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Breast Treatment Methods: Prone Versus Supine

Morgan Jostpille
4/24/17
Lymberis SC, Dewyngaert JK, Parhar P, et al. Prospective Assessment of Optimal Individual

Position (Prone Versus Supine) for Breast Radiotherapy: Volumetric and Dosimetric

Correlations in 100 Patients. International Journal of Radiation Oncology*Biology*Physics.

2012;84(4):902-99. DOI:10.1016/J.IJROBP.2012.01.040.

Researchers are constantly constructing new treatment techniques to limit radiation dose to

the heart and lungs when treating breast cancer. The authors have done research comparing

which position, either supine or prone, best spares the lung and heart from radiation exposure.

The study selected patients with stage 0-IIA breast cancer until 100 patients were selected (53

left breast and 47 right breast). A dose of 40.5 Gy was given to each patient in 15 fractions with a

boost to follow. “In 46/53 (87%) left breast cancer patients best treated prone, infield heart

volume was reduced by a mean of 12cc and by 1.8cc for the other 7/53 (13%) patients best

treated supine.”1 The mean dose of the heart and lung were highly correlated with whether the

patient was supine or prone.

A purposive sample was used to assimilate the participations of this study because all the

subjects must have stage 0-IIA breast cancer. Most of the variables were not confounding which

makes the research reliable. One example is that all patients were treated using the 3-week

treatment to the whole-breast with an IMRT boost. The researchers selected breast cancer

patients with stage 0, I, or IIA disease after a segmental mastectomy with negative margins less

than 3 involved lymph nodes and no history of concurrent malignancy within three years.1 For

each patient, the same radiation oncologist approved the target volumes and normal structures

with the same field parameters to eliminate bias. The external validity is poor because the same

doctor in the same geographic area prescribed all the radiation doses to the patient. To make the

external validity stronger, the researchers should have taken a greater diversity in their sample.
From the sample chart, race is not evenly distributed. Majority of patients were white and a very

little percentage were Black, Hispanic, or Asian. This study is prospective because it watches the

subjects over a longer period to evaluate the effects of the dosage. Overall this data seems to be

significant in showing that prone breast treatments reduce the amount of dose received to the

heart and lungs.

This study is relevant to my clinical practice because breast cancer is the most common tumor

site I treat at my clinical sites. Underneath this tissue is the primary functioning organs of the

body. Dose to these two organs is always a concern because the TD5/5 for the whole lung is

1750cGy and the heart 4000cGy. This study did not go past the stage of IIA because patients

exceeding this stage would only have a chest wall and little tissue, which makes prone

positioning irrelevant. Before this study, prone breast setup was usually reserved for women with

a large amount of breast tissue. From this data, all patients, independent of their breast size,

benefited from the prone setup when comparing dose exposure to the lung and heart. Visually

you can see the breast tissue being significantly pulled away from the ventral cavity due to

gravity in the prone position. When working with prone positioning in my past clinical rotations

the set-up duration was longer and more complicated than supine. I believe the results of prone

positioning outweigh the setup complications to achieve less dose to the heart and lungs in these

patients. I think radiation oncology centers should begin positioning every patient prone unless

the patient cannot tolerate laying in that position.

Veldeman L, Schiettecatte K, De Sutter C, et al. The 2-Year Cosmetic Outcome of a

Randomized Trial Comparing Prone and Supine Whole-Breast Irradiation in Large-Breasted


Women. International Journal of Radiation Oncology*Biology*Physics. 2016;95(4):1210-1217.

doi:10.1016/j.ijrobp.2016.03.003.

Patients often fear the cosmetic outcome after being diagnosed with breast cancer. Either with

a lumpectomy or treatment in radiation therapy can make the breast change in appearance. In this

study, the researchers focused on the two-year cosmetic outcome after radiation therapy

comparing prone and supine tangent irradiation in large-breasted women. Patients were selected

by a C cup or bigger bra size until they reached ninety-four subjects (47 supine and 47 prone).

