Long-term Cardiopulmonary Consequences of Treatment-Induced Cardiotoxicity in Survivors of ERBB2-Positive Breast Cancer

Independent and Incremental Value of ECG Markers for Prediction of Cancer Therapy-Related Cardiac Dysfunction

BACKGROUND

Strategies to estimate risk of cancer therapy-related cardiac dysfunction (CTRCD) before initiating cardiotoxic cancer treatment are needed. We hypothesized that baseline ECG markers could identify patients at risk for CTRCD.

METHODS AND RESULTS

In this retrospective cohort study, 1278 female patients with stage I-III HER2 (human epidermal growth factor receptor 2)-positive breast cancer meeting the following inclusion criteria were included: baseline ECG with QRS <120 milliseconds, baseline echocardiogram, and ≥1 follow-up echocardiogram. Quantitative measurements of ECG waveform parameters were performed using MUSE (GE Healthcare). The primary outcome of interest was CTRCD at 1 year, defined by left ventricular ejection fraction decline (≥10% to <53% or ≥16% from baseline), or clinical heart failure (New York Heart Association class III/IV). Mean age was 51.7±11.1 years, 990 (77%) received anthracyclines, and all received HER2-targeted therapy. CTRCD occurred in 160 (13%) patients. In a multivariable Cox proportional hazards model adjusting for our previously published CTRCD risk score (composed of patient and treatment-specific factors), 4 ECG markers remained independently associated with CTRCD risk: QRS axis, R-wave duration (lead II), ST segment deviation (lead II), and Sokolow-Lyon voltage (all P<0.05). Compared with a model using only clinical CTRCD risk variables, addition of ECG parameters provided incremental value for predicting CTRCD risk (P<0.001, likelihood ratio test) with continuous net reclassification improvement of 34.9% and integrated discrimination improvement of 3.4%.

CONCLUSIONS

Baseline ECG variables are predictive of subsequent CTRCD and provide incremental value to established clinical risk factors for CTRCD risk classification.

Overview of Oncology: Drug-Induced Cardiac Toxicity

Cancer medications can cause cardiac issues, which are difficult to treat in oncologic patients because of the risk of complications. In some cases, this may significantly impact their well-being and treatment outcomes. Overall, these complications fall under the term "drug induced cardiotoxicity", mainly due to chemotherapy drugs being specifically toxic to the heart, causing a decrease in the heart's capacity to pump blood efficiently and leading to a reduction in the left ventricular ejection fraction (LVEF), and subsequently possibly leading to heart failure. Anthracyclines, alkylating agents, and targeted therapies for cancer hold the potential of causing harmful effects on the heart. The incidence of heart-related issues varies from patient to patient and depends on multiple factors, including the type of medication, dosage, duration of the treatment, and pre-existing heart conditions. The underlying mechanism leading to oncologic-drug-induced cardiovascular harmful effects is quite complex. One particular group of drugs, called anthracyclines, have garnered attention due to their impact on oxidative stress and their ability to cause direct harm to heart muscle cells. Reactive oxygen species (ROS) cause harm by inducing damage and programmed cell death in heart cells. Conventional biomarkers alone can only indicate some degree of damage that has already occurred and, therefore, early detection is key. Novel methods like genetic profiling are being developed to detect individuals at risk, prior to the onset of clinical symptoms. Key management strategies-including early detection, personalized medicine approaches, and the use of novel biomarkers-play a crucial role in mitigating cardiotoxicity and improving patient outcomes. Identification of generated genetic alterations and the association to an increased likelihood of cardiotoxicity will allow treatment in a more personalized approach, aiming at decreasing rates of cardiac events while maintaining high oncological efficacy. Oncology drug-induced cardiotoxicity is managed through a combination of preventive strategies and therapeutic interventions from the union of cardiac and oncological knowledge.

Effects of Systemic Anticancer Treatment on Cardiorespiratory Fitness: A Systematic Review and Meta-Analysis

BACKGROUND

Poor cardiorespiratory fitness (CRF) is associated with a higher symptom burden and an increased prevalence of long-term treatment-related cardiovascular disease risk factors in cancer survivors. However, the magnitude of systemic therapy-related CRF impairment remains unclear.

OBJECTIVES

The aim of this study was to evaluate the effects of systemic anticancer treatment on CRF and identify physiological determinants underpinning CRF impairment.

METHODS

A systematic literature search was performed in PubMed, Embase, CINAHL, SPORTDiscus, and the Cochrane Library. The primary endpoint was the change in CRF, measured by peak oxygen consumption (Vo2peak), from before to after systemic treatment. Secondary endpoints included post-treatment differences in Vo2peak between cancer survivors and noncancer control subjects, along with physiological determinants of Vo2peak. Two meta-regressions were conducted to examine the association between CRF and cardiac output and arteriovenous oxygen difference.

RESULTS

A total of 44 studies were included, comprising 27 prospective trials (61%; n = 1,234 cancer survivors, median age 52.4 years) and 17 cross-sectional studies (39%; n = 1,372 cancer survivors, median age 54.0 years; n = 1,923 noncancer control subjects, median age 56.0 years). Systemic anticancer treatment was associated with a significant decrease in Vo2peak (weighted mean difference -2.13 mL·kg-1·min-1; 95% CI: -2.76 to -1.50 mL·kg-1·min-1). No significant differences were observed between patient subgroups (esophagogastric, breast, and colon or rectal cancers). At a median follow-up of 2 years (range: 6 weeks to 12 years) post-therapy, cancer survivors had a significantly lower Vo2peak (weighted mean difference -6.39 mL·kg-1·min-1; 95% CI: -7.60 to -5.18 mL·kg-1·min-1) compared with noncancer control subjects. Reduced arteriovenous oxygen difference was associated with lower Vo2peak (β = 2.55; 95% CI: 2.05-3.06; P < 0.001).

CONCLUSIONS

Systemic anticancer treatment leads to substantial and sustained impairments in CRF.

Association of genetically proxied cancer-targeted drugs with cardiovascular diseases through Mendelian randomization analysis

BACKGROUND

Cancer-targeted therapies are progressively pivotal in oncological care. Observational studies underscore the emergence of cancer therapy-related cardiovascular toxicity (CTR-CVT), impacting patient outcomes. We aimed to investigate the causal relationship between different types of cancer-targeted therapies and cardiovascular disease (CVD) outcomes through a two-sample Mendelian randomization (MR) study.

METHODS

This genome-wide association study was conducted using a two-sample Mendelian randomization framework. Genetic instruments for drug target gene expression were extracted from the eQTLGen consortium (31684 individuals, 37 cohorts). Genome-wide association study (GWAS) summary statistics for 19 cardiovascular diseases were derived from the FinnGen database. Primary analysis was carried out using the summary-data-based MR (SMR) method, with sensitivity analysis for validation. Colocalization analysis identifies shared causal variants between exposure eQTLs and CVD-associated single-nucleotide polymorphisms (SNPs).

RESULTS

Among the 39 drug target genes, 8 were identified with detectable cis-eQTLs and were subsequently validated through positive control analysis for further investigation. In the SMR and sensitivity analyses, genetically proxied VEGFA inhibition showed significantly strong association with stroke (odds ratio [OR] = 1.17, 95% confidence interval [CI] = 1.09-1.26, p = 1.33 × 10- 5). Additionally, the inhibition of FGFR1, FLT1, and MAP2K2 exhibited suggestive association with corresponding cardiovascular disease outcomes. Nevertheless, only VEGFA expression and stroke shared a causal variant (93.6%), whereas FGFR1, MAP2K2, and FLT1 did not share causal variants with corresponding cardiovascular diseases in the colocalization analysis.

CONCLUSIONS

This genetic association study revealed evidence supporting the genetic association between the use of VEGFA inhibitors and increased stroke risk, highlighting the need for enhanced pharmacovigilance. These findings underscore the delicate balance between cardiovascular toxicity risk and the benefits of cancer-targeted therapy.

Clinical, Analytical, and Echocardiographic Associations of Impaired Cardiorespiratory Fitness After Anthracycline Chemotherapy in Breast Cancer: EPIC Fitness Study

PURPOSE

This study explores the effects of anthracycline chemotherapy (AC) on breast cancer patients, focusing on changes in body composition, advanced echocardiographic parameters at rest and during exercise, and biomarkers; and subsequently assesses whether these parameters are associated with impaired cardiorespiratory fitness (CRF).

METHODS

In this prospective study, we evaluated women with early-stage breast cancer undergoing AC at three visits: before AC, 1 month after, and 6 months post-AC.

