Cardiotoxicity of anticancer treatments: Epidemiology, detection, and management

MicroRNA therapy inhibits hepatoblastoma growth in vivo by targeting β-catenin and Wnt signaling

Hepatoblastoma (HBL) is the most common pediatric liver cancer. In this malignant neoplasm, beta-catenin protein accumulates and increases Wnt signaling due to recurrent activating mutations in the catenin-beta 1 (CTNNB1) gene. Therefore, beta-catenin is a key therapeutic target in HBL. However, controlling beta-catenin production with therapeutic molecules has been challenging. New biological studies could provide alternative therapeutic solutions for the treatment of HBL, especially for advanced tumors and metastatic disease. In this study, we identified microRNAs (miRNAs) that target beta-catenin and block HBL cell proliferation in vitro and tumor growth in vivo. Using our dual-fluorescence-FunREG system, we screened a library of 1,712 miRNA mimics and selected candidates inhibiting CTNNB1 expression through interaction with its untranslated regions. After validating the regulatory effect of nine miRNAs on beta-catenin in HBL cells, we measured their expression in patient samples. Let-7i-3p, miR-449b-3p, miR-624-5p, and miR-885-5p were decreased in tumors compared to normal livers. Moreover, they inhibited HBL cell growth and Wnt signaling activity in vitro partly through beta-catenin down-regulation. Additionally, miR-624-5p induced cell senescence in vitro, blocked experimental HBL growth in vivo, and directly targeted the beta-catenin 3'-untranslated region. Conclusion: Our results shed light on how beta-catenin-regulating miRNAs control HBL progression through Wnt signaling inactivation. In particular, miR-624-5p may constitute a promising candidate for miRNA replacement therapy for HBL patients. (Hepatology Communications 2017;1:168-183).

Comorbidity, physical and mental health among cancer patients and survivors: An Australian population-based study

AIM

To assess the prevalence of comorbidities and measures of physical and mental health among the cancer patients and survivors compared with the general population.

METHODS

Data collected by the Australian Bureau of Statistics from 2011-2012 National Health Survey were utilized for this cross-sectional study. Comparisons were made between adults aged 25 years and over with history of cancer (n = 2170) and those respondents who did not report having had a cancer (n = 11 592) using logistic regression models. Analyses were repeated according to cancer status (current cancer vs. cancer survivor).

RESULTS

People with history of cancer had significantly higher odds of reporting mental and behavioral problems (overall cancer group adjusted odds ratio 1.36, 95 percent confidence interval 1.20-1.54; current cancer 2.53, 1.97-3.27; cancer survivor 1.20, 1.05-1.38), circulatory conditions (overall cancer group 1.25, 1.12-1.39; current cancer 1.38, 1.08-1.76; cancer survivor 1.22, 1.09-1.38), musculoskeletal conditions (overall cancer group 1.37, 1.24-1.52; current cancer 1.66, 1.30-2.12; cancer survivor 1.33, 1.19-1.48) and endocrine system disorders (overall cancer group 1.19, 1.06-1.34; current cancer 1.29, 1.00-1.66; cancer survivor 1.17, 1.04-1.33) compared with the noncancer group. Cancer patients and survivors were more likely to report poor health status, a higher level of distress, and a greater number of chronic conditions compared with the noncancer group.

CONCLUSION

Poor health and comorbidity is more prevalent among cancer patients and survivors than the noncancer population. Our results further support the need to develop models of care that effectively address multiple chronic conditions experienced by the cancer population.

Practices in management of cancer treatment-related cardiovascular toxicity: A cardio-oncology survey

BACKGROUND

Cardiovascular toxicity has become a challenging issue during cancer therapy. Nonetheless, there is a lack of consensual guidelines for their management. We aimed to determine the current practices of oncologists regarding cardiovascular toxicity related to anthracyclines, trastuzumab and angiogenic inhibitors and to gather their opinions on the development of cardio-oncology programs.

METHODS

A cross-sectional declarative study was submitted to French oncologists in the form of an individual, structured questionnaire.

RESULTS

A total of 303 oncologists responded to the survey. Ninety-nine percent of oncologists prescribed cardiotoxic therapies, including anthracyclines (83%), trastuzumab (51%) and other angiogenic inhibitors (64%). The method adopted for managing cardiovascular toxicity was based on guidelines from expert oncology societies for only 35% of oncologists. None was aware of recommendations from expert cardiology societies. Prescription of pre-, peri- and post-therapy cardiovascular assessment was inconsistent and significantly less frequent for all classes of angiogenic inhibitors than for anthracyclines and trastuzumab (P<0.0001). Relative to pre-therapy assessment, post-therapy assessment was prescribed significantly less often for all cancer therapies (P<0.0001). Attitudes regarding the onset of left ventricular dysfunction were much more inconsistent when angiogenic inhibitors were involved. Additionally, the management of hypertension and QT prolongation was also inconsistent. Finally, 88% of oncologists supported projects of cardio-oncology programs development.

CONCLUSIONS

Practices of oncologists are disparate in the field of cardiovascular toxicity. This finding underlines the complexity of managing many different situations and the need for distribution of formal guidelines from oncology and cardiology expert societies. The development of personalized cardio-oncology programs seems essential.

