{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,17]],"date-time":"2026-09-17T16:37:11Z","timestamp":1789663031256,"version":"4.0.1"},"reference-count":41,"publisher":"Public Library of Science (PLoS)","issue":"3","license":[{"start":{"date-parts":[[2026,3,30]],"date-time":"2026-03-30T00:00:00Z","timestamp":1774828800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:p>\n                    This meta-analysis aimed to determine the effect of deep inspiration breath hold (DIBH) compared with free breathing (FB) on dose to the organs at risk (OARs), such as the heart, left anterior descending (LAD) coronary artery, lungs, and contralateral breast, in patients with left-sided breast cancer treated with volumetric modulated arc therapy (VMAT). PubMed, EMBASE, and Cochrane Library electronic databases were searched for studies until March 21, 2024. Cochrane RevMan version 5.4 statistical software was used to analyze 11 eligible studies. Standard mean difference (SMD), with 95% confidence interval for OAR dose reductions, was calculated. DIBH considerably resulted in lower mean doses (Dmean) to the heart (SMD\u2009=\u2009 \u22121.40 Gy), LAD (SMD\u2009= \u22121.65 Gy), ipsilateral lung (SMD\u2009= \u22120.57 Gy), contralateral lung (SMD\u2009= \u22120.46 Gy), and contralateral breast (SMD\u2009= \u22120.20 Gy). If VMAT was delivered with an arc of &gt;180\n                    <jats:sup>O<\/jats:sup>\n                    , the heart Dmean reduction was even more pronounced. Subgroup analysis revealed that DIBH efficiently reduced heart Dmean, especially in patients with tumor bed boost without nodal irradiation. DIBH was effective in reducing dose to OARs in patients treated with VMAT in all subgroups, i.e., breast only, with\/without tumor bed boost, and with\/without nodal irradiation. Furthermore, the use of DIBH is strongly recommended for patients undergoing VMAT with a tumor bed boost or without nodal irradiation, as it is more effective in reducing heart Dmean than FB.\n                  <\/jats:p>","DOI":"10.1371\/journal.pone.0345614","type":"journal-article","created":{"date-parts":[[2026,3,30]],"date-time":"2026-03-30T17:31:48Z","timestamp":1774891908000},"page":"e0345614","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":2,"title":["Deep inspiration breath hold versus free breathing in postoperative radiotherapy strategy for patients with left-sided breast cancer treated with volumetric modulated arc therapy: A meta-analysis and systematic review"],"prefix":"10.1371","volume":"21","author":[{"given":"Pin-Yi","family":"Chiang","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pin-Jui","family":"Huang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chao-Hsiung","family":"Hung","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ching-Po","family":"Lin","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1893-4808","authenticated-orcid":true,"given":"Chih-Chia","family":"Chang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,3,30]]},"reference":[{"issue":"9503","key":"pone.0345614.ref001","doi-asserted-by":"crossref","first-page":"2087","DOI":"10.1016\/S0140-6736(05)67887-7","article-title":"Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials","volume":"366","author":"M Clarke","year":"2005","journal-title":"Lancet"},{"issue":"16","key":"pone.0345614.ref002","doi-asserted-by":"crossref","first-page":"1233","DOI":"10.1056\/NEJMoa022152","article-title":"Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer","volume":"347","author":"B Fisher","year":"2002","journal-title":"N Engl J Med"},{"issue":"4","key":"pone.0345614.ref003","doi-asserted-by":"crossref","first-page":"697","DOI":"10.1002\/cncr.11580","article-title":"Eighteen-year results in the treatment of early breast carcinoma with mastectomy versus breast conservation therapy: the National Cancer Institute Randomized Trial","volume":"98","author":"MM Poggi","year":"2003","journal-title":"Cancer"},{"issue":"16","key":"pone.0345614.ref004","doi-asserted-by":"crossref","first-page":"1227","DOI":"10.1056\/NEJMoa020989","article-title":"Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer","volume":"347","author":"U Veronesi","year":"2002","journal-title":"N Engl J Med"},{"issue":"4","key":"pone.0345614.ref005","doi-asserted-by":"crossref","first-page":"445","DOI":"10.1016\/j.jacc.2010.08.638","article-title":"Long-term cardiovascular mortality after radiotherapy for breast cancer","volume":"57","author":"K