Muhammad Fairuz Bin Jum’ee, tipsRO Young Researcher Award
ESTRO 2026 Congress Report
Deep inspiration breath-hold (DIBH) is a well-established, cardiac-sparing technique that is used in left-sided breast radiotherapy. Its use enables substantial reductions of radiation dose to the heart. However, successful implementation relies on patients' ability to maintain stable, reproducible breath-holds throughout treatment. Many patients struggle to meet these requirements despite extensive coaching and training by radiation therapists.
At the National Cancer Centre Singapore, a departmental audit conducted in 2022 revealed that only 23.7% of patients who had been referred for spirometry-based DIBH fulfilled the institutional eligibility criteria. This low success rate prompted our team to investigate whether autonomous home-based preparation could improve DIBH eligibility.
We conducted a radiation-therapist-led prospective study on 100 consecutive patients with left-sided breast cancer who were referred for DIBH radiotherapy between July 2023 and January 2024. Ninety-three patients completed the study. Participants received, during their initial consultation, a home-training package that comprised an educational booklet, guided breath-hold training videos, and a nose clip. Patients were encouraged to practise at home before their eligibility assessment. Patient-reported outcomes that evaluated anxiety, information needs, training compliance and satisfaction were collected using validated questionnaires, including the six-item Spielberger state-trait anxiety inventory (STAI-6) and the Amsterdam preoperative anxiety and information scale (APAIS).
The median interval between consultation and DIBH eligibility assessment was 13 days (interquartile range 7.5–20.5 days). Following implementation of the home-training programme, DIBH eligibility increased significantly from 23.7% in the historical audit cohort to 51.6% (95% confidence interval of 41-62.1%, p<0.001), effectively more than doubling the proportion of patients who were able to meet the spirometry-based eligibility criteria.
Age emerged as the strongest predictor of eligibility. A significant negative correlation was observed between age and successful DIBH performance (rpb=-0.325, n=93, p=0.001). Polynomial regression modelling (R²=0.9953) demonstrated a steep decline in eligibility between ages 40 and 50 years (−24.8%) and 50 and 60 years (−10.7%), reaching 0% by 67 years old. These findings suggest that age-related physiological changes may substantially influence people’s ability to consistently hold their breath as required.
Interestingly, no significant associations were observed between DIBH eligibility and body mass index, smoking history, chemotherapy, type of surgery, anxiety levels, need-for-information, previous DIBH knowledge, or self-reported home-training compliance. These findings suggest that successful DIBH performance may be influenced more by physiological and coordination-related factors than by patient motivation, knowledge, or anxiety.
The most common reasons for ineligibility were unstable breath-holds (21.5%) and poor ability to reproduce their breath-hold position (16.1%). Furthermore, a proportion of patients who initially met eligibility criteria subsequently failed during CT simulation, and this finding highlighted reproducibility as an important clinical challenge and a key target for future intervention.
Although limited by its single-arm design and use of a historical control cohort, this study demonstrates that a simple, low-cost home-training programme can significantly improve access to DIBH. Future research should focus on optimising respiratory training strategies, developing age-adapted pathways, and evaluating alternative cardiac-sparing techniques for patients who remain unsuitable for DIBH even after training.
Overall, this work demonstrates how patient-centred, radiation-therapist-led innovation can expand patients’ access to precision radiotherapy. By empowering patients to prepare before treatment and identifying age-related barriers to DIBH implementation, this study contributes to the ongoing effort to make advanced radiotherapy techniques safer, more effective, and more inclusive.
Muhammad Fairuz Bin Jum’ee
National Cancer Centre Singapore
Email: muhd.fairuz.jum.ee@nccs.com.sg
Linkedin: www.linkedin.com/in/fairuz-jum-ee-a2964717