RESULTS

The study included 32 women with breast cancer, with functional disability increasing from 9.0% pre-AC to 43.8% at 1 month and 53.1% at 6 months post-AC. At 1 month, patients with functional disability exhibited higher rates of cancer therapy-related cardiac dysfunction (CTRCD) (85.7% vs. 55.5%) and, during exercise, showed lower left ventricular ejection fraction (LVEF), reduced contractile reserve and stroke volume (SV); along with elevated IL-6, PlGF, and MPO levels. By 6 months, these patients maintained higher CTRCD rates (35.3% vs. 0%), lower SV and cardiac output (CO), reduced global longitudinal strain (GLS), and decreased global work index (GWI). During exercise, they had lower SV; additionally, they exhibited higher MPO levels and increased body and visceral fat. In our multivariable model: age, body fat, resting GWI, exercise LVEF, and CO were independently associated with VO2peak.

CONCLUSION

Significant and persistent CRF reductions are common in breast cancer patients post-AC. While resting LVEF and GLS were not linked to VO2peak, resting MWI and exercise LVEF and CO were, potentially identifying patients at increased long-term heart failure risk who would benefit from cardioprotective strategies like cardio-oncology rehabilitation. It is important to recognize that impaired CRF is multifactorial, as demonstrated by age and body fat being independently associated with VO2peak, and the impact of non-cardiac factors should be better studied. Our findings highlight the need for further research on CTRCD definition, suggesting that CPET and advanced exercise echocardiography could enhance risk stratification.

Cardiopulmonary Substructure Doses are Not Correlated With Cardiorespiratory Fitness Among Breast Cancer Survivors Treated With Contemporary Radiation Therapy

Purpose

Breast cancer radiation therapy (RT) techniques have historically delivered mean heart doses (MHDs) in the range of 5 Gy, which have been found to predispose patients to cardiopulmonary toxicities. The purpose of this study was to apply artificial intelligence (AI) cardiac substructure auto-segmentation to evaluate the corresponding substructure doses, whether there are laterality- and technique-specific differences in these doses, and if the doses are significantly associated with cardiorespiratory fitness after state-of-the-art RT planning and delivery for breast cancer.

Methods and Materials

Cardiopulmonary substructures were AI auto-segmented. Cardiorespiratory fitness was evaluated at a median of 2.3 (range, 1.1-9.8) years following RT from 2007 to 2021 among 65 breast cancer survivors. The associations between the mean dose to each of the 9 AI auto-segmented cardiopulmonary substructures, the contralateral, and the ipsilateral lung with cardiorespiratory fitness were evaluated using linear regression.

Results

The median MHD was 0.64 Gy (range, 0.12-7.1). Among the auto-segmented substructures, the highest mean doses were observed for the left ventricle (median, 0.88 Gy). The mean dose to each of the 11 structures was significantly higher for women treated with volumetric modulated arc therapy (MHD median, 3.8 Gy vs 0.57 Gy; P < .0001). Women with left-sided breast cancer had significantly higher MHDs (0.97 vs 0.38 Gy; P < .0001) due to higher doses in 3 of 4 cardiac chambers and also due to significantly higher pulmonary artery doses (median, 0.93 vs 0.32 Gy; P = .0003); women with right-sided breast cancer had significantly higher vena cava and right atrium doses (eg, right atrium median, 0.74 vs 0.29 Gy; P = .0002). No cardiopulmonary structure dose was significantly associated with reduced cardiorespiratory fitness after adjusting for age, chemotherapy agent, volumetric modulated arc therapy, RT position, and RT extent.

Conclusions

State-of-the-art breast cancer RT reduces cardiopulmonary dose, and there is a technique and cancer laterality RT dose dependence throughout the cardiopulmonary system.

Frequency of and sex differences in cancer treatment-related cardiac dysfunction in trastuzumab-treated patients with salivary gland cancer: a retrospective cohort study

BACKGROUND

Trastuzumab treatment for salivary gland, gastric, and breast cancer commonly causes cancer treatment-related cardiac dysfunction (CTRCD). CTRCD incidence by sex has not been well studied.

METHODS

This retrospective cohort study investigated frequency of and sex differences in CTRCD in patients with salivary gland cancer treated with trastuzumab at our hospital from April 2017 to March 2022. All patients underwent echocardiography at baseline and after the first, third, and sixth trastuzumab courses. We measured changes in global and regional longitudinal strain (LS) after trastuzumab administration. CTRCD was defined by left ventricular ejection fraction (LVEF) or global LS (GLS). The results were compared by sex.

RESULTS

We recorded clinical data of 49 patients (median age [IQR], 65 [55-71] years; males [75.5%]). The median follow-up period after the sixth trastuzumab course was 120 (111-128) days. One female patient and no male patient had CTRCD defined by LVEF, and two female patients (16.7%) and seven male patients (18.9%) had CTRCD, defined by GLS. The Kaplan-Meier curves showed no significant difference in CTRCD frequency, defined by GLS (log-rank, p = 0.88), between female and male patients. In the univariate analysis, sex was not associated with CTRCD, defined by GLS. A significant difference in apical LS was observed between baseline and the third follow-up results of male patients.

CONCLUSIONS

In this study, CTRCD incidence was not significantly different between male and female patients with salivary gland cancer treated with trastuzumab. Although most previous studies have looked at female patients with breast cancer, a male patient may be found to be at similar risk of myocardial damage.

Exercise-based cardio-oncology rehabilitation for cardiotoxicity prevention during breast cancer chemotherapy: The ONCORE randomized controlled trial

BACKGROUND

Breast cancer (BC) treatment with anthracyclines and/or anti-human epidermal growth factor receptor-2 (HER2) antibodies is associated with an increased risk of cardiovascular disease complications, including cancer therapy-related cardiac dysfunction (CTRCD). While Cardio-Oncology Rehabilitation (CORe) programs including exercise have emerged to minimize these risks, its role in preventing CTRCD is unclear.

OBJECTIVES

We investigated the effectiveness of an exercise-based CORe program in preventing CTRCD [left ventricular ejection fraction (LVEF) drop ≥10% to a value <53% or a decrease >15% in global longitudinal strain (GLS)]. Secondary outcomes examined changes in cardiac biomarkers, physical performance including peak oxygen consumption, psychometric and lifestyle outcomes. Safety, adherence, and patient satisfaction were also assessed.

METHODS

This is a randomized controlled trial including 122 early-stage BC women receiving anthracyclines and/or anti-HER2 antibodies, randomized to CORe (n = 60) or usual care with exercise recommendation (n = 62). Comprehensive assessments were performed at baseline and after cardiotoxic treatment completion. The average duration of the intervention was 5.8 months.

RESULTS

No cases of CTRCD were identified during the study. LVEF decreased in both groups, but was significantly attenuated in the CORe group [-1.5% (-2.9, -0.1); p = 0.006], with no changes detected in GLS or cardiac biomarkers. The CORe intervention led to significant body mass index (BMI) reduction (p = 0.037), especially in obese patients [3.1 kg/m2 (1.3, 4.8)]. Physical performance and quality-of-life remained stable, while physical activity level increased in both groups. No adverse events were detected.

CONCLUSIONS

This study suggests that CORe programs are safe and may help attenuate LVEF decline in BC women receiving cardiotoxic therapy and reduce BMI in obese patients.

Cancer history and physical function in patients with cardiovascular disease

Both cancer and cardiovascular disease (CVD) cause skeletal muscle mass loss, thereby increasing the likelihood of a poor prognosis. We investigated the association between cancer history and physical function and their combined association with prognosis in patients with CVD. We retrospectively reviewed 3,796 patients with CVD (median age: 70 years; interquartile range [IQR]: 61-77 years) who had undergone physical function tests (gait speed and 6-minute walk distance [6MWD]) at discharge. We performed multiple linear regression analyses to assess potential associations between cancer history and physical function. Moreover, Kaplan-Meier curves and Cox regression analyses were used to evaluate prognostic associations in four groups of patients categorized by the absence or presence of cancer history and of high or low physical function. Multiple regression analyses showed that cancer history was significantly and independently associated with a lower gait speed and 6MWD performance. A total of 610 deaths occurred during the follow-up period (median: 3.1 years; IQR: 1.4-5.4 years). The coexistence of low physical function and cancer history in patients with CVD was associated with a significantly higher mortality risk, even after adjusting for covariates (cancer history/low gait speed, hazard ratio [HR]: 1.93, P < 0.001; and cancer history/low 6MWD, HR: 1.61, P = 0.002). Cancer history is associated with low physical function in patients with CVD, and the combination of both factors is associated with a poor prognosis.

Virtual Reality-Based Exercise Rehabilitation in Cancer-Related Dysfunctions: Scoping Review

BACKGROUND

Virtual reality-based exercise rehabilitation (VRER) is a promising intervention for patients with cancer-related dysfunctions (CRDs). However, studies focusing on VRER for CRDs are lacking, and the results are inconsistent.

