Effect of Bra use during Radiotherapy for Large Breasted Women: Acute Toxicity and Treated Heart and Lung Volume

Abstract

Purpose/Objective(s)Larger breast sizes are associated with increased skin toxicity in women undergoing post-lumpectomy breast radiotherapy (RT). Prone positioning has been suggested for large-breasted women, but may not be tolerated by all women and has been associated with forward movement of the heart in some cases. The purpose of the study is to report the use of a bra as an alternative for large-breasted women.Materials/MethodsFrom 2001 to 2006, 246 consecutive large-breasted women (bra size >= 38 and/or >= D cup) were treated with breast-conserving surgery and radiation. A custom-fitted bustier was used during whole breast RT in 58 cases and removed for the boost. Acute dermatitis was graded weekly during treatment by the physician using the Common Terminology Criteria for Adverse Events version 3. Predictors of skin toxicity analyzed in univariate and multivariate analysis (MVA) included bra use, bra size, cup size, age, use of intensity modulated radiation therapy (IMRT), chest wall separation, beam energy, mean dose, and smoking history. Dosimetric comparison of heart and lung volumes within the tangential radiation fields was performed on a group of 12 left-sided breast cancer patients with and without a bra.ResultsBra users had a significant difference in cup size (median D, range, C-EEE vs. median D, range B-EE, p < 0.0001) and higher beam energy (22% 6 MV, 33% 10 MV, 45% 18 MV vs. 21% 6 MV, 55% 10 MV, 23% 18 MV, p = 0.002) but not bra size (p = 0.07) or chest wall separation (p = 0.55). On univariate analysis, increased Grade 2/3 dermatitis was significantly associated with use of a bra (p = 0.0003), not using IMRT (p < 0.0001), and higher dose (p = 0.001). Most skin toxicities were Grade 2: 90% of patients in a bra compared to 70% of patients not in a bra (p = 0.003). The use of IMRT reduced the rate of Grade 2/3 skin toxicity from 91% to 68% (p < 0.0001) in the entire population. The rate of Grade 2/3 dermatitis was 86% for patients without a bra and no IMRT, 64% without a bra and use of IMRT, 100% for a bra and no IMRT, and 87% for a bra and use of IMRT (p < 0.0001). On multivariate analysis (MVA), not using IMRT (OR = 3.9, 95% CI, 1.8-8.5) and use of a bra (OR = 5.5, 95% CI, 1.6-18.8) were significant predictors of Grade 2/3 skin toxicity. With the use of a bra, the volume of heart in the treatment fields decreased by 63.4% (p = 0.002), treated left lung decreased by 18.5% (p = 0.25), and chest wall separation decreased by a mean of 1 cm (range, −4.07 to +0.85, p = 0.03).ConclusionsThe use of a bra in large-breasted women was associated with significantly reduced heart volume in the treatment field. An IMRT appeared to mitigate any increased risk of dermatitis and would likely further decrease dose to the heart. The use of the bra in large-breasted women may be a preferable alternative to the prone position. Purpose/Objective(s)Larger breast sizes are associated with increased skin toxicity in women undergoing post-lumpectomy breast radiotherapy (RT). Prone positioning has been suggested for large-breasted women, but may not be tolerated by all women and has been associated with forward movement of the heart in some cases. The purpose of the study is to report the use of a bra as an alternative for large-breasted women. Larger breast sizes are associated with increased skin toxicity in women undergoing post-lumpectomy breast radiotherapy (RT). Prone positioning has been suggested for large-breasted women, but may not be tolerated by all women and has been associated with forward movement of the heart in some cases. The purpose of the study is to report the use of a bra as an alternative for large-breasted women. Materials/MethodsFrom 2001 to 2006, 246 consecutive large-breasted women (bra size >= 38 and/or >= D cup) were treated with breast-conserving surgery and radiation. A custom-fitted bustier was used during whole breast RT in 58 cases and removed for the boost. Acute dermatitis was graded weekly during treatment by the physician using the Common Terminology Criteria for Adverse Events version 3. Predictors of skin toxicity analyzed in univariate and multivariate analysis (MVA) included bra use, bra size, cup size, age, use of