Do you use breath hold techniques to minimize heart dose in whole breast radiation?

We do 2 CT scans (free breathing and deep breath hold) for every patient with left sided breast cancer treated in the supine position. We then create volumes and blocks for both scans and select the DIBH plan if it offers a clear advantage. Our approach is to attempt to keep mean heart dose under 1 Gy for women treated to the whole breast RT without nodal coverage. We find that achieving this goal often requires heart sparing techniques including the use of prone positioning, DIBH, cardiac block...

I agree that it is important to obtain both the free breathing and the breath hold scan for all supine left-sided cases. This gives the physician the freedom to plan on either scan and to compare, and to plan the boost on the free breathing scan even if breath hold is chosen for the primary treatment- I rarely use breath hold for the boost.

Given that there does not appear to be a threshold dose for radiation impact on the heart, I take the point of view that even small decreases in the mean he...