Different Cardiotoxicity of Palbociclib and Ribociclib in Breast Cancer: Gene Expression and Pharmacological Data Analyses, Biological Basis, and Therapeutic Implications

Effects of NaV1.5 and Rac1 on the Epithelial-Mesenchymal Transition in Breast Cancer

Breast cancer is a disease that seriously endangers the health of women. However, it is difficult to treat due to the emergence of metastasis and drug resistance. Exploring the metastasis mechanism of breast cancer is helpful to aim for the appropriate target. The epithelial-mesenchymal transition (EMT) is an important mechanism of breast cancer metastasis. Sodium channel 1.5(NaV1.5) and the GTPase Rac1 are factors related to the degree of malignancy of breast tumors. The expression of NaV1.5 and the activation of Rac1 are both involved in EMT. In addition, NaV1.5 can change the plasma membrane potential (Vm) by promoting the inflow of Na+ to depolarize the cell membrane, induce the activation of Rac1 and produce a cascade of reactions that lead to EMT in breast cancer cells; this sequence of events further induces the movement, migration and invasion of tumor cells and affects the prognosis of breast cancer patients. In this paper, the roles of NaV1.5 and Rac1 in EMT-mediated breast cancer progression were reviewed.

Emerging cardiovascular toxicity associated with CDK4/6 inhibitors: real-world insights from the FDA adverse event reporting system

Background

Despite the unprecedented advancement of cyclin-dependent kinase 4 and 6 inhibitors (CDK4/6i) in the treatment paradigm for hormone-dependent breast cancer, reports of cardiovascular adverse events (CVAEs) in both pivotal trials and real-world settings have garnered concerns.

Objectives

we aim to profile the incidence, clinical characteristics and risk factors of CVAEs associated CDK4/6i to provide a vigilant reference for cancer management.

Methods

The global disproportionality study was conducted by utilizing safety reports submitted to the FDA adverse event reporting system (FAERS) during the period from January 2015 to September 2024. Reporting odds ratio (ROR) was employed to identify and evaluate emerging CVAEs related to CDK4/6i. Multivariable logistic regression analysis was utilized to explore factors associated with CVAEs following CDK4/6i treatment. Parametric and cumulative distribution was used for the reported time-to-onset analysis.

Results

A total of 4,709 reports of CVAEs were identified with CDK4/6i, of which 4264 (90.5%) were classified as serious and 12.0% were fatal situation. The median onset time of CVAEs with CDK4/6i was 102 days (interquartile range [IQR], 25-374 days). Disproportionality analysis revealed that Abemaciclib was significantly increased signal of venous thromboembolism (ROR = 2.57 [2.24-2.96]), whereas cardiac arrhythmia (ROR = 2.51 [2.13-2.96]) and torsade de pointes/QT prolongation (ROR = 5.7 [5-6.5]) were showed significantly disproportionate for ribociclib. Meanwhile, cerebrovascular accident and thrombosis were showed significant associated with Abemaciclib ribociclib or palbociclib treatment. Some emerging potential CVAEs, such as myocardial infarction and pulmonary edema, were found to be significantly associated with ribociclib and palbociclib. Additionally, age exceeding 65 years and types of CDK4/6i were significant risk factors for the incidence of CDK4/6i-related CVAEs.

Conclusion

CVAEs might occur with a greater frequency in the context of CDK4/6i than had been previously acknowledged. Our study provide an overview of the incidence, characteristics and risk factors of CDK4/6i-related CVAEs, and also uncovered potential CVAEs that were not identified in the clinical trials.

Metabolic reprogramming in cancer therapy-related cardiovascular toxicity: Mechanisms and intervention strategies

Cancer therapy-related cardiovascular toxicity (CTR-CVT) poses a major challenge in managing cancer patients, contributing significantly to morbidity and mortality among survivors. CTR-CVT includes various cardiovascular issues, such as cardiomyopathy, myocardial ischemia, arrhythmias, and vascular dysfunction, which significantly impact patient prognosis and quality of life. Metabolic reprogramming, characterized by disruptions in glucose, lipid, and amino acid metabolism, represents a shared pathophysiological feature of cancer and cardiovascular diseases; however, the precise mechanisms underlying CTR-CVT remain inadequately understood. In recent years, strategies targeting metabolic pathways have shown promise in reducing cardiovascular risks while optimizing cancer treatment efficacy. This review systematically summarizes metabolic reprogramming characteristics in both cancer and cardiovascular diseases, analyzes how anticancer therapies induce cardiovascular toxicity through metabolic alterations, and explores emerging therapeutic strategies targeting metabolic dysregulation. By integrating current research advancements, this review aims to enhance the understanding of CTR-CVT and provide groundwork for the development of safer and more effective cancer approaches.