intensity modulated radiation therapy (IMRT), chest wall separation, beam energy, mean dose, and smoking history. Dosimetric comparison of heart and lung volumes within the tangential radiation fields was performed on a group of 12 left-sided breast cancer patients with and without a bra. From 2001 to 2006, 246 consecutive large-breasted women (bra size >= 38 and/or >= D cup) were treated with breast-conserving surgery and radiation. A custom-fitted bustier was used during whole breast RT in 58 cases and removed for the boost. Acute dermatitis was graded weekly during treatment by the physician using the Common Terminology Criteria for Adverse Events version 3. Predictors of skin toxicity analyzed in univariate and multivariate analysis (MVA) included bra use, bra size, cup size, age, use of intensity modulated radiation therapy (IMRT), chest wall separation, beam energy, mean dose, and smoking history. Dosimetric comparison of heart and lung volumes within the tangential radiation fields was performed on a group of 12 left-sided breast cancer patients with and without a bra. ResultsBra users had a significant difference in cup size (median D, range, C-EEE vs. median D, range B-EE, p < 0.0001) and higher beam energy (22% 6 MV, 33% 10 MV, 45% 18 MV vs. 21% 6 MV, 55% 10 MV, 23% 18 MV, p = 0.002) but not bra size (p = 0.07) or chest wall separation (p = 0.55). On univariate analysis, increased Grade 2/3 dermatitis was significantly associated with use of a bra (p = 0.0003), not using IMRT (p < 0.0001), and higher dose (p = 0.001). Most skin toxicities were Grade 2: 90% of patients in a bra compared to 70% of patients not in a bra (p = 0.003). The use of IMRT reduced the rate of Grade 2/3 skin toxicity from 91% to 68% (p < 0.0001) in the entire population. The rate of Grade 2/3 dermatitis was 86% for patients without a bra and no IMRT, 64% without a bra and use of IMRT, 100% for a bra and no IMRT, and 87% for a bra and use of IMRT (p < 0.0001). On multivariate analysis (MVA), not using IMRT (OR = 3.9, 95% CI, 1.8-8.5) and use of a bra (OR = 5.5, 95% CI, 1.6-18.8) were significant predictors of Grade 2/3 skin toxicity. With the use of a bra, the volume of heart in the treatment fields decreased by 63.4% (p = 0.002), treated left lung decreased by 18.5% (p = 0.25), and chest wall separation decreased by a mean of 1 cm (range, −4.07 to +0.85, p = 0.03). Bra users had a significant difference in cup size (median D, range, C-EEE vs. median D, range B-EE, p < 0.0001) and higher beam energy (22% 6 MV, 33% 10 MV, 45% 18 MV vs. 21% 6 MV, 55% 10 MV, 23% 18 MV, p = 0.002) but not bra size (p = 0.07) or chest wall separation (p = 0.55). On univariate analysis, increased Grade 2/3 dermatitis was significantly associated with use of a bra (p = 0.0003), not using IMRT (p < 0.0001), and higher dose (p = 0.001). Most skin toxicities were Grade 2: 90% of patients in a bra compared to 70% of patients not in a bra (p = 0.003). The use of IMRT reduced the rate of Grade 2/3 skin toxicity from 91% to 68% (p < 0.0001) in the entire population. The rate of Grade 2/3 dermatitis was 86% for patients without a bra and no IMRT, 64% without a bra and use of IMRT, 100% for a bra and no IMRT, and 87% for a bra and use of IMRT (p < 0.0001). On multivariate analysis (MVA), not using IMRT (OR = 3.9, 95% CI, 1.8-8.5) and use of a bra (OR = 5.5, 95% CI, 1.6-18.8) were significant predictors of Grade 2/3 skin toxicity. With the use of a bra, the volume of heart in the treatment fields decreased by 63.4% (p = 0.002), treated left lung decreased by 18.5% (p = 0.25), and chest wall separation decreased by a mean of 1 cm (range, −4.07 to +0.85, p = 0.03). ConclusionsThe use of a bra in large-breasted women was associated with significantly reduced heart volume in the treatment field. An IMRT appeared to mitigate any increased risk of dermatitis and would likely further decrease dose to the heart. The use of the bra in large-breasted women may be a preferable alternative to the prone position. The use of a bra in large-breasted women was associated with significantly reduced heart volume in the treatment field. An IMRT appeared to mitigate any increased risk of dermatitis and would likely further decrease dose to the heart. The use of the bra in large-breasted women may be a preferable alternative to the prone position.