Bouillon","year":"2011","journal-title":"J Am Coll Cardiol"},{"issue":"11","key":"pone.0345614.ref006","doi-asserted-by":"crossref","first-page":"987","DOI":"10.1056\/NEJMoa1209825","article-title":"Risk of ischemic heart disease in women after radiotherapy for breast cancer","volume":"368","author":"SC Darby","year":"2013","journal-title":"N Engl J Med"},{"issue":"1","key":"pone.0345614.ref007","doi-asserted-by":"crossref","first-page":"179","DOI":"10.1038\/bjc.2012.575","article-title":"Radiation-related mortality from heart disease and lung cancer more than 20 years after radiotherapy for breast cancer","volume":"108","author":"KE Henson","year":"2013","journal-title":"Br J Cancer"},{"issue":"7","key":"pone.0345614.ref008","doi-asserted-by":"crossref","first-page":"733","DOI":"10.1016\/j.ejmp.2015.06.006","article-title":"A cost-effective technique for cardiac sparing with deep inspiration-breath hold (DIBH)","volume":"31","author":"BD Macrie","year":"2015","journal-title":"Phys Med"},{"key":"pone.0345614.ref009","doi-asserted-by":"crossref","first-page":"87","DOI":"10.3389\/fonc.2018.00087","article-title":"Deep Inspiration Breath Hold: Techniques and Advantages for Cardiac Sparing During Breast Cancer Irradiation","volume":"8","author":"C Bergom","year":"2018","journal-title":"Front Oncol"},{"issue":"1","key":"pone.0345614.ref010","doi-asserted-by":"crossref","first-page":"56","DOI":"10.4103\/jcrt.JCRT_1414_16","article-title":"A dosimetric analysis of cardiac dose with or without active breath coordinator moderate deep inspiratory breath hold in left sided breast cancer radiotherapy","volume":"13","author":"B Kunheri","year":"2017","journal-title":"J Cancer Res Ther"},{"issue":"6","key":"pone.0345614.ref011","doi-asserted-by":"crossref","DOI":"10.1016\/j.prro.2017.04.006","article-title":"Deep inspiration breathhold for left-sided breast cancer patients with unfavorable cardiac anatomy requiring internal mammary nodal irradiation","volume":"7","author":"O Mohamad","year":"2017","journal-title":"Pract Radiat Oncol"},{"issue":"1","key":"pone.0345614.ref012","doi-asserted-by":"crossref","first-page":"22","DOI":"10.1177\/1533034615624311","article-title":"Dosimetric Considerations in Respiratory-Gated Deep Inspiration Breath-Hold for Left Breast Irradiation","volume":"16","author":"S Walston","year":"2017","journal-title":"Technol Cancer Res Treat"},{"issue":"3","key":"pone.0345614.ref013","article-title":"Set-up verification and 2-dimensional electronic portal imaging device dosimetry during breath hold compared with free breathing in breast cancer radiation therapy","volume":"5","author":"PJAM Brouwers","year":"2015","journal-title":"Pract Radiat Oncol"},{"issue":"3","key":"pone.0345614.ref014","doi-asserted-by":"crossref","first-page":"918","DOI":"10.1016\/j.ijrobp.2007.06.060","article-title":"Is multibeam IMRT better than standard treatment for patients with left-sided breast cancer?","volume":"69","author":"WA Beckham","year":"2007","journal-title":"Int J Radiat Oncol Biol Phys"},{"issue":"4","key":"pone.0345614.ref015","doi-asserted-by":"crossref","first-page":"1023","DOI":"10.1016\/S0360-3016(03)00183-4","article-title":"Potential gains for irradiation of chest wall and regional nodes with intensity modulated radiotherapy","volume":"56","author":"EA Krueger","year":"2003","journal-title":"Int J Radiat Oncol Biol Phys"},{"issue":"1","key":"pone.0345614.ref016","doi-asserted-by":"crossref","first-page":"287","DOI":"10.1016\/j.ijrobp.2009.05.038","article-title":"Volumetric modulated arc therapy improves dosimetry and reduces treatment time compared to conventional intensity-modulated radiotherapy for locoregional radiotherapy of left-sided breast cancer and internal mammary nodes","volume":"76","author":"CC Popescu","year":"2010","journal-title":"Int J Radiat Oncol Biol Phys"},{"issue":"11","key":"pone.0345614.ref017","doi-asserted-by":"crossref","first-page":"4727","DOI":"10.7314\/APJCP.2014.15.11.4727","article-title":"Dosimetric evaluation of 3-D conformal and intensity-modulated radiotherapy for breast cancer after conservative surgery","volume":"15","author":"S Mansouri","year":"2014","journal-title":"Asian Pac J Cancer Prev"},{"issue":"6","key":"pone.0345614.ref018","doi-asserted-by":"crossref","first-page":"484","DOI":"10.1007\/s00066-012-0075-6","article-title":"Chest wall radiotherapy with volumetric modulated arcs and the potential role of flattening filter free photon beams","volume":"188","author":"S