Take a deep breath. Hold it for 25 seconds. Exhale.
That simple act of holding a breath during a radiation cancer treatment called deep inspiration breath-hold (DIBH) could mean the difference between irradiating healthy tissue and sparing it, according to Neil Newman, MD, a radiation oncologist for Mays Cancer Center, home to UT Health San Antonio MD Anderson Cancer Center. Newman specializes in gastrointestinal cancers.
“It has major advantages. When you breathe, your bowels move, and you are actually moving your bowels closer to your tumor and radiation field, which could risk more side effects,” Newman said.
DIBH is a technique initially used for women with breast cancer on the left side of their body. The breath hold moves the heart away from the tumor and the radiation treatment, Newman said. He began using the technique on other eligible patients at the Mays Cancer Center.
“We know that there is a dose response relationship with tumors, where higher doses yield better outcomes approaching surgery. Usually, the bowel limits the ability to go this high, but this technique can yield more room to dose escalate,” he said. “I like to offer higher doses when possible, and that only happens comfortably with DIBH.”
Cameras within the radiation treatment room at Mays Cancer Center monitor patients as they inhale and exhale. During each inhalation and hold, a machine beams radiation into the planned area of the body. When the patient exhales, the machine stops the treatment.
Newman said patients in good physical condition are eligible to try the technique. He acknowledges that holding a breath for 25 – 30 seconds is not easy for most, so he gives his patients homework.
“People get good when they practice. I tell them, I want you to hold your breath for a certain amount of time three times a day. If you practice, your lungs will get better,” he said.
Practice sessions begin at the Mays Cancer Center in a room aglow in green or red lights. Newman said when patients hold their breath, the room is lit green, indicating they are doing a good job. When they exhale, the room turns red. He said the practice sessions allow him to capture images of the position of tumors during the inhale. Then, he creates an individualized treatment plan.
“When the patient comes in for treatment, we take verification scans to ensure everything is in the same position as the practice sessions, and then we treat the patient,” Newman said.
Cruz Jimenez III, a 59-year-old physical therapist, was diagnosed with bile duct cancer in February 2023.
“My first thought was, ‘Wow.’ I was just stunned. I’m 59, I play racquetball, and I’m very active,” he said.
Bile ducts are thin tubes from the liver to the small intestine. They carry bile, a fluid created by the liver but stored in the gallbladder to help digest fats in foods. The disease is rare—only about 8,000 people are diagnosed each year, Newman said. Jimenez’s cancer began in his bile ducts but quickly became a complicated case.
“Usually, bile duct cancers are in the liver or just outside the liver. Mr. Jimenez’s spread along the blood vessels near his pancreas to the middle of his body,” Newman said.
Survival rates for the disease, according to the American Cancer Society, range from 23% to 11%, depending on if the cancer is located inside or outside the liver.
Jimenez’s cancer was inside and outside the liver. After his initial diagnosis, Jimenez was given nine to 12 months to live, so he and his wife planned a bucket list of trips across the country.
He went on a four-day trip to Las Vegas with his oldest daughter, took his brother on a tour of the Smithsonian museums in Washington, D.C., and skied with his wife in Ruidoso, N.M.
“It’s weird when they give you less than a year to live,” he said.
After undergoing chemotherapy at another location and having the treatment damage his bone marrow, Jimenez was told by a doctor that there were very few options for treatment. Seeking a second opinion, Jimenez contacted the Mays Cancer Center. He spoke with Colin Court, MD, PhD, an assistant professor of surgery in the UT Health San Antonio Division of Surgical Oncology and Endocrine Surgery, and received better news.
“Dr. Court said he spoke to his biliary team, and they said,’ We feel like we can get it,'” Jimenez said.
The location of the cancer tumor made it difficult initially to remove it surgically, so Jimenez began radiation therapy with Newman. Jimenez was an eligible candidate for DIBH, so Newman aggressively treated the cancer tumor.
Jimenez was no stranger to DIBH, having used the technique during a CAT scan earlier in his life. He was so good at holding his breath that he cut the time of his radiation treatments.
“I held my breath once for a minute and 45 seconds. The technicians told me, ‘Wow, we’re almost done,'” he said.
When Jimenez met Newman, his blood test biomarkers (CA19-9) were at 196, much higher than the normal range of less than 37. Biomarkers are characteristics in the blood that, when measured and evaluated, will determine whether the markers are within a normal range or indicate disease, Newman said.
After 15 treatments that included DIBH with higher doses of radiation, his CA19-9 dropped to 11 with tumor shrinkage on CAT scans.
“The radiation treatment totally inactivated the tumor,” Newman said.
By January, the radiation treatment had shrunk the inactive tumor small enough so it could be removed surgically. Now, well past the short life expectancy he was first given, Jimenez is recovering, though it’s slow and painful. He said the average recovery time for the surgery to remove the tumor is four to six months.
Jimenez said he is easily fatigued and suffering multiple effects of the surgery; however, he tries to stay active, rehabbing his son’s duplex.
“Working on the duplex gets me through the day. I feel so guilty and beat when I have to sit on the couch. But the pain reminds me I’m still here,” he said.
To request an appointment at Mays Cancer Center, call 210-450-1000 or visit MaysCancerCenter.org/Appointments.