Cardiovascular Events Associated with CDK4/6 Inhibitors: A Safety Meta-Analysis of Randomized Controlled Trials and a Pharmacovigilance Study of the FAERS Database

BACKGROUND

CDK4/6 inhibitors are highly valued, but the incidence of cardiovascular adverse events (CVAEs) associated with CDK4/6 inhibitors is not clear.

OBJECTIVE

Our aim was therefore to assess the risk of developing CVAEs associated with CDK4/6 inhibitors, by conducting a systematic review and meta-analysis of randomized controlled trials (RCTs), along with a pharmacovigilance study of the FDA Adverse Event Reporting System (FAERS) database.

METHODS

Eligible CVAEs were extracted from the ClinicalTrials.gov registry. A systematic search of electronic databases (PubMed, Embase, Cochrane Library, and important meetings) until 3 September 2023 was conducted. A disproportionality analysis was performed from the first quarter (Q1) of 2013 to Q1 of 2023 using data from the FAERS database. Study heterogeneity was assessed using the I2 statistic. Using Peto odds ratio (Peto OR) and inverse variance methods to calculate the risk and incidence of CVAEs associated with CDK4/6 inhibitors.

RESULTS

In total, 17 RCTs with 23,437 patients were included in our meta-analysis. During the follow-up period of 8.4-34.0 months, CDK4/6 inhibitors significantly increased the risk of CVAEs (Peto OR, 1.86, 95% confidence interval, 1.30-2.68, P < 0.01). The rates of hypertension and QT prolongation were 68.07 (62.87-73.27) and 57.15 (50.83-63.48) per 1000 patients, respectively. Moreover, we identified nine CVAEs that were not reported in RCTs. These included acute coronary syndrome, arrhythmia, lymphoedema, hot flush, vein rupture, thrombophlebitis migrans, embolism venous, angiopathy and intracardiac thrombus, which were found to be strongly correlated with CDK4/6 inhibitors. Furthermore, the risk of CVAEs varied depending on the specific CDK4/6 inhibitors used, its combination with different endocrine therapies, and the patient's treatment stage.

CONCLUSION

CDK4/6 inhibitors increase the risk of CVAEs, some of which may lead to serious consequences. Early recognition and management of CVAEs is of great importance in clinical practice.

REGISTRATION

PROSPERO registration number CRD42023462059.

Comprehensive review of non-invasive-treatment-related cardiovascular toxicity in breast cancer

Cardiovascular toxicity is a significant side effect of breast cancer treatment and has emerged as a leading cause of non-tumor-related deaths among breast cancer survivors, emphasizing the critical need for effective monitoring and management of these complications. As breast cancer remains the most prevalent cancer among women, advancements in survival rates have been achieved through treatments such as chemotherapy, targeted therapy, endocrine therapy, immunotherapy, and radiotherapy. This review provides a comprehensive understanding of the cardiovascular toxicity mechanisms associated with both established and emerging breast cancer therapies, identifies potential therapeutic targets and monitoring strategies, and highlights key deficiencies and challenges in the field. By offering insights into the early detection, prevention, and management of cardiovascular complications, this review aims to guide future research directions and clinical practices, ultimately improving outcomes for breast cancer patients.

Comparative analysis of CDKI-related adverse events in older patients: a real-world data from the FDA adverse event reporting system database

BACKGROUND

Cyclin-dependent kinase 4 and 6 inhibitors (CDKIs) are effective and safe against advanced and metastatic breast cancer; however, limited information is available for older patients. We conducted an analysis of real-world data pertaining to the safety of older patients using the Adverse Event Reporting System (FAERS) database of the FDA.

RESEARCH DESIGN AND METHODS

We performed a disproportionality analysis to evaluate CDKI-related adverse events (AEs) in older adults administered abemaciclib, palbociclib, and ribociclib.

