51
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Rao VU, Reeves DJ, Chugh AR, O'Quinn R, Fradley MG, Raghavendra M, Dent S, Barac A, Lenihan D. Clinical Approach to Cardiovascular Toxicity of Oral Antineoplastic Agents: JACC State-of-the-Art Review. J Am Coll Cardiol 2021; 77:2693-2716. [PMID: 34045027 DOI: 10.1016/j.jacc.2021.04.009] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/30/2021] [Accepted: 04/06/2021] [Indexed: 12/14/2022]
Abstract
Precision medicine has ushered in a new era of targeted treatments for numerous malignancies, leading to improvements in overall survival. Unlike traditional chemotherapy, many molecular targeted antineoplastic agents are available in oral formulation, leading to enhanced patient convenience and a perception of reduced risk of adverse effects. Although oral antineoplastic agents are generally well-tolerated, cardiovascular toxicities are being reported with increasing frequency in part due to U.S. Food and Drug Administration and manufacturer recommended cardiac monitoring. Monitoring strategies have focused on left ventricular dysfunction, hypertension, and QT prolongation/arrhythmias. Given the rapid pace of development and availability of new oral antineoplastic agents, the purpose of this review is to provide clinicians with an up-to-date practical approach to monitoring and management of cardiovascular toxicities with the aim of improving overall outcomes for patients with cancer.
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Affiliation(s)
- Vijay U Rao
- Franciscan Cardio-Oncology Center, Indiana Heart Physicians, Franciscan Health, Indianapolis, Indiana, USA.
| | - David J Reeves
- Division of Oncology, Franciscan Health and Butler University College of Pharmacy and Health Sciences, Indianapolis, Indiana, USA
| | - Atul R Chugh
- Franciscan Cardio-Oncology Center, Indiana Heart Physicians, Franciscan Health, Indianapolis, Indiana, USA
| | - Rupal O'Quinn
- Cardio-Oncology Center of Excellence, Division of Cardiology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael G Fradley
- Cardio-Oncology Center of Excellence, Division of Cardiology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Meghana Raghavendra
- Franciscan Cardio-Oncology Center, Oncology and Hematology Specialists, Franciscan Health, Indianapolis, Indiana, USA
| | - Susan Dent
- Duke Cancer Institute, Duke University, Durham, North Carolina, USA
| | - Ana Barac
- Medstar Heart and Vascular Institute, Georgetown University, Washington, DC, USA
| | - Daniel Lenihan
- Cardio-Oncology Center of Excellence, Washington University in St. Louis, St. Louis, Missouri, USA
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52
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Attanasio U, Pirozzi F, Poto R, Cuomo A, Carannante A, Russo M, Ghigo A, Hirsch E, Tocchetti CG, Varricchi G, Mercurio V. Oxidative stress in anticancer therapies-related cardiac dysfunction. Free Radic Biol Med 2021; 169:410-415. [PMID: 33930514 DOI: 10.1016/j.freeradbiomed.2021.04.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 03/30/2021] [Accepted: 04/08/2021] [Indexed: 02/06/2023]
Abstract
Redox abnormalities are at the crossroad of cardiovascular diseases, cancer and cardiotoxicity from anticancer treatments. Indeed, disturbances of the redox equilibrium are common drivers of these conditions. Not only is an increase in oxidative stress a fundamental mechanism of action of anthracyclines (which have historically been the most studied anticancer treatments) but also this is at the basis of the toxic cardiovascular effects of antineoplastic targeted drugs and radiotherapy. Here we examine the oxidative mechanisms involved in the different cardiotoxicities induced by the main redox-based antineoplastic treatments, and discuss novel approaches for the treatment of such toxicities.
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Affiliation(s)
- Umberto Attanasio
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Flora Pirozzi
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Remo Poto
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Alessandra Cuomo
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Antonio Carannante
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Michele Russo
- Department of Molecular Biotechnology and Health Sciences, Molecular Biotechnology Center, University of Torino, Torino, Italy
| | - Alessandra Ghigo
- Department of Molecular Biotechnology and Health Sciences, Molecular Biotechnology Center, University of Torino, Torino, Italy
| | - Emilio Hirsch
- Department of Molecular Biotechnology and Health Sciences, Molecular Biotechnology Center, University of Torino, Torino, Italy
| | - Carlo Gabriele Tocchetti
- Department of Translational Medical Sciences, Federico II University, Naples, Italy; Interdepartmental Center of Clinical and Translational Research (CIRCET), Federico II University, Naples, Italy; Interdepartmental Hypertension Research Center (CIRIAPA), Federico II University, Naples, Italy; Center for Basic and Clinical Immunology Research (CISI), Federico II University, Naples, Italy.
| | - Gilda Varricchi
- Department of Translational Medical Sciences, Federico II University, Naples, Italy; Center for Basic and Clinical Immunology Research (CISI), Federico II University, Naples, Italy; WAO Center of Excellence, Naples, Italy; Institute of Experimental Endocrinology and Oncology "G. Salvatore" (IEOS), National Research Council (CNR), Naples, Italy
| | - Valentina Mercurio
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
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53
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Jackisch C, Cortazar P, Geyer CE, Gianni L, Gligorov J, Machackova Z, Perez EA, Schneeweiss A, Tolaney SM, Untch M, Wardley A, Piccart M. Risk-based decision-making in the treatment of HER2-positive early breast cancer: Recommendations based on the current state of knowledge. Cancer Treat Rev 2021; 99:102229. [PMID: 34139476 DOI: 10.1016/j.ctrv.2021.102229] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 05/14/2021] [Accepted: 05/17/2021] [Indexed: 01/05/2023]
Abstract
Treatment of HER2-positive early breast cancer (EBC) continues to evolve with neoadjuvant (pre-operative) and adjuvant (post-operative) HER2-targeted therapies as standard of care. There are two important decision points. The first involves deciding between neoadjuvant therapy or proceeding directly to surgery. Neoadjuvant chemotherapy (NACT) plus pertuzumab-trastuzumab is appropriate for patients with high-risk HER2-positive EBC (tumour diameter ≥2 cm, and/or node-positive disease). Patients with node-negative disease and tumour diameter <2 cm are candidates for upfront surgery followed by paclitaxel for 12 weeks plus 18 cycles of trastuzumab, with the option to add pertuzumab (if pN+). The second decision point involves the pathohistological result at surgery after neoadjuvant therapy. Total pathological complete response (tpCR: ypT0/is, ypN0) is associated with improved survival endpoints. Patients with tumours ≥2 cm and/or node-positive disease at diagnosis who have a tpCR after dual blockade should continue pertuzumab-trastuzumab in the adjuvant setting to complete 1 year (18cycles) of treatment. For patients with invasive residual disease, 14cycles of post-neoadjuvant trastuzumab emtansine (T-DM1) therapy significantly increases invasive-DFS compared with trastuzumab. Extended adjuvant therapy with neratinib is an option in selected patients (HER2-positive and oestrogen receptor [ER]-positive) who have completed adjuvant trastuzumab-based therapy. Less aggressive chemotherapy regimens are recommended in populations with a lower risk of recurrence (patients with small tumours without axillary involvement; patients unlikely to tolerate anthracycline-taxane or taxane-carboplatin regimens). Ultimately, treatment recommendations should be consistent with local and international guidelines. Further studies will guide optimisation of treatment for patients with HER2-positive EBC according to the risk of disease recurrence.
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Affiliation(s)
| | | | - Charles E Geyer
- NSABP Foundation and Houston Methodist Cancer Center, Houston, TX, USA
| | | | - Joseph Gligorov
- Institut Universitaire de Cancérologie, APHP-Sorbonne Université, Hôpital Tenon, Paris, France
| | | | - Edith A Perez
- Division of Hematology and Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Andreas Schneeweiss
- National Center for Tumor Diseases, Heidelberg University Hospital and German Cancer Research Center, Heidelberg, Germany
| | - Sara M Tolaney
- Dana-Farber Cancer Institute, and Department of Hematology-Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Michael Untch
- AGO-B and HELIOS Klinikum Berlin Buch, Berlin, Germany
| | - Andrew Wardley
- Outreach Research & Innovation Group and Manchester Breast Centre, Division of Cancer Sciences and University of Manchester, Manchester, UK; AstraZeneca PLC, UK
| | - Martine Piccart
- Institut Jules Bordet, Université Libre de Bruxelles (ULB), Brussels, Belgium
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54
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Lupi A, Ariotti S, De Pace D, Ferrari I, Bertuol S, Monti L, Guasti L, Gaudio GV, Campana C. Sacubitril/Valsartan to Treat Heart Failure in a Patient with Relapsing Hairy Cell Leukaemia: Case Report. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2021; 15:11795468211010706. [PMID: 33911910 PMCID: PMC8050758 DOI: 10.1177/11795468211010706] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 03/12/2021] [Indexed: 12/11/2022]
Abstract
Experience with angiotensin-receptor neprilysin inhibitors (ARNI) in oncologic
patients with heart failure (HF) is limited. We report a case of ARNI started as
first-choice therapy in a patient with relapsing hairy cell leukaemia (HCL) and
HF with depressed left ventricular ejection fraction (LVEF). A middle-aged male,
previously treated with rituximab for HCL, was scheduled for cardiologic
screening before starting a new antineoplastic therapy for cancer relapse. The
patient had symptomatic HF with reduced LVEF and high NT-proBNP levels. In this
patient, early ARNI treatment was well tolerated and produced a rapid and
durable improvement of symptoms, LVEF and NT-proBNP levels. Consequently, the
oncologic team could start an experimental treatment with obinutuzumab, with
complete HCL remission. In conclusion, in this patient with HCL and HF, ARNI
therapy was safe and effective, contributing to undelayed cancer treatment.
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Affiliation(s)
- Alessandro Lupi
- Department of Cardiology, ASL14 Verbano-Cusio-Ossola, Ospedale Castelli, Verbania, Italy
| | - Sara Ariotti
- Department of Cardiology, ASL14 Verbano-Cusio-Ossola, Ospedale Castelli, Verbania, Italy
| | - Doranna De Pace
- Department of Cardiology, ASL14 Verbano-Cusio-Ossola, Ospedale Castelli, Verbania, Italy
| | - Irene Ferrari
- Department of Cardiology, ASL14 Verbano-Cusio-Ossola, Ospedale Castelli, Verbania, Italy
| | - Stefano Bertuol
- Department of Cardiology, ASL14 Verbano-Cusio-Ossola, Ospedale Castelli, Verbania, Italy
| | - Lorenzo Monti
- Radiology and Cardiology Department, Humanitas Research Hospital, Rozzano (MI), Italy
| | - Luigina Guasti
- Research Center on Dyslipidemia, Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | | | - Carlo Campana
- Cardiology Department, Sant'Anna Hospital, Como, Italy
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55
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Jafari L, Akhter N. Heart failure prevention and monitoring strategies in HER2-positive breast cancer: a narrative review. Breast Cancer Res Treat 2021; 186:295-303. [PMID: 33481134 PMCID: PMC7820093 DOI: 10.1007/s10549-021-06096-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 01/05/2021] [Indexed: 01/03/2023]
Abstract
PURPOSE Cardiotoxicity from anti-human epidermal growth factor receptor 2 (HER2) therapy carries a short- and long-term risk of incident heart failure and increased cardiovascular mortality in patients with breast cancer. Interruptions in anti-HER2 therapy due to cardiotoxicity can lead to suboptimal cancer treatment. The purpose of this narrative review is to outline opportunities to optimize cardiovascular care in patients with HER2-positive breast cancer to prevent interruptions in therapy. METHODS This case-based review presents the current literature on evidence-based strategies for personalized cardiotoxicity risk assessment, risk mitigation interventions, cardiac function surveillance tools, and management of asymptomatic left ventricular dysfunction in breast cancer patients receiving anti-HER2 therapy. RESULTS Pretreatment cardiac risk assessment incorporates both treatment-related risk factors and patient-related risk factors for the development of cardiac dysfunction. Prevention and monitoring strategies while on treatment utilize risk factor modification, imaging and biomarker surveillance. Management of asymptomatic left ventricular dysfunction due to anti-HER2 therapy is evolving. Permissive cardiotoxicity in asymptomatic patients while starting cardioprotective therapies requires close collaboration between oncology and cardiology, and referral to cardio-oncology if available. CONCLUSIONS Patient-centered, multimodal strategies to prevent, detect, and manage cardiotoxicity from anti-HER2 therapy are necessary to improve outcomes in patients with HER2-positive breast cancer.