OBJECTIVE

We aimed to review the application of VRER in patients with CRDs.

METHODS

This scoping review was conducted following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist framework. Publications were included from the time of database establishment to October 14, 2023. The databases were PubMed, Embase, Scopus, Cochrane, Web of Science, ProQuest, arXiv, IEEE Xplore, MedRxiv, CNKI, Wanfang Data, VIP, and SinoMed. The population included patients with cancer. A virtual reality (VR) system or device was required to be provided in exercise rehabilitation as an intervention. Eligible studies focused on VRER used for CRDs. Study selection and data extraction were performed by 2 reviewers independently. Extracted data included authors, year, country, study type, groups, sample size, participant age, cancer type, existing or potential CRDs, VR models and devices, intervention programs and durations, effectiveness, compliance, satisfaction, and safety.

RESULTS

We identified 25 articles, and among these, 12 (48%) were randomized clinical trials, 11 (44%) were other experimental studies, and 2 (8%) were observational studies. The total sample size was 1174 (range 6-136). Among the 25 studies, 22 (88%), 2 (8%), and 1 (4%) included nonimmersive VR, immersive VR, and augmented reality, respectively, which are models of VRER. Commercial game programs (17/25, 68%) were the most popular interventions of VRER, and their duration ranged from 3 to 12 weeks. Using these models and devices, VRER was mostly applied in patients with breast cancer (14/25, 56%), leukemia (8/25, 32%), and lung cancer (3/25, 12%). Furthermore, 6 CRDs were intervened by VRER, and among these, postmastectomy syndromes were the most common (10/25, 40%). Overall, 74% (17/23) of studies reported positive results, including significant improvements in limb function, joint range of motion, edema rates, cognition, respiratory disturbance index, apnea, activities of daily living, and quality of life. The compliance rate ranged from 56% to 100%. Overall, 32% (8/25) of studies reported on patient satisfaction, and of these, 88% (7/8) reported satisfaction with VRER. Moreover, 13% (1/8) reported mild sickness as an adverse event.

CONCLUSIONS

We found that around half of the studies reported using VRER in patients with breast cancer and postmastectomy dysfunctions through nonimmersive models and commercial game programs having durations of 3-12 weeks. In addition, most studies showed that VRER was effective owing to virtualization and interaction. Therefore, VRER may be an alternate intervention for patients with CRDs. However, as the conclusions were drawn from data with acknowledged inconsistencies and limited satisfaction reports, studies with larger sample sizes and more outcome indictors are required.

HER2-Targeted Therapy-From Pathophysiology to Clinical Manifestation: A Narrative Review

Trastuzumab is the primary treatment for all stages of HER2-overexpressing breast cancer in patients. Though discovered over 20 years ago, trastuzumab-induced cardiotoxicity (TIC) remains a research topic in cardio-oncology. This review explores the pathophysiological basis of TIC and its clinical manifestations. Their understanding is paramount for early detection and cardioprotective treatment. Trastuzumab renders cardiomyocytes susceptible by inhibiting the cardioprotective NRG-1/HER2/HER4 signaling pathway. The drug acts on HER2-receptor-expressing cardiomyocytes, endothelium, and cardiac progenitor cells (see the Graphical Abstract). The activation of immune cells, fibroblasts, inflammation, and neurohormonal systems all contribute to the evolution of TIC. A substantial amount of research demonstrates that trastuzumab induces overt and subclinical left ventricular (LV) systolic failure. Data suggest the development of right ventricular damage, LV diastolic dysfunction, and heart failure with preserved ejection fraction. Further research is needed to define a chronological sequence of cardiac impairments to guide the proper timing of cardioprotection implementation.

Nomogram for Predicting Risk of Cancer Therapy-Related Cardiac Dysfunction in Patients With Human Epidermal Growth Factor Receptor 2-Positive Breast Cancer

BACKGROUND

Cancer therapy-related cardiac dysfunction (CTRCD) is an important treatment-limiting toxicity for patients with human epidermal growth factor receptor 2 (HER2)-positive breast cancer that adversely affects cancer and cardiovascular outcomes. Easy-to-use tools that incorporate readily accessible clinical variables for individual estimation of CTRCD risk are needed.

METHODS AND RESULTS

From 2004 to 2013, 1440 patients with stage I to III HER2-positive breast cancer treated with trastuzumab-based therapy were identified. A multivariable Cox proportional hazards model was constructed to identify risk factors for CTRCD and included the 1377 patients in whom data were complete. Nine clinical variables, including age, race, body mass index, left ventricular ejection fraction, systolic blood pressure, coronary artery disease, diabetes, arrhythmia, and anthracycline exposure were built into a nomogram estimating risk of CTRCD at 1 year. The nomogram was validated for calibration and discrimination using bootstrap resampling. A total of 177 CTRCD events occurred within 1 year of HER2-targeted treatment. The nomogram for prediction of 1-year CTRCD probability demonstrated good discrimination, with a concordance index of 0.687. The predicted and observed probabilities of CTRCD were similar, demonstrating good model calibration.

CONCLUSIONS

A nomogram composed of 9 readily accessible clinical variables provides an individualized 1-year risk estimate of CTRCD among women with HER2-positive breast cancer receiving HER2-targeted therapy. This nomogram represents a simple-to-use tool for clinicians and patients that can inform clinical decision-making on breast cancer treatment options, optimal frequency of cardiac surveillance, and role of cardioprotective strategies.

Exploring autonomic modulation: day-to-day recovery after exercise sessions in breast cancer survivors

Purpose

The current study aimed to analyze the changes in heart rate variability (HRV) 24h, 48h and 72h after exercise sessions in breast cancer survivors.

Methods

Sixteen survivors who had undergone chemotherapy and radiotherapy were included. Participants trained resistance and cardiovascular components 3 times per week. The intervention was supervised and delivered online for 4 weeks. In this period, patients measured their HRV daily obtaining the lnrMSSD and lnSDNN values of: day 0 (the morning of the training sessions), 24h, 48h and 72h after exercise.

Results

Significant changes in lnrMSSD (p=0.015) and lnSDNN (p=0.031) during recovery times and lnSDNN during the weeks were found (p=0.015). The most prominent differences were identified between the baseline measurement taken on day 0 and 24h after exercise (p=0.007 and p=0.048, respectively) and between measurements obtained 24h and 48h after the training session (p=0.019 and p=0.026, respectively).

Conclusion

Our study suggests that patients may decrease their lnrMSSD and lnSDNN values 24h after exercise and they were close to recover 48h after the sessions. In this regard, HRV may be an useful tool to monitor their recovery and exercise tolerance.

Cardiotoxicities of Non-Chemotherapeutic Metastatic Breast Cancer Treatments

PURPOSE OF REVIEW

Although mortality rates have declined significantly in recent years, breast cancer remains the second most common cause of cancer death in women, with rates significantly higher among women with metastatic disease. New therapeutic agents have improved the prognosis of patients with metastatic breast cancer but raise concerns around the risk of cardiovascular disease. This review aims to discuss the oncologic treatment of the different subtypes of breast cancer along with the cardiac complications associated with each therapy.

RECENT FINDINGS

This article emphasizes human epidermal growth factor receptor targeted therapies with a focus on incidence of cardiotoxicity, reversibility, long-term outcomes, and management in high-risk patients. This review will address the use of cardiac biomarkers to monitor for toxicity, as well as the utility of cardiac imaging, including global longitudinal strain as a prognostic factor. We will also include recent findings on tyrosine kinase inhibitors, cyclin dependent kinase 4/6, and immune checkpoint inhibitors. Cardiotoxicity may lead to premature discontinuation of novel cancer therapies; optimizing cardiovascular risk factors and close monitoring for cardiotoxicity allow patients to maximize their oncologic and cardiovascular outcomes.

TITAN Trial: A Randomized Controlled Trial of a Cardiac Rehabilitation Care Model in Breast Cancer

Background

Cardiac rehabilitation (CR) modeled care is recommended for patients with breast cancer to mitigate risk of cardiotoxicity. However, the cardiovascular impact of CR-modeled interventions has not been studied.

Objectives

The purpose of this study was to evaluate if a multidisciplinary model of CR reduces cardiotoxicity and improves cardiovascular risk in patients undergoing breast cancer treatment.

Methods

We randomly assigned patients with stage I to III breast cancer scheduled to receive anthracycline and/or trastuzumab-based chemotherapy to the CR intervention (n = 37) or usual care (n = 37). The intervention included guideline-directed management of cardiovascular risk factors, dietary counselling, and supervised exercise for 52 weeks. Cardiac magnetic resonance imaging, cardiopulmonary exercise testing, dual-energy x-ray absorptiometry, and serum biomarkers were acquired at baseline and 52 weeks.