RESULTS

Data were from 2132, 36916, and 4328 case reports on abemaciclib, palbociclib, and ribociclib in older patients, respectively. Disproportionality analysis revealed 242, 295, and 439 drug-AE signals. The numbers of system organ classes (SOC) for abemaciclib, palbociclib, and ribociclib were 25, 27, and 26, respectively. We found several expected AE signals consistent with those in the drug instructions, such as nausea, neutropenia, and fatigue, for all CDKIs. Interstitial lung disease, thromboembolic events, and cardiac toxicity were also noteworthy. Unexpected AE signals, such as acute kidney injury, atrial fibrillation, and memory impairment associated with abemaciclib, ribociclib, and palbociclib, respectively, were identified.

CONCLUSION

Our results aligned with clinical observations, emphasizing possible CDKI-related AEs. Conducting future clinical research is essential to confirm AE-related differences among CDKIs in older individuals.

Atrial Fibrillation and Cancer-Epidemiology, Mechanisms, and Management

Atrial fibrillation (AF) and cancer are increasingly recognized as interrelated conditions, with cancer patients showing elevated incidences of AF, and there is evidence that AF may sometimes precede cancer diagnoses. This comprehensive review investigates the epidemiology, pathophysiology, and management challenges associated with AF in cancer patients. Epidemiologically, several cancers are more closely related to increased rates of AF, including lung, colorectal, gastrointestinal, and hematologic malignancies. Mechanistically, both AF and cancer share pathophysiological pathways centered on inflammation, oxidative stress, and common cardiovascular risk factors, such as hypertension, obesity, and diabetes. The inflammatory microenvironment in tumors, marked by increased cytokines and growth factors, promotes atrial remodeling and AF susceptibility. Elevated reactive oxygen species (ROS) levels, driven by the metabolic demands of cancer, further contribute to atrial fibrosis and structural changes. Moreover, many anticancer treatments exacerbate AF risk. Management of AF in cancer patients presents many unique challenges and requires a multidisciplinary approach. Rate and rhythm control strategies are complicated by potential drug-drug interactions and limited data surrounding early implementation of rhythm control strategies in cancer patients. Interventional approaches such as catheter ablation, though effective in maintaining sinus rhythm, carry significant perioperative risk in patients with malignancy. Stroke prevention with anticoagulants is essential but requires cautious administration to avoid heightened bleeding risks, particularly in patients undergoing chemotherapy. Further, the limited applicability of standard risk stratification tools like CHA2DS2-VASc in this population complicate decisions regarding anticoagulation. This review highlights the bidirectional relationship between AF and cancer, the difficulties in management, and the critical need for further research in this field.

Pharmacokinetics and pharmacogenomics of ribociclib in black patients with metastatic breast cancer the LEANORA study

Underrepresented populations' participation in clinical trials remains limited, and the potential impact of genomic variants on drug metabolism remains elusive. This study aimed to assess the pharmacokinetics (PK) and pharmacogenomics (PGx) of ribociclib in self-identified Black women with hormone receptor-positive (HR+)/human epidermal growth factor receptor 2-negative (HER2) advanced breast cancer. LEANORA (NCT04657679) was a prospective, observational, multicenter cohort study involving 14 Black women. PK and PGx were evaluated using tandem mass spectrometry and PharmacoScan™ microarray (including CYP3A5*3, *6, and *7). CYP3A5 phenotypes varied among participants: 7 poor metabolizers (PM), 6 intermediate metabolizers (IM), and one normal metabolizer (NM). The area under the curve did not significantly differ between PMs (39,230 h*ng/mL) and IM/NMs (43,546 h*ng/mL; p = 0.38). The incidence of adverse events (AEs) was also similar. We found no association between CYP3A5 genotype and ribociclib exposure. Continued efforts are needed to include diverse populations in clinical trials to ensure equitable treatment outcomes.

QTc prolongation across CDK4/6 inhibitors: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Cyclin-dependent kinases (CDK) 4/6 inhibitors have significantly improved outcomes for patients with ER+/HER2- breast cancer. Nevertheless, they differ from each other in terms of chemical, biological, and pharmacological features, as well as toxicity profiles. We aim to determine whether QTc prolongation is caused by CDK4/6i in general or if it is associated with ribociclib only.

METHODS

We systematically searched PubMed, Embase, and Cochrane Library for randomized controlled trials (RCTs) comparing the prevalence of QTc prolongation as an adverse event in HR+ breast cancer patients treated with CDK4/6i vs those without CDK4/6i. We pooled relative risk (RR) and mean difference (MD) with 95% confidence interval (CI) for the binary endpoint of QT prolongation.