Subramaniam","year":"2012","journal-title":"Strahlenther Onkol"},{"issue":"2","key":"pone.0345614.ref019","doi-asserted-by":"crossref","first-page":"299","DOI":"10.1007\/s12282-019-01023-9","article-title":"Meta-analysis of deep inspiration breath hold (DIBH) versus free breathing (FB) in postoperative radiotherapy for left-side breast cancer","volume":"27","author":"J Lai","year":"2020","journal-title":"Breast Cancer"},{"key":"pone.0345614.ref020","doi-asserted-by":"crossref","first-page":"845037","DOI":"10.3389\/fonc.2022.845037","article-title":"Comparison of Deep Inspiration Breath Hold Versus Free Breathing in Radiotherapy for Left Sided Breast Cancer","volume":"12","author":"Y Lu","year":"2022","journal-title":"Front Oncol"},{"issue":"3","key":"pone.0345614.ref021","doi-asserted-by":"crossref","first-page":"379","DOI":"10.1016\/j.jmir.2020.03.003","article-title":"Factors Affecting Mean Heart Dose in Patients Receiving Breast Radiotherapy from 2011 to 2018 in a Single Institution","volume":"51","author":"Y Razvi","year":"2020","journal-title":"J Med Imaging Radiat Sci"},{"issue":"1","key":"pone.0345614.ref022","doi-asserted-by":"crossref","first-page":"17","DOI":"10.1016\/j.radonc.2014.04.004","article-title":"Volumetric modulated arc therapy and breath-hold in image-guided locoregional left-sided breast irradiation","volume":"112","author":"SOS Osman","year":"2014","journal-title":"Radiother Oncol"},{"issue":"20","key":"pone.0345614.ref023","doi-asserted-by":"crossref","first-page":"9033","DOI":"10.7314\/APJCP.2014.15.20.9033","article-title":"Feasibility study of deep inspiration breath-hold based volumetric modulated arc therapy for locally advanced left sided breast cancer patients","volume":"15","author":"ST Swamy","year":"2014","journal-title":"Asian Pac J Cancer Prev"},{"issue":"4","key":"pone.0345614.ref024","doi-asserted-by":"crossref","first-page":"545","DOI":"10.1111\/1754-9485.12459","article-title":"Left-sided breast cancer loco-regional radiotherapy with deep inspiration breath-hold: Does volumetric-modulated arc radiotherapy reduce heart dose further compared with tangential intensity-modulated radiotherapy?","volume":"60","author":"TT Pham","year":"2016","journal-title":"J Med Imaging Radiat Oncol"},{"issue":"10","key":"pone.0345614.ref025","doi-asserted-by":"crossref","first-page":"800","DOI":"10.1007\/s00066-017-1167-0","article-title":"Cardiac dose-sparing effects of deep-inspiration breath-hold in left breast irradiation\u00a0: Is IMRT more beneficial than VMAT?","volume":"193","author":"M Sakka","year":"2017","journal-title":"Strahlenther Onkol"},{"issue":"1","key":"pone.0345614.ref026","doi-asserted-by":"crossref","first-page":"187","DOI":"10.1186\/s13014-018-1132-9","article-title":"Reduction in low-dose to normal tissue with the addition of deep inspiration breath hold (DIBH) to volumetric modulated arc therapy (VMAT) in breast cancer patients with implant reconstruction receiving regional nodal irradiation","volume":"13","author":"VA Dumane","year":"2018","journal-title":"Radiat Oncol"},{"issue":"2","key":"pone.0345614.ref027","doi-asserted-by":"crossref","first-page":"150","DOI":"10.1016\/j.meddos.2018.04.006","article-title":"A VMAT planning technique for locally advanced breast cancer patients with expander or implant reconstructions requiring comprehensive postmastectomy radiation therapy","volume":"44","author":"L Kuo","year":"2019","journal-title":"Med Dosim"},{"issue":"39","key":"pone.0345614.ref028","article-title":"Evaluation of abches and volumetric modulated arc therapy under deep inspiration breath-hold technique for patients with left-sided breast cancer: A retrospective observational study","volume":"98","author":"T-C Yeh","year":"2019","journal-title":"Medicine (Baltimore)"},{"key":"pone.0345614.ref029","doi-asserted-by":"crossref","first-page":"1711","DOI":"10.3389\/fonc.2020.01711","article-title":"Dosimetry and Feasibility Studies of Volumetric Modulated Arc Therapy With Deep Inspiration Breath-Hold Using Optical Surface Management System for Left-Sided Breast Cancer Patients","volume":"10","author":"W Zhang","year":"2020","journal-title":"Front Oncol"},{"issue":"7","key":"pone.0345614.ref030","doi-asserted-by":"crossref","first-page":"3314","DOI":"10.21037\/qims-20-831","article-title":"Immobilization-assisted abdominal deep inspiration breath-hold in post-mastectomy radiotherapy of left-sided breast cancer with internal mammary chain coverage","volume":"11","author":"M