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Affiliation(s)
- Lua Jafari
- Division of Cardiology, David Geffen School of Medicine At UCLA, Los Angeles, CA, USA
| | - Nausheen Akhter
- Division of Cardiology, Northwestern University Feinberg School of Medicine, 675 N St. Clair St, Suite 19-100, Chicago, IL, 60611, USA.
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56
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Dobson R, Ghosh AK, Ky B, Marwick T, Stout M, Harkness A, Steeds R, Robinson S, Oxborough D, Adlam D, Stanway S, Rana B, Ingram T, Ring L, Rosen S, Plummer C, Manisty C, Harbinson M, Sharma V, Pearce K, Lyon AR, Augustine DX. British Society for Echocardiography and British Cardio-Oncology Society guideline for transthoracic echocardiographic assessment of adult cancer patients receiving anthracyclines and/or trastuzumab. Echo Res Pract 2021; 8:G1-G18. [PMID: 34106116 PMCID: PMC8052569 DOI: 10.1530/erp-21-0001] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 02/26/2021] [Indexed: 12/17/2022] Open
Abstract
The subspecialty of cardio-oncology aims to reduce cardiovascular morbidity and mortality in patients with cancer or following cancer treatment. Cancer therapy can lead to a variety of cardiovascular complications, including left ventricular systolic dysfunction, pericardial disease, and valvular heart disease. Echocardiography is a key diagnostic imaging tool in the diagnosis and surveillance for many of these complications. The baseline assessment and subsequent surveillance of patients undergoing treatment with anthracyclines and/or human epidermal growth factor (EGF) receptor (HER) 2-positive targeted treatment (e.g. trastuzumab and pertuzumab) form a significant proportion of cardio-oncology patients undergoing echocardiography. This guideline from the British Society of Echocardiography and British Cardio-Oncology Society outlines a protocol for baseline and surveillance echocardiography of patients undergoing treatment with anthracyclines and/or trastuzumab. The methodology for acquisition of images and the advantages and disadvantages of techniques are discussed. Echocardiographic definitions for considering cancer therapeutics-related cardiac dysfunction are also presented.
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Affiliation(s)
- Rebecca Dobson
- Cardio-Oncology Service, Liverpool Heart and Chest NHS Foundation Trust, Liverpool, UK
| | - Arjun K Ghosh
- Cardio-Oncology Service, Barts Heart Centre, Barts Health NHS Trust, London, UK
- Cardio-Oncology Service, Hatter Cardiovascular Research Institute, University College London and University College London Hospitals NHS Foundation Trust, London, UK
| | - Bonnie Ky
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tom Marwick
- Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Martin Stout
- University Hospital South Manchester NHS Foundation Trust, Manchester, UK
| | - Allan Harkness
- East Suffolk and North Essex NHS Foundation Trust, Colchester, UK
| | - Rick Steeds
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | | | - David Adlam
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Susannah Stanway
- Cardio-Oncology Service, Barts Heart Centre, Barts Health NHS Trust, London, UK
| | - Bushra Rana
- Imperial College Healthcare NHS Trust, London, UK
| | - Thomas Ingram
- The Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, UK
| | - Liam Ring
- West Suffolk NHS Foundation Trust, Bury St Edmunds, UK
| | - Stuart Rosen
- Royal Brompton and Harefield NHS Foundation Trust and Imperial College London, London, UK
| | - Chris Plummer
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Charlotte Manisty
- Cardio-Oncology Service, Barts Heart Centre, Barts Health NHS Trust, London, UK
| | | | - Vishal Sharma
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Keith Pearce
- University Hospital South Manchester NHS Foundation Trust, Manchester, UK
| | - Alexander R Lyon
- Royal Brompton and Harefield NHS Foundation Trust and Imperial College London, London, UK
| | - Daniel X Augustine
- Department of Cardiology, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
- Department for Health, University of Bath, Bath, UK
| | - the British Society of Echocardiography (BSE) and the British Society of Cardio-Oncology (BCOS)
- Cardio-Oncology Service, Liverpool Heart and Chest NHS Foundation Trust, Liverpool, UK
- Cardio-Oncology Service, Barts Heart Centre, Barts Health NHS Trust, London, UK
- Cardio-Oncology Service, Hatter Cardiovascular Research Institute, University College London and University College London Hospitals NHS Foundation Trust, London, UK
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Baker Heart and Diabetes Institute, Melbourne, Australia
- University Hospital South Manchester NHS Foundation Trust, Manchester, UK
- East Suffolk and North Essex NHS Foundation Trust, Colchester, UK
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- North West Anglia Foundation Trust, UK
- Liverpool John Moores University, Liverpool, UK
- University Hospitals of Leicester NHS Trust, Leicester, UK
- Royal Marsden NHS Foundation Trust and Institute of Cancer Research, London, UK
- Imperial College Healthcare NHS Trust, London, UK
- The Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, UK
- West Suffolk NHS Foundation Trust, Bury St Edmunds, UK
- Royal Brompton and Harefield NHS Foundation Trust and Imperial College London, London, UK
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
- Belfast Health and Social Care Trust, Belfast, UK
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
- Department of Cardiology, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
- Department for Health, University of Bath, Bath, UK
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57
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Xu M, Wang Y, Wang HC. Adjuvant concomitant treatment with traditional Chinese medicines in patients receiving chemotherapy for HER2-Positive breast cancer: A pilot randomized controlled trial. Complement Ther Clin Pract 2021; 43:101373. [PMID: 33773170 DOI: 10.1016/j.ctcp.2021.101373] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 02/19/2021] [Accepted: 03/15/2021] [Indexed: 11/26/2022]
Abstract
This study aimed to evaluate the impact of Chinese medicine on controlling cancer and easing adverse events in patients with HER2-positive breast cancer. We recruited consecutive HER2-positive breast cancer patients who underwent radical mastectomy from January 2015 to January 2019. Patients were randomly assigned to receive chemotherapy plus Chinese medicine or chemotherapy alone. The left ventricular global longitudinal strain was better in the experimental group (P < 0.01). The reduction in white blood cells was more significant in the control group (P < 0.01). Hepatic function in the experimental group was better than that in control group after chemotherapy (P < 0.01). In addition, the scores of symptom dimensions for pain, diarrhea, and hair loss were better in the experimental group than in the control group after chemotherapy (P < 0.01). For patients with HER2-positive breast cancer, personalization of traditional Chinese medicine can not only enhance the anti-cancer function of chemotherapy but also ease serious adverse effects.
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Affiliation(s)
- Meng Xu
- Department of Traditional Chinese Medicine, the First Affiliated Hospital of Anhui Medical University, 218 Jixi Rd, Hefei, 230022, Anhui, China
| | - Yong Wang
- Tumor Department of Anhui Provincial Hospital 17 Lu Jiang Rd, Hefei, 230001, Anhui, China; Provincial Hospital Affiliated to Anhui Medical University, Hefei, 230001, Anhui, China
| | - Hua-Cheng Wang
- Department of Traditional Chinese Medicine, the First Affiliated Hospital of Anhui Medical University, 218 Jixi Rd, Hefei, 230022, Anhui, China.
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58
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Stone JR, Kanneganti R, Abbasi M, Akhtari M. Monitoring for Chemotherapy-Related Cardiotoxicity in the Form of Left Ventricular Systolic Dysfunction: A Review of Current Recommendations. JCO Oncol Pract 2021; 17:228-236. [PMID: 33689453 DOI: 10.1200/op.20.00924] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Cardiotoxicity is a well-established complication of multiple cancer therapeutics, and the one of the most prominent effects that limits the use of these agents is in the form of left ventricular dysfunction, otherwise known as chemotherapy-induced cardiomyopathy (CIMP). Because CIMP can worsen patient outcomes and interfere with a patient's life-saving cancer treatments, it is important to implement a monitoring strategy for patients undergoing potentially cardiotoxic treatments. Efforts have been made by multiple societies to provide recommendations for screening and monitoring for CIMP in at-risk patients, with slight variations between guideline documents and expert consensuses. Most of the recommendations for monitoring for CIMP are specific to anthracyclines and the human epidermal growth factor receptor 2-antagonist trastuzumab, with very limited guidance for other cardiotoxic agents such as Tyr kinase inhibitors and proteasome inhibitors, which we cover in this article. Echocardiography remains the mainstay for imaging surveillance because of its safety profile and widespread availability, but the accuracy of cardiac magnetic resonance imaging (CMR) makes it an important modality when there are discrepancies in left ventricular ejection fraction assessment. Subclinical cardiotoxicity may be detected using laboratory biomarkers such as cardiac troponin and brain natriuretic peptide as well as myocardial deformation (strain) imaging by echocardiography or CMR. Specific recommendations for timing and frequency of laboratory biomarker assessment remain up for debate, but myocardial deformation imaging should be performed with every echocardiogram or CMR assessment. Future studies are needed to evaluate the efficacy of established surveillance recommendations and to develop specific recommendations for novel cancer therapeutics.
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Affiliation(s)
- Jeremy R Stone
- Department of Internal Medicine, Section of Cardiology, University of Nebraska Medical Center, Omaha, NE
| | - Radha Kanneganti
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Muhannad Abbasi
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
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59
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Dobson R, Ghosh AK, Ky B, Marwick T, Stout M, Harkness A, Steeds R, Robinson S, Oxborough D, Adlam D, Stanway S, Rana B, Ingram T, Ring L, Rosen S, Plummer C, Manisty C, Harbinson M, Sharma V, Pearce K, Lyon AR, Augustine DX. BSE and BCOS Guideline for Transthoracic Echocardiographic Assessment of Adult Cancer Patients Receiving Anthracyclines and/or Trastuzumab. JACC CardioOncol 2021; 3:1-16. [PMID: 34396303 PMCID: PMC8352267 DOI: 10.1016/j.jaccao.2021.01.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 01/18/2021] [Accepted: 01/19/2021] [Indexed: 01/06/2023] Open
Abstract
The subspecialty of cardio-oncology aims to reduce cardiovascular morbidity and mortality in patients with cancer or following cancer treatment. Cancer therapy can lead to a variety of cardiovascular complications, including left ventricular systolic dysfunction, pericardial disease, and valvular heart disease. Echocardiography is a key diagnostic imaging tool in the diagnosis and surveillance for many of these complications. The baseline assessment and subsequent surveillance of patients undergoing treatment with anthracyclines and/or human epidermal growth factor receptor (HER) 2-positive targeted treatment (e.g., trastuzumab and pertuzumab) form a significant proportion of cardio-oncology patients undergoing echocardiography. This guideline from the British Society of Echocardiography and British Cardio-Oncology Society outlines a protocol for baseline and surveillance echocardiography of patients undergoing treatment with anthracyclines and/or trastuzumab. The methodology for acquisition of images and the advantages and disadvantages of techniques are discussed. Echocardiographic definitions for considering cancer therapeutics-related cardiac dysfunction are also presented.