RESULTS

We included 14 RCTs comprising 16 196 patients, of whom 8576 underwent therapy with CDK4/6i. An increased risk of QTc prolongation was associated with the use of CDK4/6i (RR = 2.35, 95% CI = 1.67 to 3.29, P < .001; I2 = 44%). Subgroup analyses revealed a significant increase in the QTc interval for the ribociclib and palbociclib cohorts. The ribociclib subgroup showed a relative risk of 3.12 (95% CI = 2.09 to 4.65, P < .001; I2 = 12%), whereas the palbociclib subgroup had a relative risk of 1.51 (95% CI = 1.05 to 2.15, P = .025; I2 = 0%).

CONCLUSION

Palbociclib was associated with QTc prolongation; however, the relative risk for any grade QTc was quantitively twice with ribociclib. Furthermore, grade 3 QTc prolongations were observed exclusively with ribociclib. These results are important for guiding clinical decision-making and provide reassurance regarding the overall safety profile of this drug class.

Pharmacokinetics and Pharmacogenomics of Ribociclib in Black Patients with Metastatic Breast Cancer: The LEANORA study

Underrepresented populations' participation in clinical trials remains limited, and the potential impact of genomic variants on drug metabolism remains elusive. This study aimed to assess the pharmacokinetics (PK) and pharmacogenomics (PGx) of ribociclib in self-identified Black women with hormone receptor-positive (HR+)/human epidermal growth factor receptor 2-negative (HER2) advanced breast cancer. LEANORA (NCT04657679) was a prospective, observational, multicenter cohort study involving 14 Black women. PK and PGx were evaluated using tandem mass spectrometry and PharmacoScan™ microarray (including CYP3A5*3 , *6 , and *7 ). CYP3A5 phenotypes varied among participants: 7 poor metabolizers (PM), 6 intermediate metabolizers (IM), and one normal metabolizer (NM). The area-under-the-curve did not significantly differ between PMs (39,230 hr*ng/mL) and IM/NMs (43,546 hr*ng/mL; p = 0.38). The incidence of adverse events (AEs) was also similar. We found no association between CYP3A5 genotype and ribociclib exposure. Continued efforts are needed to include diverse populations in clinical trials to ensure equitable treatment outcomes.

Cardiac safety of ribociclib evaluated with 24-hour rhythm Holter electrocardiogram

OBJECTIVE

We aimed to evaluate cardiac safety profile of ribociclib with 24-h rhythm Holter ECG.

MATERIAL AND METHOD

Forty-two female metastatic breast cancer patients were included in the study. Rhythm Holter ECG was performed before starting treatment with ribociclib and after 3 months of the treatment initiation.

RESULTS

The mean age of the patients was 56.36 ± 12.73. 52.4% (n = 22) of the patients were using ribociclib in combination with fulvestrant and 47.6% (n = 20) with aromatase inhibitors. None of the patients developed cardiotoxicity. When the rhythm Holter results before and in third month of the treatment were compared, there was no statistically significant difference.

CONCLUSION

This is the first study evaluating effects of ribociclib treatment on cardiac rhythm with Holter ECG. The findings suggested ribociclib has a low risk of causing early cardiotoxicity.

Risk Prediction, Diagnosis and Management of a Breast Cancer Patient with Treatment-Related Cardiovascular Toxicity: An Essential Overview

Breast cancer is amongst the most common invasive cancers in adults. There are established relationships between anti-cancer treatments for breast cancer and cardiovascular side effects. In recent years, novel anti-cancer treatments have been established, as well as the availability of multi-modal cardiac imaging and the sophistication of treatment for cardiac disease. This review provides an in-depth overview regarding the interface of breast cancer and cancer therapy-related cardiovascular toxicity. Specifically, it reviews the pathophysiology of breast cancer, the method of action in therapy-related cardiovascular toxicity from anti-cancer treatment, the use of echocardiography, cardiac CT, MRI, or nuclear medicine as diagnostics, and the current evidence-based treatments available. It is intended to be an all-encompassing review for clinicians caring for patients in this situation.

Cardiovascular complications of ribociclib in breast cancer patients

Cyclin-dependent kinase 4 and 6 (CDK4/6) inhibitors have unprecedentedly advanced hormone-dependent breast cancer treatment paradigm. In the metastatic setting, ribociclib has consistently demonstrated survival benefit in pre-, peri-, and postmenopausal patients, conjugating efficacy with health-related quality of life preservation. Accordingly, the emergence of cardiac and/or vascular adverse events related to this novel targeted agent is gaining significant interest. This narrative review provides an overview of the incidence and spectrum of cardiovascular toxicity, in both clinical trial framework and real-world evidence. The potential pathogenetic mechanism, along with the available diagnostic parameters including biomarkers, and proper management, are also summarized.