Results

There was no difference in the primary outcome, left ventricular ejection fraction (LVEF), between groups at 52 weeks (61% ± 6%). Other markers of cardiotoxicity, including high-sensitivity troponin I and brain natriuretic peptide, were similar between groups. However, total cholesterol (5.2 ± 0.8 mmol/L to 4.7 ± 0.8 mmol/L, P = 0.002) and low-density lipoprotein (3.0 ± 0.7 mmol/L to 2.4 ± 0.7 mmol/L, P < 0.001) decreased in the intervention group at 52 weeks and were unchanged in usual care. In all patients, adverse cardiac and metabolic changes occurred over 52 weeks including reductions in LVEF, left ventricular mass, high-density lipoprotein, lean body mass, insulin-like growth factor-1, as well as increased triglycerides, whole-body and truncal fat mass (all P < 0.050).

Conclusions

The CR-modeled intervention had no effect on LVEF or biomarkers of cardiotoxicity. Future lifestyle intervention trials in patients with breast cancer should consider targeting other risk factors associated with incident cardiovascular disease. (Multidisciplinary Team IntervenTion in CArdio-ONcology [TITAN Study] [TITAN]; NCT01621659).

Monitoring aerobic capacity in cancer survivors using self-reported questionnaires: criterion validity and responsiveness

BACKGROUND

Evaluating the criterion validity and responsiveness of the self-reported FitMáx©-questionnaire, Duke Activity Status Index (DASI) and Veterans Specific Activity Questionnaire (VSAQ) to monitor aerobic capacity in cancer survivors.

METHODS

Cancer survivors participating in a 10-week supervised exercise program were included. The FitMáx©-questionnaire, DASI, VSAQ and a cardiopulmonary exercise test (CPET) were completed before (T₀) and after (T₁) the program. Intraclass correlation coefficients (ICC) were calculated between VO_2peak estimated by the questionnaires (questionnaire-VO_2peak) and VO_2peak measured during CPET (CPET-VO_2peak), at T₀ to examine criterion validity, and between changes in questionnaire-VO_2peak and CPET-VO_2peak (ΔT₀-T₁) to determine responsiveness. Receiver operating characteristic (ROC) analyses were performed to examine the ability of the questionnaires to detect true improvements (≥ 6%) in CPET-VO_2peak.

RESULTS

Seventy participants were included. Outcomes at T₁ were available for 58 participants (83%). Mean CPET-VO_2peak significantly improved at T₁ (Δ1.6 mL·kg^- 1·min^- 1 or 8%). Agreement between questionnaire-VO_2peak and CPET-VO_2peak at T₀ was moderate for the FitMáx©-questionnaire (ICC = 0.69) and VSAQ (ICC = 0.53), and poor for DASI (ICC = 0.36). Poor agreement was found between ΔCPET-VO_2peak and Δquestionnaire-VO_2peak for all questionnaires (ICC 0.43, 0.19 and 0.18 for the FitMáx©-questionnaire, VSAQ and DASI, respectively). ROC analysis showed that the FitMáx©-questionnaire was able to detect improvements in CPET-VO_2peak (area under the curve, AUC = 0.77), when using a cut-off value of 1.0 mL·kg^- 1·min^- 1, while VSAQ (AUC = 0.66) and DASI (AUC = 0.64) could not.

CONCLUSION

The self-reported FitMáx©-questionnaire has sufficient validity to estimate aerobic capacity in cancer survivors at group level. The responsiveness of the FitMáx©-questionnaire for absolute change is limited, but the questionnaire is able to detect whether aerobic capacity improved. The FitMáx©-questionnaire showed substantial better values of validity and responsiveness compared to DASI and VSAQ.

Part 1: The Clinical Applications of Left Ventricular Myocardial Strain

There is an increasing prevalence of cardiovascular disease and heart failure. Indices of left ventricular (LV) systolic function such as LV ejection fraction used to identify those at risk of adverse cardiac events such as heart failure may not be truly representative of LV systolic function in certain cardiac diseases. Given that LV ejection fraction reduction may represent more advanced irreversible stages of disease, measures of myocardial strain have emerged as a feasible and robust instrument for the early identification of heart disease and subtle LV systolic dysfunction. The purpose of this review was to provide an overview of myocardial strain concepts and emerging clinical applications of global longitudinal strain in cardio-oncology.

Mechanisms of trastuzumab induced cardiotoxicity - is exercise a potential treatment?

The use of the adjuvant therapeutic antibody trastuzumab in breast cancer is associated with a range of cardiotoxic side effects despite successfully reducing the severity of outcomes cancer patients,. The most common cardiac effect, a reduction in left ventricular ejection fraction (LVEF), is a known precursor to heart failure and often requires interruption of chemotherapy to avoid endangering patients further. An understanding of trastuzumab's cardiac-specific interactions is therefore critical in devising new methods to not only avoid permanent cardiac damage, but also prolong treatment time, and therefore effectiveness, for breast cancer patients. Increasingly, the use of exercise as a treatment has been indicated across the field of cardio-oncology due to encouraging evidence that it can protect against LVEF reductions and heart failure. This review explores the mechanisms of trastuzumab-mediated cardiotoxicity, as well as the physiological effects of exercise on the heart, in order to assess the suitability of exercise intervention for breast cancer patients on trastuzumab antibody-therapy. We furthermore draw comparison to existing evidence for exercise intervention as a cardioprotective treatment in doxorubicin-induced cardiotoxicity. Although preclinical evidence seems to support exercise-based approaches also in trastuzumab-cardiotoxicity, current clinical evidence is too limited to confidently recommend it as a treatment, largely owing to issues of adherence. Future studies should therefore examine how the variety and duration of exercise can be adjusted to improve treatment effectiveness at a more personalised level.

Cancer therapeutics-related cardiovascular dysfunction: Basic mechanisms and clinical manifestation

Although recent advances in cancer treatment improve cancer prognosis, cancer therapeutics-related cardiovascular dysfunction (CTRCD) significantly contributes to the global burden of cardiovascular disease. CTRCD causes two crucial issues: first, premature treatment interruption or discontinuation of chemotherapy; second, the development of congestive heart failure during and after cancer treatment. Thus, early detection and prompt treatment of CTRCD may improve the prognosis in cancer patients. This review covers representative anticancer drugs, including anthracyclines, human epidermal growth factor 2 inhibitors, tyrosine kinase inhibitors, proteasome inhibitors, and immune checkpoint inhibitors. We focus on the molecular mechanisms of CTRCD and various approaches to diagnosis, prevention, monitoring, and treatment.

Cardioprotection Using Strain-Guided Management of Potentially Cardiotoxic Cancer Therapy: 3-Year Results of the SUCCOUR Trial

BACKGROUND

Global longitudinal strain (GLS) can predict cancer therapeutics-related cardiac dysfunction and guide initiation of cardioprotection (CPT).

OBJECTIVES

In this study, the authors sought to determine whether echocardiography GLS-guided CPT provides less cardiac dysfunction in survivors of potentially cardiotoxic chemotherapy, compared with usual care at 3 years.

METHODS

In this international multicenter prospective randomized controlled trial, patients were enrolled from 28 international sites. All patients treated with anthracyclines with another risk factor for heart failure were randomly allocated to GLS-guided (>12% relative reduction in GLS) or ejection fraction (EF)-guided (>10% absolute reduction of EF to <55%) CPT. The primary end point was the change in 3-dimensional (3D) EF (ΔEF) from baseline to 3 years.

RESULTS

Among 331 patients enrolled, 255 (77%, age 54 ± 12 years, 95% women) completed 3-year follow-up (123 in the EF-guided group and 132 in the GLS-guided group). Most had breast cancer (n = 236; 93%), and anthracycline followed by trastuzumab was the most common chemotherapy regimen (84%). Although 67 (26%) had hypertension and 32 (13%) had diabetes mellitus, left ventricular function was normal at baseline (EF: 59% ± 6%, GLS: 20.7% ± 2.3%). CPT was administered in 18 patients (14.6%) in the EF-guided group and 41 (31%) in the GLS-guided group (P = 0.03). Most patients showed recovery in EF and GLS after chemotherapy; 3-year ΔEF was -0.03% ± 7.9% in the EF-guided group and -0.02% ± 6.5% in the GLS-guided (P = 0.99) group; respective 3-year EFs were 58% ± 6% and 59% ± 5% (P = 0.06). At 3 years, 17 patients (5%) had cancer therapeutics-related cardiac dysfunction (11 in the EF-guided group and 6 in the GLS guided group; P = 0.16); 1 patient in each group was admitted for heart failure.