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Key Words
- 2D, 2-dimensional
- 3D, 3-dimensional
- A2C, apical 2-chamber
- A3C, apical 3-chamber
- A4C, apical 4-chamber
- BSE, British Society of Echocardiography
- CMR, cardiac magnetic resonance
- CTRCD, cancer therapy–related cardiac dysfunction
- ECG, electrocardiogram
- GLS, global longitudinal strain
- HER2 therapy
- HER2, human epidermal growth factor receptor 2
- LV, left ventricular
- LVEF, left ventricular ejection fraction
- MV, mitral valve
- RH, right heart
- ROI, region of interest
- RV, right ventricular
- TDI, tissue Doppler imaging
- TRV, tricuspid regurgitant velocity
- anthracycline
- echocardiography
- guidelines
- imaging
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Affiliation(s)
- Rebecca Dobson
- Cardio-Oncology Service, Liverpool Heart and Chest NHS Foundation Trust, Liverpool, United Kingdom
| | - Arjun K. Ghosh
- Cardio-Oncology Service, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
- Cardio-Oncology Service, Hatter Cardiovascular Research Institute, University College London and University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Bonnie Ky
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Tom Marwick
- Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Martin Stout
- University Hospital South Manchester NHS Foundation Trust, Manchester, United Kingdom
| | - Allan Harkness
- East Suffolk and North Essex NHS Foundation Trust, Colchester, United Kingdom
| | - Rick Steeds
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | | | | | - David Adlam
- University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Susannah Stanway
- Royal Marsden NHS Foundation Trust and Institute of Cancer Research, London, United Kingdom
| | - Bushra Rana
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Thomas Ingram
- The Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, United Kingdom
| | - Liam Ring
- West Suffolk NHS Foundation Trust, Bury St. Edmunds, United Kingdom
| | - Stuart Rosen
- Royal Brompton and Harefield NHS Foundation Trust and Imperial College London, London, United Kingdom
| | - Chris Plummer
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, United Kingdom
| | - Charlotte Manisty
- Cardio-Oncology Service, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Mark Harbinson
- Belfast Health and Social Care Trust, Belfast, United Kingdom
| | - Vishal Sharma
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, United Kingdom
| | - Keith Pearce
- University Hospital South Manchester NHS Foundation Trust, Manchester, United Kingdom
| | - Alexander R. Lyon
- Royal Brompton and Harefield NHS Foundation Trust and Imperial College London, London, United Kingdom
| | - Daniel X. Augustine
- Department of Cardiology, Royal United Hospitals Bath NHS Foundation Trust, Bath, United Kingdom
| | - British Society of Echocardiography (BSE) and theBritish Society of Cardio-Oncology (BCOS)
- Cardio-Oncology Service, Liverpool Heart and Chest NHS Foundation Trust, Liverpool, United Kingdom
- Cardio-Oncology Service, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
- Cardio-Oncology Service, Hatter Cardiovascular Research Institute, University College London and University College London Hospitals NHS Foundation Trust, London, United Kingdom
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
- Baker Heart and Diabetes Institute, Melbourne, Australia
- University Hospital South Manchester NHS Foundation Trust, Manchester, United Kingdom
- East Suffolk and North Essex NHS Foundation Trust, Colchester, United Kingdom
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- North West Anglia Foundation Trust, United Kingdom
- Liverpool John Moores University, Liverpool, United Kingdom
- University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
- Royal Marsden NHS Foundation Trust and Institute of Cancer Research, London, United Kingdom
- Imperial College Healthcare NHS Trust, London, United Kingdom
- The Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, United Kingdom
- West Suffolk NHS Foundation Trust, Bury St. Edmunds, United Kingdom
- Royal Brompton and Harefield NHS Foundation Trust and Imperial College London, London, United Kingdom
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, United Kingdom
- Belfast Health and Social Care Trust, Belfast, United Kingdom
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, United Kingdom
- Department of Cardiology, Royal United Hospitals Bath NHS Foundation Trust, Bath, United Kingdom
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Raimondi L, Raimondi FM, Rossi L, Lazzeroni R, Pietranera M, Di Benedetto L, Gozzi E, Spinelli GP. Gemcitabine-induced dilated-cardiomyopathy in patient with platinum-refractory ovarian-cancer: A case report and literature review. J Oncol Pharm Pract 2021; 27:1542-1547. [PMID: 33541207 DOI: 10.1177/1078155220982044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Gemcitabine is a nucleoside analog and pyrimidine antimetabolite that inhibits RNA synthesis, currently approved for use to treat a variety of cancers, among which ovarian cancers. Gemcitabine is considered relatively safe and it is generally well tolerated, with rarely reported cardiac side effects. CASE REPORT We report a case of gemcitabine induced dilated cardiomyopathy in a 41-year-old woman receiving gemcitabine as second line treatment for platinum-resistant ovarian cancer without pre-existing hypertension or significant cardiac history.Management and Outcome: The patient presented with clinical symptoms and laboratory and imaging results suggestive of congestive cardiac failure, with a left ventricular ejection fraction of 15%. Gemcitabine administration was stopped and Furosemide with ACE-inhibitors and Beta-blocker agents were initiated. At that point the clinical situation improved: symptoms and findings disappeared with gemcitabine cessation. DISCUSSION Our case demonstrated for the first time objective evidence for dilated cardiomyopathy induced by gemcitabine in a young patient with platinum-resistant ovarian cancer without pre-existing significant cardiac history. Although rare, gemcitabine-induced cardiotoxicity should be promptly recognized in order to take appropriate measures to manage it.
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Nicol M, Sadoune M, Polidano E, Launay JM, Samuel JL, Azibani F, Cohen-Solal A. Doxorubicin-induced and trastuzumab-induced cardiotoxicity in mice is not prevented by metoprolol. ESC Heart Fail 2021; 8:928-937. [PMID: 33529501 PMCID: PMC8006653 DOI: 10.1002/ehf2.13198] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 12/04/2020] [Accepted: 12/28/2020] [Indexed: 01/01/2023] Open
Abstract
Aims Our objectives were to validate a murine model of chronic cardiotoxicity induced by Doxorubicin (Dox) and Trastuzumab (Trast) and to test the potential cardio‐protective effect of metoprolol. Methods and results Male C57Bl6 mice were intraperitoneally injected during 2 weeks with Dox (24 mg/kg) or saline, and then with Trast (10 mg/kg) or saline for two more weeks. Half of the mice received metoprolol (100 mg/kg). Cardiotoxicity was defined by a decline in left ventricular ejection fraction (LVEF) ≥ 10 points. At Day 42, Dox + Trast‐treated mice exhibited a 13‐points decline in LVEF (74 ± 2.6% vs. 87 ± 0.8% for control mice, P < 0.001) and a severe cardiac atrophy (heart weight: 105 ± 2.7 mg vs. 119 ± 3.9 mg for control mice, P < 0.01). This cardiac atrophy resulted from an excess of cardiac necrosis (assessed by plasma cardiac troponin I level: 3.2 ± 0.4 ng/L vs. 1.3 ± 0.06 ng/L for control mice, P < 0.01), an increase in apoptosis (caspase 3 activity showing a six‐fold increase for Dox + Trast‐treated mice vs. controls, P < 0.001), and cardiomyocyte atrophy (myocyte size: 0.67 ± 0.08 μm2 vs. 1.36 ± 0.10 μm2 for control mice, P < 0.001). In addition, Dox + Trast‐treated mice were shown to have an increased cardiac oxidative stress (164 ± 14 dihydroethidine‐marked nuclei per area vs. 56 ± 9.5 for control mice, P < 0.01) and increased cardiac fibrosis (the semi‐quantitative fibrosis score was three‐fold higher for Dox + Trast‐treated mice as compared with controls, P < 0.01). Metoprolol was not able to prevent either the decrease in LVEF or the severe cardiac atrophy, the cardiac necrosis, and the cardiac remodelling induced by chemotherapies. Conclusion A murine model of chronic cardiotoxicity induced by Dox and Trast was characterized by a decrease in cardiac function, a cardiac apoptosis and necrosis leading to cardiomyocyte atrophy. Metoprolol did not prevent this cardiotoxicity.
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Affiliation(s)
- Martin Nicol
- Cardiology Department, Lariboisiere Hospital, University of Paris, Paris, France.,Inserm UMR-S 942, University of Paris, Lariboisiere Hospital, Paris, France
| | - Malha Sadoune
- Inserm UMR-S 942, University of Paris, Lariboisiere Hospital, Paris, France
| | - Evelyne Polidano
- Inserm UMR-S 942, University of Paris, Lariboisiere Hospital, Paris, France
| | - Jean Marie Launay
- Inserm UMR-S 942, University of Paris, Lariboisiere Hospital, Paris, France
| | - Jane Lise Samuel
- Inserm UMR-S 942, University of Paris, Lariboisiere Hospital, Paris, France
| | - Feriel Azibani
- Inserm UMR-S 942, University of Paris, Lariboisiere Hospital, Paris, France
| | - Alain Cohen-Solal
- Cardiology Department, Lariboisiere Hospital, University of Paris, Paris, France.,Inserm UMR-S 942, University of Paris, Lariboisiere Hospital, Paris, France
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62
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Khoury K, Lynce F, Barac A, Geng X, Dang C, Yu AF, Smith KL, Gallagher C, Pohlmann PR, Nunes R, Herbolsheimer P, Warren R, Srichai MB, Hofmeyer M, Asch F, Tan M, Isaacs C, Swain SM. Long-term follow-up assessment of cardiac safety in SAFE-HEaRt, a clinical trial evaluating the use of HER2-targeted therapies in patients with breast cancer and compromised heart function. Breast Cancer Res Treat 2021; 185:863-868. [PMID: 33400034 PMCID: PMC8207895 DOI: 10.1007/s10549-020-06053-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 12/07/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE HER2-targeted therapies are associated with cardiotoxicity which is usually asymptomatic and reversible. We report the updated cardiac safety assessment of patients with compromised heart function receiving HER2-targeted therapy for breast cancer, enrolled in the SAFE-HEaRt trial, at a median follow-up of 3.5 years. METHODS Thirty patients with stage I-IV HER2-positive breast cancer receiving trastuzumab with or without pertuzumab, or ado-trastuzumab emtansine (T-DM1), with asymptomatic LVEF (left ventricular ejection fraction) 40-49%, were started on cardioprotective medications, with the primary endpoint being completion of HER2-targeted therapy without cardiac events (CE) or protocol-defined asymptomatic worsening of LVEF. IRB-approved follow-up assessment included 23 patients. RESULTS Median follow-up as of June 2020 is 42 months. The study met its primary endpoint with 27 patients (90%) completing their HER2-targeted therapies without cardiac issues. Of the 23 evaluable patients at long-term f/u, 14 had early stage breast cancer, and 9 had metastatic disease, 8 of whom remained on HER2-targeted therapies. One patient developed symptomatic heart failure with no change in LVEF. There were no cardiac deaths. The mean LVEF improved to 52.1% from 44.9% at study baseline, including patients who remained on HER2-targeted therapy, and those who received prior anthracyclines. CONCLUSIONS Long-term follow-up of the SAFE-HEaRt study continues to provide safety data of HER2-targeted therapy use in patients with compromised heart function. The late development of cardiac dysfunction is uncommon and continued multi-disciplinary oncologic and cardiac care of patients is vital for improved patient outcomes.
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Affiliation(s)
- Katia Khoury
- Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, Washington DC, USA
- O'Neal Comprehensive Cancer Center at UAB, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Filipa Lynce
- Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, Washington DC, USA
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Ana Barac
- MedStar Heart and Vascular Institute, Washington DC, USA
| | - Xue Geng
- Georgetown University, Washington DC, USA
| | - Chau Dang
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anthony F Yu
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Karen L Smith
- Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | | | - Paula R Pohlmann
- Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, Washington DC, USA
| | - Raquel Nunes
- Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | | | - Robert Warren
- Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, Washington DC, USA
| | | | - Mark Hofmeyer
- MedStar Heart and Vascular Institute, Washington DC, USA
| | - Federico Asch
- MedStar Heart and Vascular Institute, Washington DC, USA
| | - Ming Tan
- Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, Washington DC, USA
| | - Claudine Isaacs
- Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, Washington DC, USA
- Georgetown University, Washington DC, USA
| | - Sandra M Swain
- Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, Washington DC, USA.
- MedStar Health, Columbia, MD, USA.
- Georgetown University Medical Center, Building D Room 120, 4000 Reservoir Road NW, Washington DC, 20057, USA.