First-line CDK4/6 inhibitor-based combinations for HR+/HER2- advanced breast cancer: A Bayesian network meta-analysis

BACKGROUND

International guidelines recommend cyclin-dependent kinase 4/6 inhibitor (CDK4/6i)-based first-line therapy for hormone receptor-positive, human epidermal growth factor receptor 2-negative (HR+/HER2-) advanced breast cancer (ABC). However, direct drug comparisons are lacking. We aimed to identify the most effective and safe therapy through network meta-analysis (NMA).

METHODS

We searched PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials, and OpenGrey up to September 30, 2023. Eligible studies included randomized controlled trials (RCTs) assessing endocrine therapy alone or in combination with CDK4/6i as first-line endocrine treatment for HR+/HER2- ABC patients. The hazard ratios for progression-free survival (PFS) and overall survival (OS) and relative risks for objective response rate and adverse events (AEs) were available in selected trials. We performed a Bayesian NMA following PRISMA guidelines.

RESULTS

Thirteen RCTs, involving 10 treatments, were included. Most studies were at low risk of bias. Regarding PFS, ribociclib+fulvestrant ranked first with a surface under the cumulative ranking curve (SUCRA) of 85.0%, followed by dalpiciclib+nonsteroidal aromatase inhibitor (NSAI) (SUCRA = 78.9%). Considering OS, the top three ranked treatments were ribociclib+fulvestrant (SUCRA = 94.1%), abemaciclib+NSAI (SUCRA = 69.9%), and ribociclib+NSAI (SUCRA = 68.5%). Out of four CDK4/6is, ribociclib minimized the grade 3/4 AEs, while dalpiciclib demonstrated the worst safety. Publication bias could not be ignored in our analyses, and the certainty of evidence was downgraded primarily due to imprecision.

CONCLUSIONS

Ribociclib+fulvestrant probably represents the best option in a first-line setting. When combined with NSAI, dalpiciclib likely showed the best efficacy but the worst safety. Abemaciclib+NSAI and ribociclib+NSAI could also be promising treatments, while palbociclib presented inferiority. (PROSPERO Registration No. CRD42022370271).

Cardiotoxicity of Agents Used in Patients With Breast Cancer

Cancer and cardiovascular diseases are the two major causes of mortality, morbidity, and disability worldwide. The improvement in effective therapeutic options for the management of breast cancer (BC) has led to an increased number of BC survivors, who can experience long-term toxicities from cancer treatments. Adverse events including cardiovascular toxicities must be considered in light of effectiveness of recently approved drugs for BC treatment, including elacestrant, tucatinib, neratinib, olaparib, the immune checkpoint inhibitors, trastuzumab deruxtecan, or sacituzumab govitecan. Many cancer drugs affect the cardiovascular system with a range of clinical manifestations. Prompt diagnosis and treatment as well as a multidisciplinary approach involving a cardio-oncologist is optimal for management of these cardiovascular events.

CDK4/6 inhibitors in the treatment of metastatic breast cancer: Focus on toxicity and safety

The development of oral cyclin-dependent kinases 4 and 6 (CDK4/6) inhibitors, including palbociclib, ribociclib, and abemaciclib, has revolutionized the treatment landscape for patients with hormone-receptor-positive (HR+) and human epidermal growth factor receptor 2 (HER2)-negative metastatic breast cancer (BC). When combined with an aromatase inhibitor or fulvestrant, these agents have been approved as first-line therapy in the metastatic setting. Abemaciclib has also gained FDA approval for patients with HR-positive, HER2-negative, node-positive, early BC at high risk of recurrence. Moreover, ribociclib has recently improved disease-free survival in patients with stage II or III HR+/HER2-negative early BC. CDK4/6 inhibitors have favorable safety profiles. However, the available agents have different toxicity profiles that must be clearly discussed with the patients for optimal clinical decisions. This manuscript aims to review CDK4/6 inhibitor-related treatment-associated adverse events, identify risk factors for intolerable adverse events, and assess their safety in special patient populations such as the elderly and those with renal insufficiency. Enhanced knowledge and understanding of CDK4/6 inhibitor-related toxicities can improve treatment strategies and ultimately enhance patient care.