CONCLUSIONS

Among patients taking potentially cardiotoxic chemotherapy for cancer, the 3-year data showed improvement of LV dysfunction compared with 1 year, with no difference in ΔEF between GLS- and EF-guided CPT. (Strain Surveillance of Chemotherapy for Improving Cardiovascular Outcomes [SUCCOUR]; ACTRN12614000341628).

Is there a window of opportunity to optimize trastuzumab cardiac monitoring?

BACKGROUND

It remains unclear whether the current arbitrary screening recommendations of trastuzumab-related cardiotoxicity provides an adequate balance between preventing heart damage and curtailing a curative treatment.

AIM

To determine the incidence rate and consequences of trastuzumab-induced cardiotoxicity as adjuvant treatment in a real-world scenario.

METHODS

We present a retrospective analysis of cardiac function measured by echocardiogram at baseline and every 3 mo during trastuzumab treatment. Cardiotoxicity was defined as a drop in left ventricular ejection fraction (LVEF) ≥ 10% from baseline and/or any drop < 50%.

RESULTS

Between January 2011 and December 2014, 407 patients were selected. Most (93.6%) were treated with an anthracycline followed by a taxane-based regimen and trastuzumab for 12 mo. Forty patients (9.8%) had cardiotoxicity. None of them were symptomatic, and 28 (72.5%) completely recovered LVEF. Cardiotoxicity happened early as shown by LVEF measured on echocardiogram 2 to 4 as compared to 5 to 7 (odds ratio = 2.47, 95% confidence interval: 1.09, 5.63, P = 0.024). There were 54 deaths (13.3%) during the 70-mo follow-up period; 1 (0.2%) was attributed to late cardiotoxicity (4 years after treatment). The absence of symptomatic cardiotoxicity during trastuzumab treatment and moreover the early occurrence on the treatment period may translate into a strategy to evaluate less frequently.

CONCLUSION

We observed a 10% rate of asymptomatic cardiotoxicity, which mirrors the results from the large adjuvant trials. Despite being transient, an LVEF drop led to frequent treatment delays and interruptions. It remains unclear whether LVEF decline is predictive of late cardiotoxicity, and treatment efficacy is compromised.

Clinical Manifestations, Monitoring, and Prognosis: A Review of Cardiotoxicity After Antitumor Strategy

The development of various antitumor drugs has significantly improved the survival of patients with cancer. Many first-line chemotherapy drugs are cytotoxic and the cardiotoxicity is one of the most significant effects that could leads to poor prognosis and decreased survival rate. Cancer treatment include traditional anthracycline drugs, as well as some new targeted drugs such as trastuzumab and ICIs. These drugs may directly or indirectly cause cardiovascular injury through different mechanisms, and lead to increasing the risk of cardiovascular disease or accelerating the development of cardiovascular disease. Cardiotoxicity is clinically manifested by arrhythmia, decreased cardiac function, or even sudden death. The cardiotoxicity caused by traditional chemotherapy drugs such as anthracyclines are significantly known. The cardiotoxicity of some new antitumor drugs such like immune checkpoint inhibitors (ICIs) is also relatively clear and requiring further observation and verification. This review is focused on major three drugs with relatively high incidence of cardiotoxicity and poor prognosis and intended to provide an update on the clinical complications and outcomes of these drugs, and we innovatively summarize the monitoring status of survivors using these drugs and discuss the biomarkers and non-invasive imaging features to identify early cardiotoxicity. Finally, we summarize the prevention that decreasing antitumor drugs-induced cardiotoxicity.

Cardio-Oncology Rehabilitation and Telehealth: Rationale for Future Integration in Supportive Care of Cancer Survivors

The direct toxicity of cancer treatment threatens patients and survivors with an increased risk of cardiovascular disease or adverse functional changes with subsequent progression of cardiovascular complications. An accumulation of cardiovascular risk factors combined with an unhealthy lifestyle has recently become more common in cancer patients and survivors. It has been recommended to integrate a comprehensive cardiac rehabilitation model called cardio-oncology rehabilitation to mitigate cardiovascular risk. Nevertheless, cardiac rehabilitation interventions limit barriers in low utilization, further exacerbated by the restrictions associated with the COVID-19 pandemic. Therefore, it is essential to integrate alternative interventions such as telehealth, which can overcome several barriers. This literature review was designed as a framework for developing and evaluating telehealth interventions and mobile applications for comprehensive cardio-oncology rehabilitation. We identify knowledge gaps and propose strategies to facilitate the development and integration of cardio-oncology rehabilitation telehealth as an alternative approach to the standard of care for cancer patients and survivors. Despite the limited evidence, the pilot results from included studies support the feasibility and acceptability of telehealth and mobile technologies in cardio-oncology rehabilitation. This new area suggests that telehealth interventions are feasible and induce physiological and psychological benefits for cancer patients and survivors. There is an assumption that telehealth interventions and exercise may be an effective future alternative approach in supportive cancer care.

Cardioprotection for Anti-HER2 Therapy: Considerations for Primary Prevention and Use in Mildly Reduced Left Ventricular Ejection Fraction

PURPOSE OF REVIEW

This review summarizes current HER2-targeted therapies and clinical studies that have investigated primary and secondary prevention of cardiac dysfunction for HER2 + breast cancer patients undergoing targeted therapy.

RECENT FINDINGS

Primary and secondary prevention clinical trials highlight the importance of cardioprotective measures during HER2 + cancer treatment. Together, these studies suggest the safety of neurohormonal drugs, the importance for an individualized approach in starting cardiopreventive therapies, and the potential to expand HER2 + treatment options to patients with cardiac dysfunction. Cardiac dysfunction is a concerning adverse effect for HER2-targeted treatment. The goal of primary and secondary prevention is to prevent (further) cardiac function decline and heart failure symptoms, while delivering appropriate cancer therapy. Clinical trials investigating preventative therapies in the context of primary and secondary prevention are paving the path for reducing adverse cardiac effects and expanding treatment options for patients previously unable to undergo HER + therapy.

Novel Imaging Biomarkers to Assess Oncologic Treatment-Related Changes

Cancer therapeutics cause various treatment-related changes that may impact patient follow-up and disease monitoring. Although atypical responses such as pseudoprogression may be misinterpreted as treatment nonresponse, other changes, such as hyperprogressive disease seen with immunotherapy, must be recognized early for timely management. Radiation necrosis in the brain is a known response to radiotherapy and must be distinguished from local tumor recurrence. Radiotherapy can also cause adverse effects such as pneumonitis and local tissue toxicity. Systemic therapies, like chemotherapy and targeted therapies, are known to cause long-term cardiovascular effects. Thus, there is a need for robust biomarkers to identify, distinguish, and predict cancer treatment-related changes. Radiomics, which refers to the high-throughput extraction of subvisual features from radiologic images, has been widely explored for disease classification, risk stratification, and treatment-response prediction. Lately, there has been much interest in investigating the role of radiomics to assess oncologic treatment-related changes. We review the utility and various applications of radiomics in identifying and distinguishing atypical responses to treatments, as well as in predicting adverse effects. Although artificial intelligence tools show promise, several challenges-including multi-institutional clinical validation, deployment in health care settings, and artificial-intelligence bias-must be addressed for seamless clinical translation of these tools.

Respiratory Physiotherapy Intervention Strategies in the Sequelae of Breast Cancer Treatment: A Systematic Review

Breast cancer treatments can trigger respiratory sequelae. Respiratory physiotherapy helps to eliminate or mitigate the sequelae by optimizing respiratory function. This systematic review aims to synthesize the scientific evidence and assess its quality regarding the use of respiratory physiotherapy in the sequelae of breast cancer. The Cochrane Library, Physiotherapy Evidence Database, PubMed, Web of Science, Scientific Electronic Library Online, Cumulative Index of Nursing and Allied Literature Complete, and Scopus were searched. Study quality was determined using the PEDro scale, STROBE Statement, and Single-Case Experimental Design Scale. Ten studies, six clinical trials, one case study, and three observational studies were selected. The mean methodological quality of the clinical trials was 5.6, that of the case study was 7, and that of the observational studies was 56%. Respiratory physiotherapy has been observed to improve respiratory capacity, lung function, respiratory muscle strength, effort tolerance, dyspnea, fatigue, thoracic mobility, upper limb volume, sleep quality and quality of life, as well as sensitivity to adverse physiological reactions, nausea, vomiting, and anxiety. However, it is not effective for vasomotor symptoms. More clinical trials are needed. These studies should homogenize the techniques used, as well as improve their methodological quality.