Chen","year":"2021","journal-title":"Quant Imaging Med Surg"},{"issue":"3","key":"pone.0345614.ref031","doi-asserted-by":"crossref","first-page":"288","DOI":"10.1016\/j.meddos.2022.04.005","article-title":"Dosimetric advantages of volumetric modulated arc therapy (VMAT) with deep inspiration breath hold (DIBH) technique in Halcyon Linac for left breast cancer treatment","volume":"47","author":"AP-Y Cheung","year":"2022","journal-title":"Med Dosim"},{"issue":"5","key":"pone.0345614.ref032","doi-asserted-by":"crossref","first-page":"461","DOI":"10.1515\/oncologie-2023-0134","article-title":"Pre-treatment predictors of cardiac dose exposure in left-sided breast cancer radiotherapy patients after breast conserving surgery","volume":"25","author":"L Xu","year":"2023","journal-title":"Oncologie"},{"issue":"1","key":"pone.0345614.ref033","doi-asserted-by":"crossref","first-page":"71","DOI":"10.1186\/s13014-020-01501-x","article-title":"Recent advances in radiotherapy of breast cancer","volume":"15","author":"J Haussmann","year":"2020","journal-title":"Radiat Oncol"},{"issue":"9804","key":"pone.0345614.ref034","doi-asserted-by":"crossref","first-page":"1707","DOI":"10.1016\/S0140-6736(11)61629-2","article-title":"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","volume":"378","author":"(EBCTCG) Early Breast Cancer Trialists\u2019 Collaborative Group","year":"2011","journal-title":"Lancet"},{"key":"pone.0345614.ref035","doi-asserted-by":"crossref","first-page":"99","DOI":"10.1186\/1748-717X-5-99","article-title":"Reduction of radiation pneumonitis by V20-constraints in breast cancer","volume":"5","author":"U Blom Goldman","year":"2010","journal-title":"Radiat Oncol"},{"issue":"5","key":"pone.0345614.ref036","doi-asserted-by":"crossref","first-page":"298","DOI":"10.1016\/j.prro.2013.10.006","article-title":"Introduction of moderate deep inspiration breath hold for radiation therapy of left breast: Initial experience of a regional cancer center","volume":"4","author":"D Comsa","year":"2014","journal-title":"Pract Radiat Oncol"},{"issue":"3","key":"pone.0345614.ref037","doi-asserted-by":"crossref","DOI":"10.1016\/j.prro.2014.08.003","article-title":"Deep inspiration breath-hold technique in left-sided breast cancer radiation therapy: Evaluating cardiac contact distance as a predictor of cardiac exposure for patient selection","volume":"5","author":"N Rochet","year":"2015","journal-title":"Pract Radiat Oncol"},{"issue":"3","key":"pone.0345614.ref038","doi-asserted-by":"crossref","first-page":"447","DOI":"10.1093\/jrr\/rraa006","article-title":"Dosimetric evaluation of deep inspiration breath hold for left-sided breast cancer: analysis of patient-specific parameters related to heart dose reduction","volume":"61","author":"R Yamauchi","year":"2020","journal-title":"J Radiat Res"},{"issue":"1","key":"pone.0345614.ref039","doi-asserted-by":"crossref","first-page":"63","DOI":"10.3390\/jpm14010063","article-title":"Radiation Dose to Critical Cardiac Structures from Three-Dimensional Conformal Radiation Therapy (3D-CRT), Intensity-Modulated Radiation Therapy (IMRT) and Volumetric Modulated Arc Therapy (VMAT) Techniques for Left-Sided Breast Cancer","volume":"14","author":"E Konstantinou","year":"2024","journal-title":"J Pers Med"},{"issue":"1","key":"pone.0345614.ref040","doi-asserted-by":"crossref","first-page":"116","DOI":"10.1186\/s13014-018-1062-6","article-title":"Abdominal DIBH reduces the cardiac dose even further: a prospective analysis","volume":"13","author":"F Zhao","year":"2018","journal-title":"Radiat Oncol"},{"key":"pone.0345614.ref041","doi-asserted-by":"crossref","first-page":"109734","DOI":"10.1016\/j.radonc.2023.109734","article-title":"ESTRO-ACROP guideline: Recommendations on implementation of breath-hold techniques in radiotherapy","volume":"185","author":"MC Aznar","year":"2023","journal-title":"Radiother Oncol"}],"container-title":["PLOS One"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0345614","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,3,30]],"date-time":"2026-03-30T17:31:57Z","timestamp":1774891917000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0345614"}},"subtitle":[],"editor":[{"given":"Christopher","family":"Njeh","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2026,3,30]]},"references-count":41,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2026,3,30]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0345614","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,3,30]]}}}