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Iacopo F, Branch M, Cardinale D, Middeldorp M, Sanders P, Cohen JB, Achirica MC, Jaiswal S, Brown SA. Preventive Cardio-Oncology: Cardiovascular Disease Prevention in Cancer Patients and Survivors. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021. [DOI: 10.1007/s11936-020-00883-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Cardiotoxicity during long-term trastuzumab use in patients with HER2-positive metastatic breast cancer: who needs cardiac monitoring? Breast Cancer Res Treat 2021; 186:851-862. [PMID: 33394273 PMCID: PMC8019427 DOI: 10.1007/s10549-020-06039-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 11/25/2020] [Indexed: 12/26/2022]
Abstract
Purpose Patients with HER2-positive metastatic breast cancer (MBC) usually receive many years of trastuzumab treatment. It is unknown whether these patients require continuous left ventricular ejection fraction (LVEF) monitoring. We studied a real-world cohort to identify risk factors for cardiotoxicity to select patients in whom LVEF monitoring could be omitted. Methods We included patients with HER2-positive MBC who received > 1 cycle of trastuzumab-based therapy in eight Dutch hospitals between 2000 and 2014. Cardiotoxicity was defined as LVEF < 50% that declined > 10%-points and was categorized into non-severe cardiotoxicity (LVEF 40–50%) and severe cardiotoxicity (LVEF < 40%). Multivariable Cox and mixed model analyses were performed to identify risk factors associated with cardiotoxicity. Additionally, we explored the reversibility of cardiotoxicity in patients who continued trastuzumab. Results In total, 429 patients were included. Median follow-up for cardiotoxicity was 15 months (interquartile range 8–31 months). The yearly incidence of non-severe + severe cardiotoxicity in the first and second year was 11.7% and 9.1%, respectively, which decreased thereafter. The yearly incidence of severe cardiotoxicity was low (2.8%) and stable over time. In non-smoking patients with baseline LVEF > 60% and no cardiotoxicity during prior neoadjuvant/adjuvant treatment, the cumulative incidence of severe cardiotoxicity was 3.1% after 4 years of trastuzumab. Despite continuing trastuzumab, LVEF decline was reversible in 56% of patients with non-severe cardiotoxicity and in 33% with severe cardiotoxicity. Conclusions Serial cardiac monitoring can be safely omitted in non-smoking patients with baseline LVEF > 60% and without cardiotoxicity during prior neoadjuvant/adjuvant treatment. Supplementary Information The online version of this article (10.1007/s10549-020-06039-w) contains supplementary material, which is available to authorized users.
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HOLTER ECG MONITORING AND HEART RATE VARIABILITY IN BREAST CANCER PATIENTS. WORLD OF MEDICINE AND BIOLOGY 2021. [DOI: 10.26724/2079-8334-2021-4-78-105-110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Cardiovascular Toxicity of Novel HER2-Targeted Therapies in the Treatment of Breast Cancer. Curr Oncol Rep 2021; 23:128. [PMID: 34453232 PMCID: PMC8395382 DOI: 10.1007/s11912-021-01114-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW HER2-targeted therapies have led to improved clinical outcomes in early and advanced breast cancer (BC). We review the long-term cardiotoxicity of HER2-targeted therapy in early and advanced BC, our current knowledge of cardiotoxicity of novel HER2-targeted therapies, and propose a cardiac monitoring (CM) strategy for this population. RECENT FINDINGS Long-term data from studies with HER2-targeted therapy in the adjuvant setting have failed to demonstrate an increase in cardiotoxicity over time, and rates of cardiotoxicity seen with novel HER2 agents remain low. Despite over a decade of experience with HER2-targeted therapy, CM in clinical practice is inconsistent in patients with early BC and almost non-existent in advanced BC. Long-term follow-up of clinical trials with HER2-targeted agents in early and advanced BC has failed to demonstrate increased rates of cardiotoxicity over time, attesting to the long-term safety of this class of drugs for the majority of patients, although the long-term cardiac safety of newer HER2 agents in the non-clinical trial setting is largely unknown. We propose CM incorporating clinical history, cardiac imaging, and biomarkers.
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Ruddy KJ, Patel SR, Higgins AS, Armenian SH, Herrmann J. Cardiovascular Health during and after Cancer Therapy. Cancers (Basel) 2020; 12:E3737. [PMID: 33322622 PMCID: PMC7763346 DOI: 10.3390/cancers12123737] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 12/04/2020] [Accepted: 12/08/2020] [Indexed: 01/22/2023] Open
Abstract
Certain cancer treatments have been linked to specific cardiovascular toxicities, including (but not limited to) cardiomyopathy, atrial fibrillation, arterial hypertension, and myocarditis. Radiation, anthracyclines, human epidermal growth factor receptor 2 (Her2)-directed therapies, fluoropyrimidines, platinums, tyrosine kinase inhibitors and proteasome inhibitors, immune checkpoint inhibitors, and chimeric antigen-presenting (CAR)-T cell therapy can all cause cardiovascular side effects. Management of cardiovascular dysfunction that occurs during cancer therapy often requires temporary or permanent cessation of the risk-potentiating anti-neoplastic drug as well as optimization of medical management from a cardiovascular standpoint. Stem cell or bone marrow transplant recipients face unique cardiovascular challenges, as do patients at extremes of age.
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Affiliation(s)
| | - Shruti R. Patel
- Department of Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA;
| | | | - Saro H. Armenian
- Department of Population Sciences, City of Hope, Duarte, CA 91010, USA;
| | - Joerg Herrmann
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, MN 55905, USA;
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Cuomo A, Pirozzi F, Attanasio U, Franco R, Elia F, De Rosa E, Russo M, Ghigo A, Ameri P, Tocchetti CG, Mercurio V. Cancer Risk in the Heart Failure Population: Epidemiology, Mechanisms, and Clinical Implications. Curr Oncol Rep 2020; 23:7. [PMID: 33263821 PMCID: PMC7716920 DOI: 10.1007/s11912-020-00990-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Along with population aging, the incidence of both heart failure (HF) and cancer is increasing. However, little is known about new-onset cancer in HF patients. This review aims at showing recent discoveries concerning this subset of patients. RECENT FINDINGS Not only cancer and HF share similar risk factors but also HF itself can stimulate cancer development. Some cytokines produced by the failing heart induce mild inflammation promoting carcinogenesis, as it has been recently suggested by an experimental model of HF in mice. The incidence of new-onset cancer is higher in HF patients compared to the general population, and it significantly worsens their prognosis. Moreover, the management of HF patients developing new-onset cancer is challenging, especially due to the limited therapeutic options for patients affected by both cancer and HF and the higher risk of cardiotoxicity from anticancer drugs.
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Affiliation(s)
- Alessandra Cuomo
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Flora Pirozzi
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Umberto Attanasio
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Riccardo Franco
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Francesco Elia
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Eliana De Rosa
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Michele Russo
- Department of Molecular Biotechnology and Health Sciences, Molecular Biotechnology Center, University of Torino, Torino, Italy
| | - Alessandra Ghigo
- Department of Molecular Biotechnology and Health Sciences, Molecular Biotechnology Center, University of Torino, Torino, Italy
| | - Pietro Ameri
- Cardiovascular Disease Unit, IRCCS Italian Cardiovascular Network, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Internal Medicine, University of Genova, Genoa, Italy
| | - Carlo Gabriele Tocchetti
- Department of Translational Medical Sciences, Federico II University, Naples, Italy.
- Interdepartmental Center of Clinical and Translational Research, Federico II University, Naples, Italy.
| | - Valentina Mercurio
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
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Copeland-Halperin RS, Al-Sadawi M, Patil S, Liu JE, Steingart RM, Dang CT, Yu AF. Early Trastuzumab Interruption and Recurrence-Free Survival in ERBB2-Positive Breast Cancer. JAMA Oncol 2020; 6:1971-1972. [PMID: 33057570 PMCID: PMC7563661 DOI: 10.1001/jamaoncol.2020.4749] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 07/28/2020] [Indexed: 01/27/2023]
Affiliation(s)
| | | | - Sujata Patil
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer, New York, New York
- Weill Cornell Medical College, New York, New York
| | - Jennifer E. Liu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medical College, New York, New York
| | - Richard M. Steingart
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medical College, New York, New York
| | - Chau T. Dang
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medical College, New York, New York
| | - Anthony F. Yu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medical College, New York, New York
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Broberg AM, Geisler J, Tuohinen S, Skytta T, Hrafnkelsdóttir ÞJ, Nielsen KM, Hedayati E, Omland T, Offersen BV, Lyon AR, Gulati G. Prevention, Detection, and Management of Heart Failure in Patients Treated for Breast Cancer. Curr Heart Fail Rep 2020; 17:397-408. [PMID: 32979150 PMCID: PMC7683437 DOI: 10.1007/s11897-020-00486-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/08/2020] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW Long-term survival has increased significantly in breast cancer patients, and cardiovascular side effects are surpassing cancer-related mortality. We summarize risk factors, prevention strategies, detection, and management of cardiotoxicity, with focus on left ventricular dysfunction and heart failure, during breast cancer treatment. RECENT FINDINGS Baseline treatment of cardiovascular risk factors is recommended. Anthracycline and trastuzumab treatment constitute a substantial risk of developing cardiotoxicity. There is growing evidence that this can be treated with beta blockers and angiotensin antagonists. Early detection of cardiotoxicity with cardiac imaging and circulating cardiovascular biomarkers is currently evaluated in clinical trials. Chest wall irradiation accelerates atherosclerotic processes and induces fibrosis. Immune checkpoint inhibitors require consideration for surveillance due to a small risk of severe myocarditis. Cyclin-dependent kinases4/6 inhibitors, cyclophosphamide, taxanes, tyrosine kinase inhibitors, and endocrine therapy have a lower-risk profile for cardiotoxicity. Preventive and management strategies to counteract cancer treatment-related left ventricular dysfunction or heart failure in breast cancer patients should include a comprehensive cardiovascular risk assessment and individual clinical evaluation. This should include both patient and treatment-related factors. Further clinical trials especially on early detection, cardioprevention, and management are urgently needed.
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Affiliation(s)
- Agneta Månsson Broberg
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Jürgen Geisler
- Department of Oncology, Akershus University Hospital, Lørenskog & Institute of Clinical Medicine, University of Oslo, Campus AHUS, Lørenskog, Norway
| | - Suvi Tuohinen
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Tanja Skytta
- Department of Oncology, Tampere University Hospital, Tampere, Finland
| | - Þórdís Jóna Hrafnkelsdóttir
- Department of Cardiology, Landspitali University Hospital, Reykjavík, Iceland and Faculty of Medicine, University of Iceland, Reykjavík, Iceland
| | | | - Elham Hedayati
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
- Department of Breast Cancer, Sarcoma and Endocrine Tumors, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Torbjørn Omland
- Department of Cardiology, Akershus University Hospital, Lørenskog and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Birgitte V. Offersen
- Department of Experimental Clinical Oncology & Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Alexander R. Lyon
- Cardio-Oncology Service, Royal Brompton Hospital and Imperial College London, London, UK
| | - Geeta Gulati
- Department of Cardiology, Oslo University Hospital, Postbox 4950, Ullevål, Nydalen, 0424 Oslo, Norway
- Department of Research, Akershus University Hospital, Lørenskog and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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de Boer RA, Hulot J, Tocchetti CG, Aboumsallem JP, Ameri P, Anker SD, Bauersachs J, Bertero E, Coats AJ, Čelutkienė J, Chioncel O, Dodion P, Eschenhagen T, Farmakis D, Bayes‐Genis A, Jäger D, Jankowska EA, Kitsis RN, Konety SH, Larkin J, Lehmann L, Lenihan DJ, Maack C, Moslehi JJ, Müller OJ, Nowak‐Sliwinska P, Piepoli MF, Ponikowski P, Pudil R, Rainer PP, Ruschitzka F, Sawyer D, Seferovic PM, Suter T, Thum T, van der Meer P, Van Laake LW, von Haehling S, Heymans S, Lyon AR, Backs J. Common mechanistic pathways in cancer and heart failure. A scientific roadmap on behalf of the Translational Research Committee of the Heart Failure Association (HFA) of the European Society of Cardiology (ESC). Eur J Heart Fail 2020; 22:2272-2289. [PMID: 33094495 PMCID: PMC7894564 DOI: 10.1002/ejhf.2029] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 09/13/2020] [Accepted: 10/18/2020] [Indexed: 12/18/2022] Open
Abstract
The co-occurrence of cancer and heart failure (HF) represents a significant clinical drawback as each disease interferes with the treatment of the other. In addition to shared risk factors, a growing body of experimental and clinical evidence reveals numerous commonalities in the biology underlying both pathologies. Inflammation emerges as a common hallmark for both diseases as it contributes to the initiation and progression of both HF and cancer. Under stress, malignant and cardiac cells change their metabolic preferences to survive, which makes these metabolic derangements a great basis to develop intersection strategies and therapies to combat both diseases. Furthermore, genetic predisposition and clonal haematopoiesis are common drivers for both conditions and they hold great clinical relevance in the context of personalized medicine. Additionally, altered angiogenesis is a common hallmark for failing hearts and tumours and represents a promising substrate to target in both diseases. Cardiac cells and malignant cells interact with their surrounding environment called stroma. This interaction mediates the progression of the two pathologies and understanding the structure and function of each stromal component may pave the way for innovative therapeutic strategies and improved outcomes in patients. The interdisciplinary collaboration between cardiologists and oncologists is essential to establish unified guidelines. To this aim, pre-clinical models that mimic the human situation, where both pathologies coexist, are needed to understand all the aspects of the bidirectional relationship between cancer and HF. Finally, adequately powered clinical studies, including patients from all ages, and men and women, with proper adjudication of both cancer and cardiovascular endpoints, are essential to accurately study these two pathologies at the same time.