A Combined Echocardiography Approach for the Diagnosis of Cancer Therapy-Related Cardiac Dysfunction in Women With Early-Stage Breast Cancer

IMPORTANCE

Diagnosis of cancer therapy-related cardiac dysfunction (CTRCD) remains a challenge. Cardiovascular magnetic resonance (CMR) provides accurate measurement of left ventricular ejection fraction (LVEF), but access to repeated scans is limited.

OBJECTIVE

To develop a diagnostic model for CTRCD using echocardiographic LVEF and strain and biomarkers, with CMR as the reference standard.

DESIGN, SETTING, AND PARTICIPANTS

In this prospective cohort study, patients were recruited from University of Toronto-affiliated hospitals from November 2013 to January 2019 with all cardiac imaging performed at a single tertiary care center. Women with human epidermal growth factor receptor 2 (HER2)-positive early-stage breast cancer were included. The main exclusion criterion was contraindication to CMR. A total of 160 patients were recruited, 136 of whom completed the study.

EXPOSURES

Sequential therapy with anthracyclines and trastuzumab.

MAIN OUTCOMES AND MEASURES

Patients underwent echocardiography, high-sensitivity troponin I (hsTnI), B-type natriuretic peptide (BNP), and CMR studies preanthracycline and postanthracycline every 3 months during and after trastuzumab therapy. Echocardiographic measures included 2-dimensional (2-D) LVEF, 3-D LVEF, peak systolic global longitudinal strain (GLS), and global circumferential strain (GCS). LVEF CTRCD was defined using the Cardiac Review and Evaluation Committee Criteria, GLS or GCS CTRCD as a greater than 15% relative change, and abnormal hsTnI and BNP as greater than 26 pg/mL and ≥ 35 pg/mL, respectively, at any follow-up point. Combinations of echocardiographic measures and biomarkers were examined to diagnose CMR CTRCD using conditional inference tree models.

RESULTS

Among 136 women (mean [SD] age, 51.1 [9.2] years), CMR-identified CTRCD occurred in 37 (27%), and among those with analyzable images, in 30 of 131 (23%) by 2-D LVEF, 27 of 124 (22%) by 3-D LVEF, 53 of 126 (42%) by GLS, 61 of 123 (50%) by GCS, 32 of 136 (24%) by BNP, and 14 of 136 (10%) by hsTnI. In isolation, 3-D LVEF had greater sensitivity and specificity than 2-D LVEF for CMR CTRCD while GLS had greater sensitivity than 2-D or 3-D LVEF. Regression tree analysis identified a sequential algorithm using 3-D LVEF, GLS, and GCS for the optimal diagnosis of CTRCD (area under the receiver operating characteristic curve, 89.3%). The probability of CTRCD when results for all 3 tests were negative was 1.0%. When 3-D LVEF was replaced by 2-D LVEF in the model, the algorithm still performed well; however, its primary value was to rule out CTRCD. Biomarkers did not improve the ability to diagnose CTRCD.

CONCLUSIONS AND RELEVANCE

Using CMR CTRCD as the reference standard, these data suggest that a sequential approach combining echocardiographic 3-D LVEF with 2-D GLS and 2-D GCS may provide a timely diagnosis of CTRCD during routine CTRCD surveillance with greater accuracy than using these measures individually.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02306538.

Herceptin-Mediated Cardiotoxicity: Assessment by Cardiovascular Magnetic Resonance

Herceptin (trastuzumab) is a recombinant, humanized, monoclonal antibody that targets the human epidermal growth factor receptor 2 (HER2) and is used in the treatment of HER2-positive breast and gastric cancers. However, it carries a risk of cardiotoxicity, manifesting as left ventricular (LV) systolic dysfunction, conventionally assessed for by transthoracic echocardiography. Clinical surveillance of cardiac function and discontinuation of trastuzumab at an early stage of LV systolic dysfunction allow for the timely initiation of heart failure drug therapies that can result in the rapid recovery of cardiac function in most patients. Often considered the reference standard for the noninvasive assessment of cardiac volume and function, cardiac magnetic resonance (CMR) imaging has superior reproducibility and accuracy compared to other noninvasive imaging modalities. However, due to limited availability, it is not routinely used in the serial assessment of cardiac function in patients receiving trastuzumab. In this article, we review the diagnostic and prognostic role of CMR in trastuzumab-mediated cardiotoxicity.

Evaluation of Risk Prediction Models to Identify Cancer Therapeutics Related Cardiac Dysfunction in Women with HER2+ Breast Cancer

Cancer-therapeutics-related cardiac dysfunction (CTRCD) is an important concern in women receiving trastuzumab therapy for HER2+ breast cancer. However, the ability to assess CTRCD risk remains limited. In this retrospective cohort study, we apply three published risk prediction models (Ezaz et al., NSABP-31 cardiac risk scores (CRS), and HFA-ICOS trastuzumab proforma) to 629 women (mean age 52.4 ± 10.9 years) with Stage I-III HER2+ breast cancer treated with trastuzumab ± anthracyclines to assess their performance to identify CTRCD during or immediately post treatment. Using these models, patients were classified into CTRCD risk categories according to the pre-treatment characteristics. With NSABP-31 CRS and HFA-ICOS proformas, patients in the highest risk category had a 1.7-to-2.4-fold higher relative risk of CTRCD than the low-risk category (p = 0.010 and 0.005, respectively). However, with all three risk models, those in the low-risk category had a high absolute risk of CTRCD (15.5–25.5%). The discrimination of the models for CTRCD (AUC 0.51–0.60) and their calibration was limited. NSAP-31 CRS and HFA-ICOS proformas can identify relative differences in CTRCD risk between patients, but when considering absolute risk, they are only able to identify the highest risk patients. There remains an ongoing need for accurate CTRCD risk prediction models in women with HER2+ breast cancer.

Late consequences of chemotherapy on left ventricular function in women with breast cancer

BACKGROUND

Cardiovascular disease is the main cause of death among breast cancer survivors. Several chemotherapy drugs may cause cardiovascular toxicity. Our study aimed to assess the late effects of chemotherapy on left ventricular (LV) systolic and diastolic function in a group of female breast cancer survivors.

METHODS

Our study was a case-control study consisted of 60 breast cancer survivors who had undergone chemotherapy for more than 5 years and a control group of 49 women without breast cancer. All patients underwent echocardiography and left ventricular ejection fraction (LVEF), global longitudinal strain (GLS), pulse-Doppler early transmitral peak flow velocity (E wave), early diastolic (e'), and left atrial (LA) diameter were calculated.

RESULTS

The mean LVEF and GLS were reduced in chemotherapy group (51.63±7.93% vs. 55.37±3.50%, P=0.002 and -17.99±3.27% vs. -19.25±2.27%, P=0.025). Also, the chemotherapy group had a larger left ventricular end-systolic internal diameter than the control group (1.74±0.44cm/m² vs. 1.58±0.22cm/m², P= 0.011). Logistic regression analysis showed among the different cardiovascular risk factors, chemotherapy had an association with decreasing LVEF.

CONCLUSION

Breast cancer survivors might have an excess risk of having subclinical LV dysfunction over time. These findings present the potential benefits of echocardiographic assessment in breast cancer survivors.

In-hospital mortality, length of stay and hospital costs for hospitalized breast cancer patients with comorbid heart failure in the USA

OBJECTIVES

Breast cancer and heart failure (HF) are frequently interconnected due to shared risk factors and the cardiotoxicity of breast cancer treatment. However, the association between HF and hospital outcomes among breast cancer patients has not been studied. This study examined the association between HF and hospital outcomes among hospitalized patients with breast cancer.

METHODS

This cross-sectional study using the 2015-2018 Healthcare Cost and Utilization Project-National Inpatient Sample data included hospitalized women who were aged 18 years or older and had a primary diagnosis code for breast cancer. Logistic regression, negative binomial regression, and generalized linear models with log-link and gamma distribution were used to assess the associations of HF with in-hospital mortality, length of stay (LOS) and hospital costs.

RESULTS

Among 17,335 hospitalized patients with breast cancer, 4.2% (n = 1021) had HF. Compared to breast cancer patients without HF, those with HF were more likely to die during hospitalization (odds ratio = 1.65, 95% CI = 1.27-2.16, p < .001), stay in the hospital longer (incidence rate ratio = 1.22, 95% CI = 1.15-1.30, p < .001) and have higher hospital costs (cost ratio = 1.09, 95% CI = 1.03-1.14, p = .003) during hospitalization, controlling for covariates.

CONCLUSION

HF has a substantial negative impact on health outcomes among hospitalized breast cancer patients. Breast cancer and HF are often considered separate medical conditions, but promoting effective management of comorbid HF in breast cancer patients may help to improve hospital outcomes in this population.