The CDK4/6 inhibitors biomarker landscape: The most relevant biomarkers of response or resistance for further research and potential clinical utility

Cyclin-Dependent Kinase 4/6 inhibitors (CDK4/6is) in combination with Endocrine Therapy (ET) represent the standard frontline therapy for patients with Hormone Receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-negative metastatic Breast Cancer (mBC). Clinical activity and efficacy of CDK4/6is-based therapies have been proven both in the endocrine sensitive and resistant settings. Therapy resistance eventually underpins clinical progression to any CDK4/6is-based therapies, yet there is a lack of validated molecular biomarkers predictive of either intrinsic or acquired resistance to CDK4/6is in clinical practice. As the "post-CDK4/6is" landscape for the management of HR-positive/HER2-negative mBC is rapidly evolving with the introduction of novel therapies, there is an urgent need for the definition of clinically relevant molecular biomarkers of intrinsic/acquired resistance mechanisms to CDK4/6is. This narrative review outlines the role of currently approved CDK4/6is-based therapies, describes the most relevant molecular biomarkers of CDK4/6is-resistance, and ultimately provides a perspective on the clinical and research scenario.

CDK4/6 inhibitors: basics, pros, and major cons in breast cancer treatment with specific regard to cardiotoxicity - a narrative review

Breast cancer is characterized by the uncontrolled proliferation of breast cells, with a high incidence reported in 2020 to have affected over 2 million women. In recent years, the conventional methods of treating breast cancer have involved radiotherapy and chemotherapy. However, the emergence of CDK4/6 inhibitors has shown potential as a promising cancer therapy. Cyclin-dependent kinases (CDK) inhibitors are a class of molecules that impede the formation of an active kinase complex, thereby hindering its activity and consequently halting the progression of the cell cycle. It was discovered that they have a significant impact on impeding the progression of the cancer. This is evident with the Food and Drug Administration's approval of drugs such as palbociclib, ribociclib, and abemaciclib for hormone receptor-positive metastatic breast cancer in combination with specific endocrine therapies. In spite of enormous success in breast cancer treatment, certain obstacles have emerged, such as therapy resistance, side effects, and most of all, cardiotoxicity. Some of these drawbacks have been successfully overcome by dosage reduction, different combinations of the drugs, and the assessment of each patient's condition and suitability prior to treatment. Yet other drawbacks still require tenacious research, especially certain cases of cardiotoxicities. This article delves into the biological mechanisms of CDK4/6 in the cell cycle and cancer, as well as the clinical advantages and most common adverse events (AEs) associated with CDK4/6 inhibitors. The primary objective of this review is to provide a comprehensive analysis of cardiotoxic AEs and elucidate the underlying pathophysiological mechanisms responsible for the cardiotoxicity of CDK4/6 inhibitors.

Corrected QT Interval (QTc) Diagnostic App for the Oncological Routine: Development Study

BACKGROUND

Numerous antineoplastic drugs such as chemotherapeutics have cardiotoxic side effects and can lead to long QT syndrome (LQTS). When diagnosed and treated in time, the potentially fatal outcomes of LQTS can be prevented. Therefore, regular electrocardiogram (ECG) assessments are critical to ensure patient safety. However, these assessments are associated with patient discomfort and require timely support of the attending oncologist by a cardiologist.

OBJECTIVE

This study aimed to examine whether this approach can be made more efficient and comfortable by a smartphone app (QTc Tracker), supporting single-lead ECG records on site and transferring to a tele-cardiologist for an immediate diagnosis.

METHODS

To evaluate the QTc Tracker, it was implemented in 54 cancer centers in Germany. In total, 266 corrected QT interval (QTc) diagnoses of 122 patients were recorded. Moreover, a questionnaire on routine ECG workflow, turnaround time, and satisfaction (1=best, 6=worst) was answered by the centers before and after the implementation of the QTc Tracker.

RESULTS

Compared to the routine ECG workflow, the QTc Tracker enabled a substantial turnaround time reduction of 98% (mean 2.67, 95% CI 1.72-2.67 h) and even further time efficiency in combination with a cardiologic on-call service (mean 12.10, 95% CI 5.67-18.67 min). Additionally, nurses and patients reported higher satisfaction when using the QTc Tracker. In particular, patients' satisfaction sharply improved from 2.59 (95% CI 2.41-2.88) for the routine ECG workflow to 1.25 (95% CI 0.99-1.51) for the QTc Tracker workflow.