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Affiliation(s)
- Rudolf A. de Boer
- Department of CardiologyUniversity Medical Center GroningenGroningenThe Netherlands
| | - Jean‐Sébastien Hulot
- Université de Paris, PARCC, INSERMParisFrance
- CIC1418 and DMU CARTE, AP‐HP, Hôpital Européen Georges‐PompidouParisFrance
| | - Carlo Gabriele Tocchetti
- Department of Translational Medical Sciences and Interdepartmental Center of Clinical and Translational ResearchFederico II UniversityNaplesItaly
| | | | - Pietro Ameri
- Department of Internal Medicine and Center of Excellence for Biomedical ResearchUniversity of GenovaGenoaItaly
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San MartinoGenoaItaly
| | - Stefan D. Anker
- Department of Cardiology & Berlin Institute of Health Center for Regenerative Therapies (BCRT), German Center for Cardiovascular Research (DZHK), Partner Site BerlinCharité‐Universitätsmedizin Berlin (Campus CVK)BerlinGermany
| | - Johann Bauersachs
- Department of Cardiology and AngiologyHannover Medical SchoolHannoverGermany
| | - Edoardo Bertero
- Comprehensive Heart Failure CenterUniversity Clinic WürzburgWürzburgGermany
| | | | - Jelena Čelutkienė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of MedicineVilnius UniversityVilniusLithuania
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases ‘Prof. C.C. Iliescu’University of Medicine Carol DavilaBucharestRomania
| | | | - Thomas Eschenhagen
- Institute of Experimental Pharmacology and ToxicologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
- Partner Site Hamburg/Kiel/Lübeck, DZHK (German Centre for Cardiovascular Research)HamburgGermany
| | - Dimitrios Farmakis
- University of Cyprus Medical SchoolNicosiaCyprus
- Cardio‐Oncology Clinic, Heart Failure Unit, Department of CardiologyAthens University Hospital ‘Attikon’, National and Kapodistrian University of Athens Medical SchoolAthensGreece
| | - Antoni Bayes‐Genis
- Heart Failure Unit and Cardiology DepartmentHospital Universitari Germans Trias i Pujol, CIBERCVBadalonaSpain
- Department of MedicineUniversitat Autònoma de BarcelonaBarcelonaSpain
- CIBER CardiovascularInstituto de Salud Carlos IIIMadridSpain
| | - Dirk Jäger
- Department of Medical Oncology, National Center for Tumor Diseases (NCT)University Hospital HeidelbergHeidelbergGermany
| | - Ewa A. Jankowska
- Department of Heart Diseases, Wroclaw Medical University, and Centre for Heart DiseasesUniversity HospitalWroclawPoland
| | - Richard N. Kitsis
- Departments of Medicine (Cardiology) and Cell BiologyWilf Family Cardiovascular Research Institute, Albert Einstein Cancer Center, Albert Einstein College of MedicineNew YorkNYUSA
| | - Suma H. Konety
- Cardiovascular Division, Cardio‐Oncology Program, Department of MedicineUniversity of Minnesota Medical SchoolMinneapolisMNUSA
| | | | - Lorenz Lehmann
- Cardio‐Oncology Unit, Department of CardiologyUniversity of HeidelbergHeidelbergGermany
- DZHK (German Centre for Cardiovascular Research), partner siteHeidelberg/MannheimGermany
- DKFZ (German Cancer Research Center)HeidelbergGermany
| | - Daniel J. Lenihan
- Cardio‐Oncology Center of Excellence, Cardiovascular DivisionWashington University in St. LouisSt. LouisMOUSA
| | - Christoph Maack
- Comprehensive Heart Failure CenterUniversity Clinic WürzburgWürzburgGermany
| | - Javid J. Moslehi
- Division of Cardiovascular Medicine and OncologyCardio‐Oncology Program, Vanderbilt University Medical Center and Vanderbilt‐Ingram Cancer CenterNashvilleTNUSA
| | - Oliver J. Müller
- Department of Internal Medicine IIIUniversity of KielKielGermany
- DZHK (German Centre for Cardiovascular Research), partner siteHamburg/Kiel/LübeckGermany
| | - Patrycja Nowak‐Sliwinska
- School of Pharmaceutical SciencesUniversity of Geneva, Institute of Pharmaceutical Sciences of Western Switzerland, University of GenevaGenevaSwitzerland
- Translational Research Center in OncohaematologyGenevaSwitzerland
| | | | - Piotr Ponikowski
- Department of Heart Diseases, Wroclaw Medical University, and Centre for Heart DiseasesUniversity HospitalWroclawPoland
| | - Radek Pudil
- 1st Department Medicine‐CardioangiologyUniversity Hospital and Medical FacultyHradec KraloveCzech Republic
| | - Peter P. Rainer
- Medical University of GrazUniversity Heart Center – Division of CardiologyGrazAustria
| | - Frank Ruschitzka
- Department of CardiologyUniversity Hospital Zurich, University Heart CenterZurichSwitzerland
| | - Douglas Sawyer
- Center for Molecular Medicine, Maine Medical Center Research InstituteMaine Medical CenterScarboroughMEUSA
| | - Petar M. Seferovic
- University of Belgrade Faculty of Medicine, Serbian Academy of Sciences and ArtsBelgradeSerbia
| | - Thomas Suter
- Swiss Cardiovascular CentreBern UniversityBernSwitzerland
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS)Hannover Medical SchoolHannoverGermany
| | - Peter van der Meer
- Department of CardiologyUniversity Medical Center GroningenGroningenThe Netherlands
| | - Linda W. Van Laake
- Division Heart and Lungs and Regenerative Medicine CentreUniversity Medical Centre Utrecht and Utrecht UniversityUtrechtThe Netherlands
| | - Stephan von Haehling
- Department of Cardiology and Pneumology, Heart CenterUniversity of Göttingen Medical CenterGöttingenGermany
- German Center for Cardiovascular Research (DZHK), partner site GöttingenGöttingenGermany
| | - Stephane Heymans
- Department of Cardiology, CARIM School for Cardiovascular Diseases Faculty of Health, Medicine and Life SciencesMaastricht UniversityMaastrichtThe Netherlands
- Department of Cardiovascular SciencesCentre for Molecular and Vascular Biology, KU LeuvenLeuvenBelgium
| | - Alexander R. Lyon
- Cardio‐Oncology Service, Royal Brompton Hospital, and National Heart and Lung Institute, Imperial College LondonLondonUK
| | - Johannes Backs
- Institute of Experimental CardiologyHeidelberg University HospitalHeidelbergGermany
- DZHK (German Centre for Cardiovascular Research), partner siteHeidelberg/MannheimGermany
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Zamorano JL, Gottfridsson C, Asteggiano R, Atar D, Badimon L, Bax JJ, Cardinale D, Cardone A, Feijen EA, Ferdinandy P, López-Fernández T, Gale CP, Maduro JH, Moslehi J, Omland T, Plana Gomez JC, Scott J, Suter TM, Minotti G. The cancer patient and cardiology. Eur J Heart Fail 2020; 22:2290-2309. [PMID: 32809231 PMCID: PMC8278961 DOI: 10.1002/ejhf.1985] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/12/2020] [Accepted: 08/14/2020] [Indexed: 02/06/2023] Open
Abstract
Advances in cancer treatments have improved clinical outcomes, leading to an increasing population of cancer survivors. However, this success is associated with high rates of short- and long-term cardiovascular (CV) toxicities. The number and variety of cancer drugs and CV toxicity types make long-term care a complex undertaking. This requires a multidisciplinary approach that includes expertise in oncology, cardiology and other related specialties, and has led to the development of the cardio-oncology subspecialty. This paper aims to provide an overview of the main adverse events, risk assessment and risk mitigation strategies, early diagnosis, medical and complementary strategies for prevention and management, and long-term follow-up strategies for patients at risk of cancer therapy-related cardiotoxicities. Research to better define strategies for early identification, follow-up and management is highly necessary. Although the academic cardio-oncology community may be the best vehicle to foster awareness and research in this field, additional stakeholders (industry, government agencies and patient organizations) must be involved to facilitate cross-discipline interactions and help in the design and funding of cardio-oncology trials. The overarching goals of cardio-oncology are to assist clinicians in providing optimal care for patients with cancer and cancer survivors, to provide insight into future areas of research and to search for collaborations with industry, funding bodies and patient advocates. However, many unmet needs remain. This document is the product of brainstorming presentations and active discussions held at the Cardiovascular Round Table workshop organized in January 2020 by the European Society of Cardiology.
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Affiliation(s)
- José Luis Zamorano
- Department of Cardiology, University Hospital Ramón y Cajal, CiberCV, Madrid, Spain
| | - Christer Gottfridsson
- Cardiovascular Safety Centre of Excellence, Patient Safety, CMO Organization, AstraZeneca, Gothenburg, Sweden
| | - Riccardo Asteggiano
- ESC Council of Cardio-Oncology, Insubria University of Medicine, Varese, Italy
- LARC (Laboratorio Analisi Ricerca Clinica), Turin, Italy
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital Ulleval, Oslo, Norway
- Institute of Clinical Sciences, University of Oslo, Oslo, Norway
| | - Lina Badimon
- ESC Advocacy Committee 2018–2020, Director Cardiovascular Programme (ICCC)-IR Hospital de la Santa Creu I Sant Pau, CiberCV, Barcelona, Spain
| | - Jeroen J. Bax
- Department of Cardiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Daniela Cardinale
- Cardio-Oncology Unit, European Institute of Oncology, IRCCS, Milan, Italy
| | | | | | - Péter Ferdinandy
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
- Pharmahungary Group, Szeged, Hungary
| | | | - Chris P. Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - John H. Maduro
- Department of Radiation Oncology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Javid Moslehi
- Cardio-Oncology Program, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Torbjørn Omland
- Department of Cardiology, Akershus University Hospital, University of Oslo, Oslo, Norway
| | - Juan Carlos Plana Gomez
- Department of Cardiology, Texas Heart Institute and Baylor College of Medicine, Houston, TX, USA
| | - Jessica Scott
- Exercise Oncology Research Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Thomas M. Suter
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Giorgio Minotti
- Campus Bio-Medico University School of Medicine, Rome, Italy
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73
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Sardesai S, Sukumar J, Kassem M, Palettas M, Stephens J, Morgan E, Addison D, Baliga R, Stover DG, VanDeusen J, Williams N, Cherian M, Lustberg M, Wesolowski R, Ramaswamy B. Clinical impact of interruption in adjuvant Trastuzumab therapy in patients with operable HER-2 positive breast cancer. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2020; 6:26. [PMID: 33292843 PMCID: PMC7643282 DOI: 10.1186/s40959-020-00081-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 10/20/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Trastuzumab-induced cardiotoxicity (TIC) can lead to early discontinuation of adjuvant therapy, however there is limited evidence on long-term survival outcomes in patients with operable human epidermal growth factor receptor 2 (HER2)-positive breast cancer (BC) experiencing treatment interruption or discontinuation. METHODS The primary objective of the study was to evaluate disease-free survival (DFS) in non-metastatic, HER2-positive, female BC patients who experienced treatment interruption or early discontinuation of trastuzumab therapy. Clinical and histopathological data were collected on 400 patients at The Ohio State University, an NCI-designated comprehensive cancer center between January 2005 and December 2015. Treatment interruption was defined as any delay of ≥2 weeks during trastuzumab therapy, including permanent cessation prior to completing planned therapy. TIC was defined as LVEF < 50% or > 15 points decline from baseline as evaluated by 2D echocardiogram after initiation of (neo) adjuvant therapy. DFS was defined as the time from diagnosis to first recurrence (loco-regional or distant recurrence) including second primary BC or death. Overall survival (OS) was defined as the time from diagnosis to death or last known follow up. OS/DFS estimates were generated using Kaplan-Meier methods and compared using Log-rank tests. Cox proportional hazard models were used to calculate adjusted hazard ratios (aHR) for OS/DFS. RESULTS A total of 369 patients received trastuzumab therapy; 106 (29%) patients experienced treatment interruption at least once and 42 (11%) permanently discontinued trastuzumab prior to completing planned therapy. TIC was the most common reason for interruption (66 patients, 62%). The median duration of trastuzumab in patients with treatment interruption was 11.3 months (range: 0.5-16.9) with 24 (23%) patients receiving ≤6 months of therapy. This duration includes the time delay related to treatment interruption. Patients with any treatment interruption had worse DFS (aHR: 4.4, p = 0.001) and OS (aHR: 4.8, p < 0.001) after adjusting for age, stage, grade, ER, node status and TIC. CONCLUSIONS Treatment interruption or early discontinuation of trastuzumab therapy in early HER2-positive BC, most often from TIC, is an independent prognostic marker for worse DFS and OS in operable HER2-positive BC. Future prospective studies should consider targeting at-risk populations and optimizing cardiac function to avoid interruption in trastuzumab therapy.