Clinical, Echocardiographic, and Biomarker Associations With Impaired Cardiorespiratory Fitness Early After HER2-Targeted Breast Cancer Therapy

Background

Cardiorespiratory fitness (CRF) is reduced in cancer survivors and predicts cardiovascular disease (CVD)–related and all-cause mortality. However, routine measurement of CRF is not always feasible.

Objectives

The purpose of this study was to identify clinical, cardiac biomarker, and imaging measures associated with reduced peak oxygen consumption (VO₂peak) (measure of CRF) early post–breast cancer therapy to help inform CVD risk.

Methods

Consecutive women with early-stage HER2+ breast cancer receiving anthracyclines and trastuzumab were recruited prospectively. Within 6 ± 2 weeks of trastuzumab completion, we collected clinical information, systolic/diastolic echocardiographic measures, high-sensitivity troponin I, B-type natriuretic peptide, and VO₂peak using a cycle ergometer. Regression models were used to examine the association between VO₂peak and clinical, imaging, and cardiac biomarkers individually and in combination.

Results

Among 147 patients (age 52.2 ± 9.3 years), the mean VO₂peak was 19.1 ± 5.0 mL O₂·kg⁻¹·min⁻¹ (84.2% ± 18.7% of predicted); 44% had a VO₂peak below threshold for functional independence (<18 mL O₂·kg⁻¹·min⁻¹). In multivariable analysis, absolute global longitudinal strain (GLS) (β = 0.58; P = 0.007), age per 10 years (β: -1.61; P = 0.001), and E/e’ (measure of diastolic filling pressures) (β = -0.45; P = 0.038) were associated with VO₂peak. GLS added incremental value in explaining the variability in VO₂peak. The combination of age ≥50 years, E/e’ ≥7.8, and GLS <18% identified a high probability (85.7%) of compromised functional independence, whereas age <50 years, E/e’ <7.8, and GLS ≥18% identified a low probability (0%). High-sensitivity troponin I and B-type natriuretic peptide were not associated with VO₂peak.

Conclusions

Readily available clinical measures were associated with VO₂peak early post–breast cancer therapy. A combination of these parameters had good discrimination to identify patients with compromised functional independence and potentially increased future CVD risk.

Exercise to Reduce Anthracycline-Mediated Cardiovascular Complications in Breast Cancer Survivors

While developments in cancer therapeutics have greatly reduced morbidity and mortality in females with breast cancer, it comes at a cost of an increased risk of cardiovascular complications. In particular, anthracyclines, like doxorubicin, which are a mainstay of current chemotherapy regimens, are associated with dose-dependent cardiotoxicity. Exercise has been widely accepted as an effective intervention in reducing cardiovascular risk in a variety of different clinical conditions. However, the benefits of exercise in anthracycline-mediated cardiotoxicity are not clearly understood. First, this review discusses the pre-clinical studies which have elucidated the cardioprotective mechanisms of aerobic and resistance exercise in improving cardiovascular function in the setting of anthracycline treatment. Next, it aims to summarize the results of aerobic and resistance exercise clinical trials conducted in females with breast cancer who received anthracycline-based chemotherapy. The review further discusses the current exercise guidelines for women undergoing chemotherapy and contraindications for exercise. Finally, the review addresses gaps in research, specifically the need for further clinical trials to establish a recommended exercise prescription within this patient population.

Skeletal Muscle Deconditioning in Breast Cancer Patients Undergoing Chemotherapy: Current Knowledge and Insights From Other Cancers

Breast cancer represents the most commonly diagnosed cancer while neoadjuvant and adjuvant chemotherapies are extensively used in order to reduce tumor development and improve disease-free survival. However, chemotherapy also leads to severe off-target side-effects resulting, together with the tumor itself, in major skeletal muscle deconditioning. This review first focuses on recent advances in both macroscopic changes and cellular mechanisms implicated in skeletal muscle deconditioning of breast cancer patients, particularly as a consequence of the chemotherapy treatment. To date, only six clinical studies used muscle biopsies in breast cancer patients and highlighted several important aspects of muscle deconditioning such as a decrease in muscle fibers cross-sectional area, a dysregulation of protein turnover balance and mitochondrial alterations. However, in comparison with the knowledge accumulated through decades of intensive research with many different animal and human models of muscle atrophy, more studies are necessary to obtain a comprehensive understanding of the cellular processes implicated in breast cancer-mediated muscle deconditioning. This understanding is indeed essential to ultimately lead to the implementation of efficient preventive strategies such as exercise, nutrition or pharmacological treatments. We therefore also discuss potential mechanisms implicated in muscle deconditioning by drawing a parallel with other cancer cachexia models of muscle wasting, both at the pre-clinical and clinical levels.

Anticancer Drug-Induced Cardiotoxicity: Insights and Pharmacogenetics

The advancement in therapy has provided a dramatic improvement in the rate of recovery among cancer patients. However, this improved survival is also associated with enhanced risks for cardiovascular manifestations, including hypertension, arrhythmias, and heart failure. The cardiotoxicity induced by chemotherapy is a life-threatening consequence that restricts the use of several chemotherapy drugs in clinical practice. This article addresses the prevalence of cardiotoxicity mediated by commonly used chemotherapeutic and immunotherapeutic agents. The role of susceptible genes and radiation therapy in the occurrence of cardiotoxicity is also reviewed. This review also emphasizes the protective role of antioxidants and future perspectives in anticancer drug-induced cardiotoxicities.

An overview of cycling as active transportation and as benefit for health

Active transportation is defined as travelling on foot, by bicycle or other non-motorized means, sometimes in combination with other forms of public transportation, in contrast with the use of motor vehicles. The prevalence of sedentary lifestyle and physical inactivity is a growing epidemic in most developed countries that spread over the last three decades; active transportation may be a promising approach to increase physical activity and reduce the risk of non-communicable diseases improving cardiorespiratory fitness and cardiometabolic health. The health benefits of physical activity in reducing mortality and morbidity have been proved by several publications. Cardiorespiratory fitness can be improved by regular physical activity with an amelioration of insulin sensitivity, blood lipid profile, body composition, inflammation, and blood pressure. Active transportation as a daily physical activity is less expensive compared to motor vehicle use. The advantages are remarkable in terms of contrasting obesity and sedentary lifestyle, decrease motor traffic congestion and mitigate climate change. Massive investments in policies and interventions aimed to increase active transportation are not generally promoted and there are differences in the prevalence of active transportation in the daily routine among different areas. As in the literature several studies as randomized trials or observational studies have been published, with different end-points, in order to investigate if active commuting may be the right answer to improve cardiorespiratory fitness and cardiometabolic health, we aimed to review the available evidences of cycling as an active transportation and to consider its benefits on health.

British Society for Echocardiography and British Cardio-Oncology Society guideline for transthoracic echocardiographic assessment of adult cancer patients receiving anthracyclines and/or trastuzumab

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.

BSE and BCOS Guideline for Transthoracic Echocardiographic Assessment of Adult Cancer Patients Receiving Anthracyclines and/or Trastuzumab

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.

Association between physical activity and subsequent cardiovascular disease among 5-year breast cancer survivors

PURPOSE

To examine the association of physical activity among long-term breast cancer survivors on the occurrence of subsequent cardiovascular disease (CVD).

METHODS

We investigated the risk of CVD among 39,775 breast cancer patients who were newly diagnosed in 2006 and survived until 2011 within the Korean National Health Insurance Service database. Patients were followed up from 5 years after breast cancer diagnosis to the date of CVD event, death, or December 31, 2018, whichever came earliest. Every 500 MET-mins/week correspond to 152, 125, and 62.5 min per week of light-, moderate-, and vigorous-intensity physical activity, respectively. Adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for CVD were calculated using Cox proportional hazards regression by physical activity levels.

RESULTS

Compared with those with physical activity of 0 MET-min/week, those with 1-499 (aHR 0.82, 95% CI 0.69-0.98), 500-999 (aHR 0.75, 95% CI 0.63-0.90), and ≥ 1,000 (aHR 0.76, 95% CI 0.63-0.93) MET-min/week of PA had lower risk of CVD. Higher levels of PA were associated with lower risk of stroke (p for trend = 0.016). The benefits of PA on obese and overweight breast cancer survivors were smaller than those in normal weight survivors. The frequency of moderate-to-vigorous physical activity (MVPA) showed a reverse J-curve association with CVD, and the best benefit occurred in the 3-4 times MVPA per week group (aHR 0.59, 95% CI 0.46-0.74).

CONCLUSIONS

The study showed that even small amounts of PA may be beneficial in potentially decreasing the risk of CVD, CHD, and stroke in breast cancer survivors. Our result will be useful to prescribe and delivery exercise among long-term breast cancer survivors.

