Elisabetta Bonzano MD PhD; 2025 EBCC: BRAVE-HEART Study Shows How Breath-Holding System Halves Coronary Radiation Dose During Left Breast Irradiation

BRAVE-HEART Study Shows How Breath-Holding System Halves Coronary Radiation Dose During Left Breast Irradiation

An interview with:

Elisabetta Bonzano MD PhD, IRCCS San Matteo Polyclinic Foundation, Radiation Oncology, Pavia, Italy

BARCELONA, Spain—A system known as Active Breathing Co-ordination had a large, consistent and significant effect in reducing radiation dose to the heart and left anterior descending coronary artery in the BRAVE HEART study led by radiation oncologists from Pavia in Italy.

Elisabetta Bonzano MD PhD, IRCCS San Matteo Polyclinic Foundation, Radiation Oncology, Pavia, Italy reported her group’s findings at the 2025 European Breast Cancer Conference. Afterwards she talked about more of the details for this edition of the Audio Journal of Oncology:

AUDIO JOURNAL OF ONCOLOGY: Elisabetta Bonzano MD PhD

IN: [GOODWIN]” Peter Goodwin here at the….

OUT: ………of Oncology, I’m Peter Goodwin.  5: 54 secs

EBCC Presentation number:PB-008

Abstract title:

BRAVE-HEART: Clinical and dosimetric validation of Active Breath Control for cardiac sparing in breast cancer radiotherapy

Bonzano1,, L. Squillace1,, A. Lancia1,, J. Saddi1,, S. Colombo1,, S. La Mattina1,, D.A. Santos1,, P. Pedrazzoli2,.

1IRCCS San Matteo Polyclinic Foundation, Radiation Oncology, Pavia, Italy.

2IRCCS San Matteo Polyclinic Foundation, Oncology, Pavia, Italy.

Background:

Cardiac exposure during left-sided breast cancer (LBC) radiotherapy remains a key determinant of long-term morbidity and mortality. The BRAVE-HEART trial explores the clinical and dosimetric impact of Deep Inspiration Breath Hold (DIBH) using the Active Breathing Coordinator (ABC) system. This analysis quantifies the cardiac-sparing effect of ABC versus free-breathing (FB) across three fractionation schedules, validates its intrinsic benefit through intra-patient paired replanning, and assesses real-world feasibility. (ClinicalTrials.gov awaiting release)

Methods:

This ambispective single-center study included 400 patients with early or locally advanced LBC treated with 26 Gy/5 fx, 40 Gy/15 fx, or 50 Gy/25 fx ± SIB. Dosimetric parameters were extracted for the heart and LAD (Dmean, Dmax). Statistical analyses used the Shapiro–Wilk, Mann–Whitney U, and Wilcoxon tests; effect size was reported as Cohen’s d. Model-based estimation of cardiac mortality risk (NTCP) was performed for the replanning subgroup using the Gagliardi relative-seriality model. For this subgroup, paired FB and ABC-DIBH plans were generated on separate CT scans. Breath-hold performance (hold duration, threshold volume) was recorded to evaluate feasibility. The study was approved by the Ethics Committee of the Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.

Results:

ABC significantly reduced cardiac and LAD exposure across all fractionations (all p < 0.001), with large effect sizes (Cohen’s d ≥0.8) indicating a strong clinical impact (Tab. 1). In intra-patient replanning, ABC confirmed its dosimetric superiority over FB (p < 0.05). Model-based NTCP for late cardiac mortality showed a halving of predicted cardiac risk with ABC (0.04 vs 0.08, p < 0.001). Breath-hold metrics confirmed high feasibility (mean DIBH ≈ 25 s; threshold ≈ 1.4 L), including in elderly patients (mean age 75 years).

Conclusions:

ABC-assisted DIBH consistently and significantly reduced cardiac and coronary exposure across all dose regimens, with high reproducibility and feasibility. Model-based NTCP and intra-patient replanning analyses demonstrate a clinically and biologically relevant reduction in predicted long-term cardiac mortality, confirming ABC-DIBH as a reliable strategy to improve cardiac safety in left-sided breast cancer radiotherapy.

Elisabetta Bonzano MD PhD