The judges observed digital photographs before and after the radiation treatments determining

the cosmetic outcome by using the 4-point Harvard cosmesis scale. Breast Cancer Conservation

Treatment cosmetic results software was also used to determine the breast changes. “The study

found a worsening of color change occurred more frequently in the supine than in the prone

cohort (19/46 vs 10/46 patients). Five patients in the prone group (11%) and twelve patients in

the supine group (26%) presented with a worse scoring of edema at 2-year follow-up.”2

The research design took a purposive sample because the patients needed to have breast

cancer to be selected. A cohort study was conducted to establish the patients breast tissue over a

two-year period. Patients treated supine were matched with the same treatment characteristics of

the prone patient and were not significantly different. Therefore, I believe the internal validity is

moderately strong when matching the subjects. The three potential biased observers knew

exactly what they were observing. Therefore, no single or double blindness was used. Prone set-

up was generally a little better in presentation, but not by a significant amount. It was even found

that retraction and fibrosis of the tissue was the same for both positioning methods. When taking

another sample of subjects the results are likely to be different due to confounding variables

which makes this study unreliable. This research design would be hard to evaluate due to
different perspectives of the judges, different healing patterns of the subjects, and the

continuation of care each subject promoted. Stronger study results would need to be proven

before the implicating prone positioning just from a cosmetic standpoint.

This study is relevant to my clinical practice because many patients diagnosed with breast

cancer are concerned about how cancer will affect them. This study also determines if prone

positioning outweighs supine in the cosmetic aspect. From reading through all the data, I

determined that this study is not significant and should not be applied to practice. I would not

apply this research to my everyday practice because I believe curing the cancer should be the

number one priority and cosmetic appearance last. To solve this problem, I think patients should

use preventive and continuation of care during their treatment. This includes moisturizing the

whole breast with aquaphor, leaving the skin open to air as much as possible (try to avoid

wearing a bra), and avoid using harsh soaps or fragrances. As I stated before, the results of the

study are not even significantly different to apply this technique due to just cosmetic factors.

Wurschmidt F, Stoltenberg S, Kretschmer M, Petersen C. Incidental dose to coronary arteries is

higher in prone than in supine whole breast irradiation. Strahlentherapie und Onkologie.

2014;190(6):563-568. doi:10.1007/s00066-014-0606-4.

This article researches specifically the coronary arteries of the heart when treating breast

patients with radiation. The study included forty-six patients with large breasts that received 50.4

Gy of radiation to the whole breast. Prone whole breast irradiation showed higher dose to right

circumflex artery and the left anterior descending artery. “In left breast, the mean left anterior

descending artery prone was 33.5 Gy vs. supine of 25.6 Gy. The right coronary artery received
a significantly higher average mean dose of 1.94 Gy in prone compared to the mean dose of

1.37 Gy for supine.”3 The overall heart dose had no difference whether the patient was prone

or supine.

To make this purposive sample stronger there needs to be a larger sample size. If the

researchers would redo this study with new participants they would likely get very different

result, making this study lack in external validity. Evaluating a total of forty-six patients is not

a big enough sample size to apply it to the general population because it would have a large

standard error. The study design was conducted with the only independent variable, whether

the patient was supine or prone. Looking at the follow-up results, they are consistent with the

original results in the study making the study reliable.

This study is relevant to my clinical practice because if we were to transition to a prone

protocol we would need to determine all the effects of this positioning. I would not disregard

prone positioning because of this one negative research study. As stated in the article, “one

positive sparing artery is the circumflex artery receiving a lower dose when treated prone

rather than supine.”3 After more research is conducted, we will need to outweigh the

disadvantages and benefits of both supine and prone to see which one is better for the patients’

health.
Referances

1. Lymberis SC, Dewyngaert JK, Parhar P, et al. Prospective Assessment of Optimal

Individual Position (Prone Versus Supine) for Breast Radiotherapy: Volumetric and

Dosimetric Correlations in 100 Patients. International Journal of Radiation

Oncology*Biology*Physics. 2012;84(4):902-99. DOI:10.1016/J.IJROBP.2012.01.040.

2. Veldeman L, Schiettecatte K, De Sutter C, et al. The 2-Year Cosmetic Outcome of a

Randomized Trial Comparing Prone and Supine Whole-Breast Irradiation in Large-

Breasted Women. International Journal of Radiation Oncology*Biology*Physics.

2016;95(4):1210-1217. doi:10.1016/j.ijrobp.2016.03.003.

3. Wurschmidt F, Stoltenberg S, Kretschmer M, Petersen C. Incidental dose to coronary

arteries is higher in prone than in supine whole breast irradiation. Strahlentherapie und

Onkologie. 2014;190(6):563-568. doi:10.1007/s00066-014-0606-4.