Background: Deep inspiration breath-hold (DIBH) is an established cardiac-sparing technique for left-sided breast radiotherapy; however, its implementation can be challenging in routine practice, particularly in resource-constrained settings. Methods: We conducted a retrospective cohort study at Anbar Cancer Center (Iraq) after DIBH introduction (August-November 2025). Forty-three consecutive women with left-sided breast cancer treated with adjuvant radiotherapy after breast-conserving surgery or modified radical mastectomy were evaluated for DIBH. Patients achieving a reproducible ≥ 20 s breath-hold received DIBH (n = 33), whereas those unable to do so were treated using free breathing (FB) and served as a pragmatic comparator (n = 10). Dosimetric endpoints included PTV coverage (V95%), cardiac indices (mean heart dose, Heart V3/V5, maximum LAD dose), and lung/contralateral structures metrics; workflow measures included scan and treatment times. Results: DIBH significantly improved target coverage (median PTV V95% 94.0% vs 90.5% with FB; p < 0.001) and reduced cardiac exposure, including mean heart dose (median 2.0 vs 4.0 Gy; p < 0.001), Heart V3 (median 8.0 vs 11.0; p = 0.018), Heart V5 (median 3.0 vs 5.5; p = 0.027), and maximum LAD dose (12.67 ± 6.31 vs 31.00 ± 7.73 Gy; p < 0.001). Contralateral breast mean dose was lower with DIBH (p = 0.006), while contralateral lung V4 was slightly higher (p = 0.043). Ipsilateral lung dose-volume metrics did not differ significantly. Workflow analysis showed longer total scan time (p < 0.001) and total treatment time (p = 0.001) with DIBH, while CT acquisition time was similar (p = 0.130). Conclusion: In routine clinical implementation, DIBH provided substantial cardiac/LAD sparing and improved PTV coverage with minimal change in ipsilateral lung dosimetry, but with increased workflow time and minor contralateral low-dose trade-offs.
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