Strain Imaging in Cardio-Oncology

Echocardiographic imaging is crucial for patient management during cardiotoxic cancer therapy. Left ventricular ejection fraction is the most commonly used parameter for identifying left ventricular dysfunction. However, it lacks sensitivity to detect subclinical changes in cardiac function due to cardiotoxic treatment. Global longitudinal strain (GLS) is the best studied strain parameter with established diagnostic and prognostic value. Multiple studies have demonstrated changes in GLS as an early marker of cardiotoxicity. This document serves as a primer to help clinicians in the acquisition and interpretation of strain in cardio-oncology. Cases with embedded videos illustrate a step-by-step approach to obtaining GLS measurements and common pitfalls to avoid. The document includes a concise summary of the indications of GLS in cardio-oncology and its role in guiding oncological therapy. Practical approaches on how to implement strain in the echo laboratory with guidance on training and quality assurance are also discussed.

Strain-Guided Management of Potentially Cardiotoxic Cancer Therapy

BACKGROUND

In patients at risk of cancer therapy-related cardiac dysfunction (CTRCD), initiation of cardioprotective therapy (CPT) is constrained by the low sensitivity of ejection fraction (EF) for minor changes in left ventricular (LV) function. Global longitudinal strain (GLS) is a robust and sensitive marker of LV dysfunction, but existing observational data have been insufficient to support a routine GLS-guided strategy for CPT.

OBJECTIVES

This study sought to identify whether GLS-guided CPT prevents reduction in LVEF and development of CTRCD in high-risk patients undergoing potentially cardiotoxic chemotherapy, compared with usual care.

METHODS

In this international, multicenter, prospective, randomized controlled trial, 331 anthracycline-treated patients with another heart failure risk factor were randomly allocated to CPT initiation guided by either ≥12% relative reduction in GLS (n = 166) or >10% absolute reduction of LVEF (n = 165). Patients were followed for EF and development of CTRCD (symptomatic EF reduction of >5% or >10% asymptomatic to <55%) over 1 year.

RESULTS

Of 331 randomized patients, 2 died, and 22 withdrew consent or were lost to follow-up. Among 307 patients (age: 54 ± 12 years; 94% women; baseline LVEF: 59 ± 6%; GLS: -20.6 ± 2.4%) with a median (interquartile range) follow-up of 1.02 years (0.98 to 1.07 years), most (n = 278) had breast cancer. Heart failure risk factors were prevalent: 29% had hypertension, and 13% had diabetes mellitus. At the 1-year follow-up, although the primary outcome of change in LVEF was not significantly different between the 2 arms, there was significantly greater use of CPT, and fewer patients met CTRCD criteria in the GLS-guided than the EF-guided arm (5.8% vs. 13.7%; p = 0.02), and the 1-year EF was 57 ± 6% versus 55 ± 7% (p = 0.05). Patients who received CPT in the EF-guided arm had a larger reduction in LVEF at follow-up than in the GLS-guided arm (9.1 ± 10.9% vs. 2.9 ± 7.4%; p = 0.03).

CONCLUSIONS

Although the change in LVEF was not different between the 2 arms as a whole, when patients who received CPT were compared, those in the GLS-guided arm had a significantly lower reduction in LVEF at 1 year follow-up. Furthermore, GLS-guided CPT significantly reduced a meaningful fall of LVEF to the abnormal range. The results support the use of GLS in surveillance for CTRCD. (Strain Surveillance of Chemotherapy for Improving Cardiovascular Outcomes [SUCCOUR]; ACTRN12614000341628).

HER2 Testing for Breast Cancer in the Genomics Laboratory: A Sea Change for Fluorescence In Situ Hybridization

CONTEXT.—

Guidelines for HER2 testing in breast cancer have changed over time, from the US Food and Drug Administration guideline to the American Society of Clinical Oncology (ASCO)/College of American Pathologists (CAP) guidelines published in 2007, 2013, and 2018.

OBJECTIVE.—

To investigate the change in assignment of HER2 status in breast cancers with equivocal (2+) immunohistochemistry (IHC) results by fluorescence in situ hybridization (FISH) following implementation of the ASCO/CAP 2018 guideline.

DESIGN.—

The study included 3556 invasive breast cancers that were HER2 equivocal (2+) by IHC and were submitted to our FISH laboratory after July 2018. Reflex testing (with repeat IHC staining) was performed on certain categories of FISH results known as groups 2, 3, and 4. Concomitant review of IHC and FISH was performed on these reflex cases per 2018 guideline recommendations. The FISH data were analyzed to compare US Food and Drug Administration and ASCO/CAP 2007, 2013, and 2018 interpretations.

RESULTS.—

Of 3548 invasive breast cancers with complete data available, the percentage agreement for FISH according to different guidelines was highest for ASCO/CAP 2018 versus US Food and Drug Administration (96.5%), followed by ASCO/CAP 2018 versus 2007 (93.8%), and lowest with ASCO/CAP 2018 versus 2013 (83.7%). Per the 2018 guideline, reflex IHC testing was performed on 633 breast cancers (17.8%); the majority of reflex testing results were negative (541 of 633; 85.5%). The overall distribution of HER2 FISH results (per the 2018 guideline) was 88.5% negative and 11.5% positive.

CONCLUSIONS.—

By eliminating the equivocal FISH category, the 2018 ASCO/CAP guideline significantly reduced the HER2 FISH-positive rate in tumors with equivocal (2+) IHC results.

Aerobic Exercise-Induced Changes in Cardiorespiratory Fitness in Breast Cancer Patients Receiving Chemotherapy: A Systematic Review and Meta-Analysis

While performing aerobic exercise during chemotherapy has been proven feasible and safe, the efficacy of aerobic training on cardiorespiratory fitness (CRF) in women with breast cancer undergoing chemotherapy has not yet been systematically assessed. Therefore, the objective of this work was to determine (a) the efficacy of aerobic training to improve CRF; (b) the role of aerobic training intensity (moderate or vigorous) on CRF response; (c) the effect of the aerobic training mode (continuous or interval) on changes in CRF in women with breast cancer (BC) receiving chemotherapy. A systematic review and meta-analysis were conducted as per PRISMA guidelines, and randomized controlled trials comparing usual care (UC) and aerobic training in women with BC undergoing chemotherapy were eligible. The results suggest that increases in CRF are favored by (a) aerobic training when compared to usual care; (b) vigorous-intensity aerobic exercise (64–90% of maximal oxygen uptake, VO_2max) when compared to moderate-intensity aerobic exercise (46–63% of VO_2max); and (c) both continuous and interval aerobic training are effective at increasing the VO_2max. Aerobic training improves CRF in women with BC undergoing chemotherapy. Notably, training intensity significantly impacts the VO_2max response. Where appropriate, vigorous intensity aerobic training should be considered for women with BC receiving chemotherapy.

Cardioncological Approach for Trastuzumab Therapy in Breast Cancer Patients With Cardiotoxicity: Impact on Adherence and Clinical Outcome

Background

Treatment with Trastuzumab is associated with cardiotoxicity. If Trastuzumab could be administered in a safe manner to patients who develop a reduced left ventricular ejection fraction (EF) of < 50% remains poorly understood.

Objective

To evaluate the impact of a cardioncological approach in terms of adherence and continuation of oncological therapy with Trastuzumab.

Methods and Results

Internal databases of candidates for trastuzumab chemotherapy with evidence of cardiotoxicity according to echocardiographic criteria were retrospectively evaluated. Eighty-four female patients (age 51.7 years, 95% CI 49.5–53.8), were finally included. Patients were divided to receive a standard (n 27) or cardioncological (n 57) scheme. Baseline EF values were within normal limits (60.9, 95% CI 60 - 61.9%; p=0.5 between groups). The nadir of EF observed during trastuzumab therapy was more pronounced in the standard care group (40.6, 95% CI 37.3–43.9% vs. 46.3, 95% CI 44.3–48.3%; p=0.002). At re-challenge, after cardiotoxicity detection, all patients in the cardioncological arm resumed and completed trastuzumab therapy (p<0.0001). An overall reduction of EF was observed at the final evaluation (p <0.0001 vs. baseline). Cardioncological approach was the only independent determinant of ΔEF from baseline to final evaluation (R²0.12; p=0.004). We observed a total of 13 (15%) HF events, seven (26%) in the standard, and six (10%) in the cardioncological approach group (p =0.1). Patients in the cardioncological approach arm had a better outcome (Log Rank Chi-squared 4.89; p=0.02).

Conclusions

A targeted cardioncological approach, in patients with evidence of cardiotoxicity during HER-2 inhibitor therapy, could favorably influence the oncological management of breast cancer patients, reducing the adverse cardiovascular impact of chemotherapy.