2016) Clinical application of data mining: evaluation and comparison of radiotherapy treatment plans for breast cancer. Aust Phys Eng Sci Med 39(4):1168

    Google Scholar 

  26. 26.

    Donovan E, Bleakley N, Denholm E (2007) Randomised trial of standard 2D radiotherapy (RT) versus intensity modulated radiotherapy (IMRT) in patients prescribed breast radiotherapy. Radiother Oncol 82(3):254–264

    Article  PubMed  Google Scholar 

  27. 27.

    Donovan E, Yarnold J, Adams E (2014) An investigation into methods of IMRT planning applied to breast radiotherapy. Br J Radiol 81(964):311–322

    Article  Google Scholar 

  28. 28.

    Marks LB, Yorke ED, Jackson A (2010) Use of normal tissue complication probability models in the clinic. Int J Radiat Oncol Biol Phys 76(3):S10–S19

    Article  PubMed  PubMed Central  Google Scholar 

  29. 29.

    Gagliardi G, Constine LS, Moiseenko V (2010) Radiation dosevolume effects in the heart. Int J Radiat Oncol Biol Phys 76(3):S77–S85

    Article  PubMed  Google Scholar 

  30. 30.

    Cao J, Roeske JC, Chmura SJ (2009) Calculation and prediction of the effect of respiratory motion on whole breast radiation therapy dose distributions. Med Dosim 34(2):126–132

    Article  PubMed  Google Scholar 

  31. 31.

    Yin A, Dawes J, Sylvander SR (2018) Interplay effect for IMRT treatments of breast cancer. Aust Phys Eng Sci Med 41(1):252

    Google Scholar 

  32. 32.

    Chino JP, Marks LB (2008) Prone positioning causes the heart to be displaced anteriorly within the thorax: implications for breast cancer treatment. Int J Radiat Oncol Biol Phys 70(3):916–920

    Article  PubMed  Google Scholar 

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Acknowledgements

The authors with to acknowledge the assistance of Nigel Middlebrook for helpful discussions and guidance during the early stages of this work.

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Correspondence to T. Kairn.

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Low-risk ethics approval for retrospective analysis of de-identified patient data was obtained from the Genesis Cancer Care Queensland Research Committee.

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Otherwise, this article does not contain any studies with human participants or animals performed by any of the authors.

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Preliminary aspects of this work were presented at the International Conference of Computers in Radiotherapy, London, 2016 and the Engineering and Physical Sciences in Medicine conference, Sydney, 2016. A selection of final results of this work were presented at the IUPESM World Congress on Medical Physics and Biomedical Engineering, Prague, 2018.

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Kairn, T., Crowe, S.B. Application of retrospective data analysis to clinical protocol design: can the potential benefits of breath-hold techniques for breast radiotherapy be assessed without testing on patients?. Australas Phys Eng Sci Med 42, 227–233 (2019). https://doi.org/10.1007/s13246-019-00725-w

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Keywords

  • Radiation therapy
  • Treatment planning
  • Dosimetry
  • Breast cancer