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Affiliation(s)
- Sagar Sardesai
- Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, 43210, USA.
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, 1204A Lincoln Tower, 1800 Cannon Dr, Columbus, OH, USA.
| | - Jasmine Sukumar
- Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, 43210, USA
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, 1204A Lincoln Tower, 1800 Cannon Dr, Columbus, OH, USA
| | - Mahmoud Kassem
- Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, 43210, USA
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, 1204A Lincoln Tower, 1800 Cannon Dr, Columbus, OH, USA
| | - Marilly Palettas
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University, Columbus, OH, USA
| | - Julie Stephens
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University, Columbus, OH, USA
| | - Evan Morgan
- Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, 43210, USA
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, 1204A Lincoln Tower, 1800 Cannon Dr, Columbus, OH, USA
| | - Daniel Addison
- Division of Cardiology, The Ohio State University, Columbus, OH, USA
| | - Ragavendra Baliga
- Division of Cardiology, The Ohio State University, Columbus, OH, USA
| | - Daniel G Stover
- Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, 43210, USA
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, 1204A Lincoln Tower, 1800 Cannon Dr, Columbus, OH, USA
| | - Jeffrey VanDeusen
- Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, 43210, USA
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, 1204A Lincoln Tower, 1800 Cannon Dr, Columbus, OH, USA
| | - Nicole Williams
- Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, 43210, USA
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, 1204A Lincoln Tower, 1800 Cannon Dr, Columbus, OH, USA
| | - Mathew Cherian
- Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, 43210, USA
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, 1204A Lincoln Tower, 1800 Cannon Dr, Columbus, OH, USA
| | - Maryam Lustberg
- Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, 43210, USA
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, 1204A Lincoln Tower, 1800 Cannon Dr, Columbus, OH, USA
| | - Robert Wesolowski
- Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, 43210, USA
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, 1204A Lincoln Tower, 1800 Cannon Dr, Columbus, OH, USA
| | - Bhuvaneswari Ramaswamy
- Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, 43210, USA
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, 1204A Lincoln Tower, 1800 Cannon Dr, Columbus, OH, USA
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74
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Blaes A, Manisty C, Barac A. How to Follow, Manage and Treat Cardiac Dysfunction in Patients With Her2+ Breast Cancer. JACC CardioOncol 2020; 2:661-665. [PMID: 34396278 PMCID: PMC8352336 DOI: 10.1016/j.jaccao.2020.08.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 08/26/2020] [Accepted: 08/26/2020] [Indexed: 01/01/2023] Open
Affiliation(s)
- Anne Blaes
- University of Minnesota, Division of Hematology/Oncology, Minneapolis, Minnesota, USA
| | - Charlotte Manisty
- University College London and Barts Health NHS Trust, Division of Cardiology, London, United Kingdom
| | - Ana Barac
- MedStar Heart and Vascular Institute, Cardio-Oncology Program, Georgetown University, Washington, DC, USA
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75
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Rassaf T, Totzeck M, Backs J, Bokemeyer C, Hallek M, Hilfiker-Kleiner D, Hochhaus A, Lüftner D, Müller OJ, Neudorf U, Pfister R, von Haehling S, Lehmann LH, Bauersachs J. Onco-Cardiology: Consensus Paper of the German Cardiac Society, the German Society for Pediatric Cardiology and Congenital Heart Defects and the German Society for Hematology and Medical Oncology. Clin Res Cardiol 2020; 109:1197-1222. [PMID: 32405737 PMCID: PMC7515958 DOI: 10.1007/s00392-020-01636-7] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 03/13/2020] [Indexed: 12/11/2022]
Abstract
The acute and long-lasting side effects of modern multimodal tumour therapy significantly impair quality of life and survival of patients afflicted with malignancies. The key components of this therapy include radiotherapy, conventional chemotherapy, immunotherapy and targeted therapies. In addition to established tumour therapy strategies, up to 30 new therapies are approved each year with only incompletely characterised side effects. This consensus paper discusses the risk factors that contribute to the development of a potentially adverse reaction to tumour therapy and, in addition, defines specific side effect profiles for different treatment groups. The focus is on novel therapeutics and recommendations for the surveillance and treatment of specific patient groups.
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Affiliation(s)
- Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Centre Essen, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany.
| | - Matthias Totzeck
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Centre Essen, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Johannes Backs
- Institute for Experimental Cardiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Carsten Bokemeyer
- Department of Oncology, Hematology and Bone Marrow Transplantation with the Section Pneumology, Centre for Oncology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Hallek
- Department I of Internal Medicine, Center for Integrated Oncology ABCD, University Hospital of Cologne, Cologne, Germany
| | | | - Andreas Hochhaus
- Department of Hematology and Medical Oncology, University Hospital Jena, Jena, Germany
| | - Diana Lüftner
- Department of Haematology, Oncology and Tumour Immunology, Charité, Humboldt University Berlin, Berlin, Germany
| | - Oliver J Müller
- Department of Internal Medicine III (Cardiology, Angiology and Internal Intensive Care Medicine), University Hospital Schleswig-Holstein, University of Kiel, Kiel, Germany
| | - Ulrich Neudorf
- Department of Pediatrics III, West German Heart and Vascular Centre Essen, University Hospital Essen, Essen, Germany
| | - Roman Pfister
- Clinic III for Internal Medicine, General and Interventional Cardiology, Electrophysiology, Angiology, Pneumology and Internal Intensive Care Medicine, University Hospital Cologne, Cologne, Germany
| | - Stephan von Haehling
- Department of Cardiology and Pneumology, Heart Center Göttingen, University of Göttingen Medical Center and German Center for Cardiovascular Research (DZHK), partner site Göttingen, Göttingen, Germany
| | - Lorenz H Lehmann
- Department of Cardiology, Angiology, Pneumology, University Hospital Heidelberg, Heidelberg, Germany
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
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Mallouppas M, Walker JM, Guha A, Dobson R, Ghosh AK. Cardio-oncology for the general physician: 'old' and 'new' cardiovascular toxicities and how to manage them. Br J Hosp Med (Lond) 2020; 81:1-11. [PMID: 32990088 DOI: 10.12968/hmed.2020.0269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Cardio-oncology is the care of cancer patients with cardiovascular disease. The need for a dedicated subspecialty emerged to address heart failure caused by drugs such as anthracyclines and anti-human epidermal growth factor receptor 2 (HER2) therapies, but over time has expanded into an exciting subspecialty with widening horizons. While still dealing with a lot of commonly recognised toxicities, such as heart failure, hypertension and coronary disease, new and revolutionary cancer therapies have been associated with challenging cardiovascular complications, requiring specialist input to manage effectively. Echocardiography is a key investigation, with advanced techniques such as three-dimensional and strain assessment allowing more accurate diagnosis and earlier detection of subtle changes. Cardiac magnetic resonance and biomarkers are useful adjuncts to aid diagnosis and management. With increasing cancer incidence and improved cancer survival rates, it is important that general cardiologists and physicians are aware of cardiac complications associated with cancer and how to manage them.
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Affiliation(s)
- Michael Mallouppas
- Cardio-Oncology Service, University College London Hospital NHS Foundation Trust, London, UK.,Hatter Cardiovascular Institute, University College London, London, UK
| | - J Malcolm Walker
- Cardio-Oncology Service, University College London Hospital NHS Foundation Trust, London, UK.,Hatter Cardiovascular Institute, University College London, London, UK
| | - Avirup Guha
- Harrington Heart and Vascular Institute, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | | | - Arjun K Ghosh
- Cardio-Oncology Service, University College London Hospital NHS Foundation Trust, London, UK.,Hatter Cardiovascular Institute, University College London, London, UK.,Cardio-Oncology Service, Bart's Heart Centre, St Bartholomew's Hospital, London, UK
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77
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López-Fernández T. Cardiac Imaging in Oncology Patients in Europe: a Model for Advancement of CV Safety and Development of Comprehensive CV Care. J Cardiovasc Transl Res 2020; 13:490-494. [PMID: 32583314 PMCID: PMC7314619 DOI: 10.1007/s12265-020-10028-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 05/11/2020] [Indexed: 12/18/2022]
Abstract
Cancer therapy-related cardiovascular events are widely recognized as a global problem, and cardio-oncology has been proposed as a new approach to coordinate preventive strategies in oncologic patients. Cardiac imaging plays a critical role in this process. This article summarizes current practices and future needs in cardiac imaging to improve the cardiovascular surveillance of cancer patients.
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Affiliation(s)
- Teresa López-Fernández
- Cardiology Department, Cardiac Imaging and Cardio-Oncology Unit, IdiPAZ, CIBER CV, La Paz University Hospital, Madrid, Spain.
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78
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Upshaw JN. Cardioprotective Strategies to Prevent Cancer Treatment-Related Cardiovascular Toxicity: a Review. Curr Oncol Rep 2020; 22:72. [DOI: 10.1007/s11912-020-00923-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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79
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Yu AF, Moskowitz CS, Lee Chuy K, Yang J, Dang CT, Liu JE, Oeffinger KC, Steingart RM. Cardiotoxicity Surveillance and Risk of Heart Failure During HER2 Targeted Therapy. JACC CardioOncol 2020; 2:166-175. [PMID: 33103123 PMCID: PMC7584138 DOI: 10.1016/j.jaccao.2020.03.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 03/05/2020] [Accepted: 03/14/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Guidelines recommend left ventricular ejection fraction (LVEF) assessments every 3 months for cardiotoxicity monitoring during human epidermal growth factor receptor 2 (HER2) targeted therapy. Evidence in support of this practice is lacking. OBJECTIVES This study examines the association between adherence to cardiotoxicity surveillance guidelines and heart failure (HF) in HER2-positive breast cancer patients. METHODS A case-control study was performed in 53 patients who developed cardiotoxicity during HER2 targeted therapy, and 159 controls matched by age, anthracycline exposure, and year of treatment. Cardiotoxicity was defined as HF (New York Heart Association functional class III or IV) or cardiac death. Adherence to cardiotoxicity surveillance guidelines was ascertained from the beginning of HER2 targeted therapy to the diagnosis date of HF for cases or the corresponding timepoint for matched controls. Conditional logistic regression was used for case-control comparisons. RESULTS Eighty-one percent of cases and controls were previously treated with an anthracycline. Adherence to cardiotoxicity surveillance guidelines during the entire observation period or during the first 6 months of treatment was not associated with lower risk of HF. An LVEF <55% at any surveillance timepoint was identified in 49% of cases and 3% of controls, and an LVEF <55% during the final surveillance timepoint before developing HF was identified in 54% of cases and 4% of controls. In multivariable-adjusted analyses, LVEF <55% at any timepoint or during the final surveillance timepoint (odds ratio: 27.0; 95% confidence interval: 9.3 to 78.8 and odds ratio: 25.6; 95% confidence interval: 7.3 to 90.3, respectively) was associated with HF. CONCLUSIONS Patients with LVEF <55% on routine surveillance during HER2 targeted therapy are at increased risk for HF. Additional studies to define their optimal management are warranted.