Rationale for Cardio-Oncology Units

With the rapidly rising number of patients surviving cancer, often in the setting of new or pre-existing cardiovascular disease and risk factors, a need has arisen for a specialty within the realm of cardiovascular care that can evaluate and manage these patients along with our colleagues in oncology and hematology. By the same token, all health care providers involved in the care of cancer patients with heart disease must be fully aware of the impact of adverse cardiovascular effects on the survival of these patients. Collaboration is required to mitigate the effect of cardiovascular toxicity associated with these necessary life-saving cancer therapies. The cardio-oncologist plays a pivotal role in bridging the 2 specialties, by creating a comprehensive plan to address the comorbidities as well as to provide guidance on the optimal choice of therapy. In this 3-part review, we will outline: a) the significant impact of cancer therapies on the cardiovascular health of patients with cancer and cancer survivors, b) the advantage of a multidisciplinary team in addressing these cardiovascular complications, and c) the delivery of clinical care to patients with cancer and heart disease.

Early Diagnosis and Prediction of Anticancer Drug-induced Cardiotoxicity: From Cardiac Imaging to "Omics" Technologies

Heart failure due to antineoplastic therapy remains a major cause of morbidity and mortality in oncological patients. These patients often have no prior manifestation of disease. There is therefore a need for accurate identification of individuals at risk of such events before the appearance of clinical manifestations. The present article aims to provide an overview of cardiac imaging as well as new "-omics" technologies, especially with regard to genomics and proteomics as promising tools for the early detection and prediction of cardiotoxicity and individual responses to antineoplastic drugs.

Emerging Cardiac Imaging Modalities for the Early Detection of Cardiotoxicity Due to Anticancer Therapies

The undeniable advances in the field of oncology have finally led to a decrease in overall cancer-related mortality. However, this population of long-term cancer survivors is now facing a shift toward a substantial increase in cardiovascular morbidity and mortality. Because the development of overt cardiotoxicity can be associated with poor outcomes, preclinical identification of cardiac toxicity is important. This will promote early instauration of treatments to prevent overt heart dysfunction and allow oncologists to continue cancer therapy in an uninterrupted manner. Surveillance strategies for the early detection of cardiac injury include cardiac imaging and biomarkers during treatment. In this review, we outline existing cardiac imaging modalities to detect myocardial changes in patients undergoing cancer treatment and in survivors, and their strengths and limitations.

Cardiovascular disease and physical activity in adult cancer survivors: a nested, retrospective study from the Atlantic PATH cohort

PURPOSE

The study aimed to examine the relationship between cardiovascular disease (CVD) and physical activity (PA) levels in cancer survivors (CS).

METHODS

Using a nested, retrospective follow-up design, this study presents the self-reported prevalence of CVD in an Atlantic Canadian population-based cohort of 1526 CS and 6034 age-sex matched, non-cancer controls ranging from 35 to 69 years of age. Univariate and multiple logistic regression models were used to explore the association between CVD and PA.

RESULTS

Overall, CS were 30% more likely to have ever experienced a CVD event than controls (OR = 1.3; 95% CI 1-1.7, p = .07). Survivors were also significantly more likely to report having hypertension (OR = 1.60; 95% CI 1.03-1.3, p = .02) and diabetes (OR = 1.27; 95% CI 1.03-1.16, p = .02). Compared to controls, CS were significantly less likely to engage in high levels of PA. For survivors, compared to those who were least physically active, the odds of having a CVD risk factor was 35% lower for those who were moderately active (OR = 0.65; 95% CI 0.48-0.88) and 45% lower in the most highly active group (OR = 0.55; 95% CI 0.4-0.73). For controls, the odds of having a CVD risk factor was 25% lower for those in the moderately active group (OR = 0.75; 95% CI 0.64-0.88) and 30% lower for those in the high active group (OR = 0.70; 95% CI 0.6-0.81).

CONCLUSION

Low active survivors appear to be at a high risk of CVD-related comorbidity.

IMPLICATIONS FOR CANCER SURVIVORS

PA is associated with lower CVD-related comorbidity in CS, suggesting that interventions directed at increasing PA should be implemented to improve long-term health outcomes.

[Summary of the ESC position paper on cancer treatment and cardiovascular toxicity]

The numbers of survivors of cancer have increased as a consequence of advances in chemotherapy; however, the side effects of cancer treatment have become increasingly more important. The most frequent side effects include cardiovascular complications, which can lead to acute and delayed morbidity and mortality, often many years later. The discipline of cardio-oncology deals with the prevention, diagnostics and treatment of cardiovascular diseases caused by cancer therapy. The most important cardiovascular side effects of cytostatic therapy are heart failure due to myocardial dysfunction (cardiotoxicity), coronary artery disease, valvular disease and ventricular arrhythmia as a result of QT extension. In addition, arterial hypertension, thromboembolic events, pulmonary hypertension, vasculopathy and pericardial complications can also occur. Fundamentally, a strict limitation of risk factors is necessary to minimize the cardiovascular side effects of potentially cardiotoxic therapeutic procedures. Patients with impaired left ventricular function should be identified by echocardiographic examination prior to cardiotoxic chemotherapy. Treatment with beta blockers and angiotensin-converting enzyme (ACE) inhibitors can also be indicated in asymptomatic patients in order to minimize the effects of chemotherapy on myocardial dysfunction. Prophylactic administration of ACE inhibitors and beta blockers during anthracycline chemotherapy can be considered in patients free of cardiac disease.