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Affiliation(s)
- Anthony F. Yu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Weill Cornell Medical College, New York, New York, USA
| | - Chaya S. Moskowitz
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | | | - Ji Yang
- New York Presbyterian Brooklyn Methodist Hospital, New York, New York, USA
| | - Chau T. Dang
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Weill Cornell Medical College, New York, New York, USA
| | - Jennifer E. Liu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Weill Cornell Medical College, New York, New York, USA
| | - Kevin C. Oeffinger
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Richard M. Steingart
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Weill Cornell Medical College, New York, New York, USA
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80
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Denduluri N. Examining Cardiotoxicity With HER2 Therapies. JACC CardioOncol 2020; 2:176-178. [PMID: 34396227 PMCID: PMC8352334 DOI: 10.1016/j.jaccao.2020.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Neelima Denduluri
- Address for correspondence: Dr. Neelima Denduluri, Virginia Cancer Specialists, The US Oncology Networkm 635 N. George Mason Drive, Suite 170, Arlington, Virginia 22205. @ndenduluri1
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81
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Clinical Practice and Research in Cardio-Oncology: Finding the "Rosetta Stone" for Establishing Program Excellence in Cardio-oncology. J Cardiovasc Transl Res 2020; 13:495-505. [PMID: 32444945 DOI: 10.1007/s12265-020-10010-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 04/17/2020] [Indexed: 02/06/2023]
Abstract
The burgeoning field of cardio-oncology (C-O) is now necessary for the delivery of excellent care for patients with cancer. Many factors have contributed to this increasing population of cancer survivors or those being treated with novel and targeted cancer therapies. There is a tremendous need to provide outstanding cardiovascular (CV) care for these patients; however, current medical literature actually provides a paucity of guidance. C-O therefore provides a novel opportunity for clinical, translational, and basic research to advance patient care. This review aims to be a primer for cardio-oncologists on how to develop a vibrant and comprehensive C-O program, use practical tools to assist in the construction of C-O services, and to proactively incorporate translational and clinical research into the training of future leaders as well as enhance clinical care.
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82
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Calvillo-Argüelles O, Abdel-Qadir H, Suntheralingam S, Michalowska M, Amir E, Thavendiranathan P. Trastuzumab-Related Cardiotoxicity and Cardiac Care in Patients With HER2 Positive Metastatic Breast Cancer. Am J Cardiol 2020; 125:1270-1275. [PMID: 32087998 DOI: 10.1016/j.amjcard.2020.01.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 01/12/2020] [Accepted: 01/15/2020] [Indexed: 12/26/2022]
Abstract
Prolonged trastuzumab therapy is the standard of care for women with metastatic HER2 positive (HER2+) breast cancer. There are limited data on the incidence of cardiotoxicity, its treatment implication, and cardiac care in these patients. We retrospectively identified consecutive women who received >12 months of trastuzumab treatment at Princess Margaret Cancer Centre (Toronto, ON) from 2007 to 2012 for metastatic HER2 positive breast cancer and followed them until death or August 2018. Patients were included if a pretherapy multigated acquisition scan and ≥2 subsequent follow-up scans were available. The Cardiac Review and Evaluation Committee Criteria were used to identify cardiotoxicity. Baseline characteristics and outcomes (final left ventricular ejection fraction, change in LVEF, trastuzumab interruption) were compared in patients with and without cardiotoxicity. Cardiac care and treatment received were recorded. Sixty patients (mean age 52 ± 10.4 years) were included. The median trastuzumab exposure was 37 cycles (interquartile range 23 to 56) over 28 months (interquartile range 19 to 49) and 48% received previous anthracycline therapy. The cumulative incidence of cardiotoxicity was 35% (95% CI 23 to 48) at 3 years. Patients who developed cardiotoxicity were more likely to receive third-line cancer treatments and had lower final LVEF than patients without (54.9% ± 6.3% vs 64% ± 4.9%, p <0.001). Of the 23 patients with cardiotoxicity, 10 (43%) had trastuzumab interrupted for at least 1 cycle, only 7 (30%) patients were seen by a cardiologist and 4 (17%) received cardiac medications. In conclusion, patients with metastatic breast cancer receiving prolonged trastuzumab therapy appear to have high rates of cardiotoxicity. This was associated with high rates of trastuzumab interruption, but low rates of cardiology referral and cardiac treatment, reflecting a potential cardiac care gap.
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Affiliation(s)
- Oscar Calvillo-Argüelles
- Division of Cardiology, Peter Munk Cardiac Center, Ted Rogers Program in Cardiotoxicity Prevention, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Husam Abdel-Qadir
- Division of Cardiology, Peter Munk Cardiac Center, Ted Rogers Program in Cardiotoxicity Prevention, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, Division of Cardiology, Women's College Hospital, Toronto, Ontario, Canada
| | - Sivisan Suntheralingam
- Division of Cardiology, Peter Munk Cardiac Center, Ted Rogers Program in Cardiotoxicity Prevention, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Maria Michalowska
- Division of Cardiology, Peter Munk Cardiac Center, Ted Rogers Program in Cardiotoxicity Prevention, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, Division of Cardiology, Women's College Hospital, Toronto, Ontario, Canada
| | - Eitan Amir
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Center, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Paaladinesh Thavendiranathan
- Division of Cardiology, Peter Munk Cardiac Center, Ted Rogers Program in Cardiotoxicity Prevention, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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83
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Leemasawat K, Phrommintikul A, Chattipakorn SC, Chattipakorn N. Mechanisms and potential interventions associated with the cardiotoxicity of ErbB2-targeted drugs: Insights from in vitro, in vivo, and clinical studies in breast cancer patients. Cell Mol Life Sci 2020; 77:1571-1589. [PMID: 31650186 PMCID: PMC11104997 DOI: 10.1007/s00018-019-03340-w] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 09/22/2019] [Accepted: 10/10/2019] [Indexed: 02/07/2023]
Abstract
Breast cancer is the most frequently occurring cancer among women worldwide. Human epidermal growth factor receptor 2 (HER2 or ErbB2) is overexpressed in between 20 and 25% of invasive breast cancers and is associated with poor prognosis. Trastuzumab, an anti-ErbB2 monoclonal antibody, reduces cancer recurrence and mortality in HER2-positive breast cancer patients, but unexpectedly induces cardiac dysfunction, especially when used in combination with anthracycline-based chemotherapy. Novel approved ErbB2-targeting drugs, including lapatinib, pertuzumab, and trastuzumab-emtansine, also potentially cause cardiotoxicity, although early clinical studies demonstrate their cardiac safety profile. Unfortunately, the mechanism involved in causing the cardiotoxicity is still not completely understood. In addition, the use of preventive interventions against trastuzumab-induced cardiac dysfunction, including angiotensin-converting enzyme inhibitors and beta-blockers, remain controversial. Thus, this review aims to summarize and discuss the evidence currently available from in vitro, in vivo, and clinical studies regarding the mechanism and potential interventions associated with the cardiotoxicity of ErbB2-targeted drugs.
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Affiliation(s)
- Krit Leemasawat
- Division of Cardiovascular Diseases, Department of Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Arintaya Phrommintikul
- Division of Cardiovascular Diseases, Department of Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai, Thailand
| | - Siriporn C Chattipakorn
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai, Thailand
| | - Nipon Chattipakorn
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand.
- Cardiac Electrophysiology Unit, Department of Physiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai, Thailand.
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84
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Barac A, Blaes A, Lynce F. Lessons From Primary Cardiac Prevention Trials During Trastuzumab Therapy: End of One Size Fits All. J Am Coll Cardiol 2020; 73:2869-2871. [PMID: 31171093 DOI: 10.1016/j.jacc.2019.04.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 04/02/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Ana Barac
- Medstar Heart and Vascular Institute, Washington, DC; Georgetown Lombardi Comprehensive Cancer Center, Washington, DC.
| | - Anne Blaes
- University of Minnesota, Hematology/Oncology, Minneapolis, Minnesota
| | - Filipa Lynce
- Georgetown Lombardi Comprehensive Cancer Center, Washington, DC
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85
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Cleland JGF, Lyon AR, McDonagh T, McMurray JJV. The year in cardiology: heart failure. Eur Heart J 2020; 41:1232-1248. [PMID: 31901936 PMCID: PMC7084174 DOI: 10.1093/eurheartj/ehz949] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 12/19/2019] [Indexed: 12/11/2022] Open
Affiliation(s)
- John G F Cleland
- Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow G12 8QQ, UK
- National Heart & Lung Institute, Imperial College, London, UK
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow G12 8QQ, UK
| | - Alexander R Lyon
- National Heart & Lung Institute, Imperial College, London, UK
- Royal Brompton Hospital, London, UK
| | - Theresa McDonagh
- King’s College Hospital, London, UK
- King’s College London, London, UK
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow G12 8QQ, UK
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86
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Slivnick J, Vallakati A, Addison D, Wallner A, Tong MS. Personalized Approach to Cancer Treatment-Related Cardiomyopathy. Curr Heart Fail Rep 2020; 17:43-55. [PMID: 32125627 DOI: 10.1007/s11897-020-00453-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Cancer treatment-related cardiotoxicity (CTRC) represents a significant cause of morbidity and mortality worldwide. The purpose of our review is to summarize the epidemiology, natural history, and pathophysiology of cardiotoxicity-related to cancer treatment. We also summarize appropriate screening, surveillance, and management of CTRC. While cardiotoxicity is characteristically associated with anthracyclines, HER2-B antagonists, and radiation therapy (XRT), there is growing recognition of toxicity with immune checkpoint inhibitors (ICI), tyrosine kinase inhibitors, and proteasome inhibitors. RECENT FINDINGS Patients at risk for cardiotoxicity should be screened based on available guidelines, generally with serial echocardiograms. The role of medical heart failure (HF) therapies is controversial in patients with asymptomatic left ventricular dysfunction but may be considered in some instances. Once symptomatic HF has developed, treatment should be in accordance with ACC/AHA guidelines. The goal in caring for patients receiving cancer treatment is to optimize cardiac function and prevent interruptions in potentially lifesaving cancer treatment.
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Affiliation(s)
- Jeremy Slivnick
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Medicine, The Ohio State University, Columbus, OH, USA
| | - Ajay Vallakati
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Medicine, The Ohio State University, Columbus, OH, USA
| | - Daniel Addison
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Medicine, The Ohio State University, Columbus, OH, USA.,Division of Cancer Prevention and Control, Department of Medicine, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Alexander Wallner
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Medicine, The Ohio State University, Columbus, OH, USA
| | - Matthew S Tong
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Medicine, The Ohio State University, Columbus, OH, USA.
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87
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Affiliation(s)
- Michael A. Biersmith
- Cardio‐Oncology ProgramDivision of Cardiovascular MedicineDepartment of MedicineThe Ohio State UniversityColumbusOH
| | - Matthew S. Tong
- Cardio‐Oncology ProgramDivision of Cardiovascular MedicineDepartment of MedicineThe Ohio State UniversityColumbusOH
| | - Avirup Guha
- Cardio‐Oncology ProgramDivision of Cardiovascular MedicineDepartment of MedicineThe Ohio State UniversityColumbusOH
- Harrington Heart and Vascular InstituteCase Western Reserve UniversityClevelandOH
| | - Orlando P. Simonetti
- Cardio‐Oncology ProgramDivision of Cardiovascular MedicineDepartment of MedicineThe Ohio State UniversityColumbusOH
| | - Daniel Addison
- Cardio‐Oncology ProgramDivision of Cardiovascular MedicineDepartment of MedicineThe Ohio State UniversityColumbusOH
- Division of Cancer Prevention and ControlDepartment of MedicineCollege of MedicineThe Ohio State UniversityColumbusOH
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88
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The Current and Future Role of Echocardiography for the Detection of Cardiotoxicity Related to Cancer Therapy. CURRENT CARDIOVASCULAR IMAGING REPORTS 2020. [DOI: 10.1007/s12410-019-9523-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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89
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Abstract
A growing number of effective cancer therapies is associated with cardiovascular (CV) toxicities including myocardial injury or dysfunction, leading to reduced ventricular function, and increased risk of heart failure. As the timing of administration of cancer treatment is known, the potential for risk stratification pre-treatment, and appropriate surveillance and monitoring during treatment, and intervention with cardio-protective treatment strategies in patients exhibiting early evidence of CV toxicity is an appealing clinical strategy. The field of cardio-oncology has developed, and the application of monitoring strategies using CV biomarkers and CV imaging has been to focus of many studies and is now implemented in dedicated cardio-oncology services supporting oncology centres. In this article, we review the background and rationale for monitoring, the different options and their strengths, weaknesses and where they are helpful in specific cardiotoxic cancer therapies, and the impact in cardio-oncology care.
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Affiliation(s)
- Mohsen Habibian
- The Prince Charles Hospital and University of Queensland, Rode Road, Chermside, QLD 4032, Australia.,Cardio-Oncology Service, Royal Brompton Hospital, Sydney Street, Chelsea, London, SW3 6NP, UK
| | - Alexander R Lyon
- Cardio-Oncology Service, Royal Brompton Hospital, Sydney Street, Chelsea, London, SW3 6NP, UK.,National Heart and Lung Institute, Imperial College London, Cale Street, Chelsea, London, SW3 6LY, UK
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90
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Sharma AV, Reddin G, Forrestal B, Barac A. Cardiovascular Disease Risk in Survivors of Breast Cancer. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:79. [PMID: 31820123 DOI: 10.1007/s11936-019-0788-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Early detection and improved treatment in breast cancer have resulted in an increased number of survivors. Cardiovascular disease now remains an important cause for morbidity and mortality in this population. There is a growing gap in the knowledge about the optimal long-term cardiovascular management of this population. FINDINGS Breast cancer and cardiovascular disease share a number of common risk factors. Different breast cancer treatment modalities, including anthracyclines, radiation, and hormonal therapy, can act in synergy with preexisting and/or new cardiovascular risk factors to result in significant cardiovascular disease. We summarize the recent evidence about cardiovascular effects of breast cancer therapy and recommendations for their diagnosis and management during the cancer treatment continuum into survivorship. We also present current research initiatives and how they inform clinical care.
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Affiliation(s)
| | - Gemma Reddin
- MedStar Georgetown University Hospital, Washington, DC, USA
| | - Brian Forrestal
- MedStar Washington Hospital Center, Washington, DC, USA.,MedStar Georgetown University Hospital, Washington, DC, USA
| | - Ana Barac
- MedStar Washington Hospital Center, Washington, DC, USA. .,MedStar Georgetown University Hospital, Washington, DC, USA. .,MedStar Heart and Vascular Institute, Georgetown University, Washington, DC, USA.
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91
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Bhat S, Gahungu N, Thavendiranathan P, Dwivedi G. The Role of Echocardiography in Cardio-oncology Patients: Contemporary Indications and Future Directions. CURRENT CARDIOVASCULAR IMAGING REPORTS 2019. [DOI: 10.1007/s12410-019-9519-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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92
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93
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Agunbiade TA, Zaghlol RY, Barac A. Heart Failure in Relation to Tumor-Targeted Therapies and Immunotherapies. Methodist Debakey Cardiovasc J 2019; 15:250-257. [PMID: 31988685 PMCID: PMC6977568 DOI: 10.14797/mdcj-15-4-250] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Tumor-targeted therapies such as trastuzumab have led to significant improvements in survival of human epidermal growth factor receptor 2 (HER2)-positive breast cancer. However, these therapies have also been associated with significant left ventricular dysfunction. The incidence of trastuzumab-induced heart failure has decreased significantly since the initial reports, in large part due to improved screening, closer monitoring for early changes in left ventricular function, and a significant decrease in the concurrent administration of anthracyclines. The mechanism of trastuzumab cardiotoxicity is still not well understood, but current knowledge suggests that ErbB2 inhibition in cardiac myocytes plays a key role. In addition to trastuzumab and other HER2-targeted agents, vascular endothelial growth factor inhibitors, proteasome inhibitors, and immune checkpoint inhibitors are all additional classes of drugs used with great success in the treatment of solid tumors and hematologic malignancies. Yet these, too, have been associated with cardiac toxicity that ranges from a mild asymptomatic decrease in ejection fraction to fulminant myocarditis. In this review, we summarize the cardiotoxic effects of tumor-targeted and immunotherapies with a focus on HER2 antagonists.
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Affiliation(s)
| | - Raja Y Zaghlol
- MEDSTAR WASHINGTON HOSPITAL CENTER, GEORGETOWN UNIVERSITY, WASHINGTON, DC
| | - Ana Barac
- MEDSTAR WASHINGTON HOSPITAL CENTER, GEORGETOWN UNIVERSITY, WASHINGTON, DC
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94
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Wang J, Xu B. Targeted therapeutic options and future perspectives for HER2-positive breast cancer. Signal Transduct Target Ther 2019; 4:34. [PMID: 31637013 PMCID: PMC6799843 DOI: 10.1038/s41392-019-0069-2] [Citation(s) in RCA: 200] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Revised: 08/22/2019] [Accepted: 08/22/2019] [Indexed: 12/12/2022] Open
Abstract
Over the past 2 decades, there has been an extraordinary progress in the regimens developed for the treatment of human epidermal growth factor receptor 2 (HER2)-positive breast cancer. Trastuzumab, pertuzumab, lapatinib, and ado-trastuzumab emtansine (T-DM1) are commonly recommended anti-HER2 target agents by the U.S. Food and Drug Administration. This review summarizes the most significant and updated research on clinical scenarios related to HER2-positive breast cancer management in order to revise the guidelines of everyday clinical practices. In this article, we present the data on anti-HER2 clinical research of neoadjuvant, adjuvant, and metastatic studies from the past 2 decades. We also highlight some of the promising strategies that should be critically considered. Lastly, this review lists some of the ongoing clinical trials, findings of which may soon be available.
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Affiliation(s)
- Jiani Wang
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17, Panjiayuannanli, Chaoyang District, 100021 Beijing, China
| | - Binghe Xu
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17, Panjiayuannanli, Chaoyang District, 100021 Beijing, China
- State Key Laboratory of Molecular Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17, Panjiayuannanli, Chaoyang District, 100021 Beijing, China
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95
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Affiliation(s)
- Richard M. Steingart
- Department of Medicine, Memorial Sloan Kettering Cancer Center and Weill Medical College of Cornell University, New York, New York, USA
| | - Anthony F. Yu
- Department of Medicine, Memorial Sloan Kettering Cancer Center and Weill Medical College of Cornell University, New York, New York, USA
| | - Chau T. Dang
- Department of Medicine, Memorial Sloan Kettering Cancer Center and Weill Medical College of Cornell University, New York, New York, USA
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96
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Barron CC, Tyagi NK, Alhussein MM, Mukherjee SD, Ellis PM, Dhesy-Thind S, Leong DP. Adjuvant Trastuzumab Therapy: Can We Balance Efficacy and Safety? Oncologist 2019; 24:1405-1409. [PMID: 31315962 DOI: 10.1634/theoncologist.2019-0263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 06/06/2019] [Indexed: 01/03/2023] Open
Abstract
Trastuzumab is an effective treatment for HER2-positive breast cancer. Current guidelines recommend withholding trastuzumab in patients experiencing a significant asymptomatic decline in left ventricular function. In this commentary, we discuss the survival benefits afforded by trastuzumab juxtaposed against the risk of trastuzumab-mediated cardiotoxicity. It is not known whether the net benefit of continuing trastuzumab in the setting of mild cardiotoxicity outweighs the associated risks. We describe a potential approach undertaken by our group, and others, and call for a randomized trial.
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Affiliation(s)
- Carly C Barron
- Departments of Medicine, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Nidhi Kumar Tyagi
- Departments of Oncology, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | | | - Som D Mukherjee
- Departments of Oncology, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Peter M Ellis
- Departments of Oncology, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Departments of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Sukhbinder Dhesy-Thind
- Departments of Oncology, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Darryl P Leong
- Departments of Medicine, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Departments of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- The Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
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97
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Leong DP, Cosman T, Alhussein MM, Kumar Tyagi N, Karampatos S, Barron CC, Wright D, Tandon V, Magloire P, Joseph P, Conen D, Devereaux PJ, Ellis PM, Mukherjee SD, Dhesy-Thind S. Safety of Continuing Trastuzumab Despite Mild Cardiotoxicity: A Phase I Trial. JACC: CARDIOONCOLOGY 2019; 1:1-10. [PMID: 34396157 PMCID: PMC8352338 DOI: 10.1016/j.jaccao.2019.06.004] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 06/18/2019] [Accepted: 06/19/2019] [Indexed: 01/03/2023]
Abstract
Objectives This study sought to evaluate the safety of continuing trastuzumab in patients with human epidermal growth factor receptor–positive breast cancer who developed mild cardiotoxicity. Background Cardiotoxicity is the most common dose-limiting toxicity associated with trastuzumab. Current standard of care is discontinuation of trastuzumab, which can lead to worse cancer outcomes. It is unknown whether it is safe to continue trastuzumab despite mild cardiotoxicity. Methods Patients were eligible for this phase I, prospective, single-arm trial if left ventricular ejection fraction (LVEF) was between 40% and the lower limit of normal or if it fell ≥15% from baseline. Participants were treated with angiotensin-converting enzyme (ACE) inhibitors and/or beta-blockers in a cardio-oncology clinic and were followed clinically and with serial echocardiograms for 1 year. The primary outcome was cardiac dose-limiting toxicity, defined as cardiovascular death, LVEF <40% together with any heart failure symptoms, or LVEF <35%. Results All 20 participants received ACE inhibitors and/or beta-blockers. A total of 18 participants (90%) received all planned trastuzumab doses. Two (10%) participants developed cardiac dose-limiting toxicity (heart failure with LVEF <40%). Their LVEF and heart failure symptoms improved to nearly normal following permanent trastuzumab discontinuation. There were no deaths. LVEF rose progressively from a mean of 49% at enrollment to 55% at 12 months (p < 0.001). Conclusions It may be feasible to continue trastuzumab despite mild cardiotoxicity in the setting of a cardio-oncology clinic, where ACE inhibitors and beta-blockers are administered. Approximately 10% of patients may develop moderate to severe heart failure using this approach. (Safety of Continuing Chemotherapy in Overt Left Ventricular Dysfunction Using Antibodies to Human Epidermal Growth Factor Receptor-2 [SCHOLAR]; NCT02907021)
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Affiliation(s)
- Darryl P Leong
- Department of Medicine, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada.,The Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Tammy Cosman
- Department of Medicine, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Muhammad M Alhussein
- Department of Medicine, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Nidhi Kumar Tyagi
- Department of Oncology, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Sarah Karampatos
- The Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Carly C Barron
- Department of Medicine, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Douglas Wright
- Department of Medicine, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Vikas Tandon
- Department of Medicine, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Patrick Magloire
- Department of Medicine, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Philip Joseph
- Department of Medicine, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada.,The Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - David Conen
- Department of Medicine, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada.,The Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - P J Devereaux
- Department of Medicine, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada.,The Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Peter M Ellis
- Department of Oncology, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Som D Mukherjee
- Department of Oncology, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Sukhbinder Dhesy-Thind
- Department of Oncology, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
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