Extended anti-HER2 therapy in early breast cancer: longer beats shorter?

PURPOSE OF REVIEW

One-year duration of adjuvant trastuzumab is the gold standard since 2005. During the last decade many attempts have been made to both increase and reduce the treatment duration. The purpose of this article is to review the current available evidence regarding alternative anti-HER2 therapy durations in the (neo)adjuvant treatment of HER2-positive localized breast cancer patients.

RECENT FINDINGS

According to the majority of published data, shorter trastuzumab schedule has shown a decreased benefit in the overall HER2 population, whereas extending adjuvant trastuzumab, beyond 1 year, does not improve the outcome and is associated with increased cardiac toxicity. However, new challenging questions are raised by the recent results of ExteNet trial, in which sequential introduction of 1 year neratinib after standard trastumab-based therapy improved the outcome, especially in the estrogen receptor-positive subset of patients.

SUMMARY

To date the standard duration of adjuvant trastuzumab remains 1 year in the adjuvant setting. It is likely that ongoing trials will clarify which patients could benefit from a shorter or a longer treatment. Taking into account patient's specific risk/benefit ratio and new biomarkers, in future, a 'personalized' treatment duration would be warranted.

ACT-ONE - ACTION at last on cancer cachexia by adapting a novel action beta-blocker

Novel action beta-blockers combine many different pharmacological effects. The espindolol exhibits effects through β and central 5-HT1α receptors to demonstrate pro-anabolic, anti-catabolic, and appetite-stimulating actions. In the ACT-ONE trial, espindolol reversed weight loss and improved handgrip strength in patients with cachexia due to non-small cell lung cancer or colorectal cancer. With this trial, another frontier of cachexia management is in sight. Nonetheless, more efficacy and safety data is needed before new therapeutic indications for novel action beta-blockers can be endorsed.

EXercise to prevent AnthrCycline-based Cardio-Toxicity (EXACT) in individuals with breast or hematological cancers: a feasibility study protocol

BACKGROUND

Anthracyclines (AC), widely used and effective anticancer agents, are known to induce both acute and chronic declines in cardiovascular health, ranging in severity from asymptomatic, subclinical dysfunction to substantial cardiomyopathy leading to congestive heart failure and death. There is substantial evidence that physical activity, higher levels of cardiorespiratory fitness, and exercise therapy can help prevent cardiovascular disease. Moreover, animal studies have shown that exercise performed concomitantly with AC treatment may attenuate early cardiac damage that results from AC exposure. Our primary objective is to assess the feasibility of a 12-week aerobic exercise training (AET) program in patients receiving AC-based chemotherapy.

METHODS/DESIGN

This is a prospective, single-arm (pre-post-test design), feasibility study of a supervised 12-week progressive, light-to-moderate to moderate-to-vigorous intensity AET program for patients (18-65 years) receiving AC chemotherapeutic treatment for a primary/non-recurrent breast cancer or hematological malignancy. Both feasibility (e.g., participant recruitment, program adherence, safety) and intervention outcome (e.g., biological markers of cardiotoxicity, aerobic capacity, quality of life) measures will be collected. The AET program will include two, 45-min community-based exercise sessions (treadmill or cycle) per week for a total of 12 weeks. All exercise sessions will be supervised by trained exercise specialists.

DISCUSSION

Data from the EXACT study will be evaluated to determine the need to refine patient recruitment methods and general acceptability of the AET program. Preliminary data on the effects of the AET intervention on pertinent cardiac and health outcomes will also be evaluated and used to inform future studies in terms of the most appropriate outcome measure(s) to adopt and sample size estimation.

TRIAL REGISTRATION

ClinicalTrails.gov, NCT02471053.

Cancer treatment-related cardiac toxicity: prevention, assessment and management

Cancer therapies, especially anthracyclines and monoclonal antibodies, have been linked with increased rates of cardiotoxicity. The development of some cardiac side effects happens over several months, and changes in ejection fraction can be detected long before permanent damage or disability occurs. Advanced heart failure could be averted with better and earlier detection. Methodologies for early detection of cardiac changes include stress echocardiograms, cardiac velocity measurements, radionuclide imaging, cardiac MRI and several potential biomarkers. Many agents have been described for prophylaxis of cardiac events precipitated by cancer therapy. Prophylactic use of beta-blockers and ACE inhibitors may be considered for use with trastuzumab in breast cancer as tolerated. Recovery of cardiac function is possible early after the injury from a cancer therapy. Late complications for coronary artery disease, hypertension and arrhythmia are underappreciated. Treatments for severe cancer therapy-related cardiac complications follow the existing paradigms for congestive heart failure and coronary artery disease, although outcomes for cancer patients differ from outcomes for non-cancer patients.