CONCLUSIONS

These results reveal a significant improvement regarding reduced turnaround time and increased user satisfaction. Best patient care might be guaranteed as the exposure of patients with an uncontrolled risk of QTc prolongations can be avoided by using the fast and easy QTc Tracker. In particular, as regular side-effect monitoring, the QTc Tracker app promises more convenience for patients and their physicians. Finally, future studies are needed to empirically test the usability and validity of such mobile ECG assessment methods.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04055493; https://classic.clinicaltrials.gov/ct2/show/NCT04055493.

Radiation therapy in the thoracic region: Radio-induced cardiovascular disease, cardiac delineation and sparing, cardiac dose constraints, and cardiac implantable electronic devices

Radiation therapy in the thoracic region may deliver incidental ionizing radiation to the surrounding healthy structures, including the heart. Radio-induced heart toxicity has long been a concern in breast cancer and Hodgkin's lymphoma and was deemed a long-term event. However, recent data highlight the need to limit the dose to the heart in less favorable thoracic cancers too, such as lung and esophageal cancers in which incidental irradiation led to increased mortality. This article will summarize available cardiac dose constraints in various clinical settings and the types of radio-induced cardiovascular diseases encountered as well as delineation of cardiac subheadings and management of cardiac devices. Although still not completely deciphered, heart dose constraints remain intensively investigated and the mean dose to the heart is no longer the only dosimetric parameter to consider since the left anterior descending artery as well as the left ventricle should also be part of dosimetry constraints.

Adverse Cardiovascular Events Associated With Cyclin-Dependent Kinase 4/6 Inhibitors in Patients With Metastatic Breast Cancer

Background Cyclin-dependent kinase (CDK) 4 and 6 inhibitors have significantly improved survival in patients with hormone receptor-positive metastatic breast cancer. There are few data regarding the epidemiology of cardiovascular adverse events (CVAEs) with these therapies. Methods and Results Using the OneFlorida Data Trust, adult patients without prior cardiovascular disease who received at least 1 CDK4/6 inhibitor were included in the analysis. CVAEs identified from International Classification of Diseases, Ninth and Tenth Revisions (ICD-9/10) codes included hypertension, atrial fibrillation(AF)/atrial flutter (AFL), heart failure/cardiomyopathy, ischemic heart disease, and pericardial disease. Competing risk analysis (Fine-Gray model) was used to determine the association between CDK4/6 inhibitor therapy and incident CVAEs. The effect of CVAEs on all-cause death was studied using Cox proportional hazard models. Propensity-weight analyses were performed to compare these patients to a cohort of patients treated with anthracyclines. A total of 1376 patients treated with CDK4/6 inhibitors were included in the analysis. CVAEs occurred in 24% (35.9 per 100 person-years). CVAEs were slightly higher in patients who received CKD4/6 inhibitors compared with anthracyclines (P=0.063), with higher death rate associated with the development of AF/AFL or cardiomyopathy/heart failure in the CDK4/6 group. The development of cardiomyopathy/heart failure and AF/AFL was associated with increased all-cause death (adjusted hazard ratio [HR], 4.89 [95% CI, 2.98-8.05]; and 5.88 [95% CI, 3.56-9.73], respectively). Conclusions CVAEs may be more common with CDK4/6 inhibitors than previously recognized, with increased death rates in these patients who develop AF/AFL or heart failure. Further research is needed to definitively determine cardiovascular risk associated with these novel anticancer treatments.

New Concepts in Cardio-Oncology

Cancer and cardiovascular disease are the two major causes of morbidity and mortality in worldwide. Discovering new therapeutic agents for the management of breast cancer (BC) has increased the numbers of cancer survivors but with the risk of cardiovascular adverse events (CV-AEs). All drugs can potentially damage the cardiovascular system, with different types of clinical manifestations from ischemic myocardial disease to vasculitis, thrombosis or pericarditis. An early detection of CV-AEs guarantees an earlier treatment, which is associated with better outcomes. Cardio-oncology field enlarged its studies to improve prevention, monitoring and treatment of all cardiotoxic manifestations related to old or modern oncological agents. A multidisciplinary approach with a close partnership between oncologists and cardiologists is essential for an optimal management and therapeutic decision-making. The aim of this chapter is to review all types of cardiotoxic manifestations related to novel and old agents approved for treatment of BC patients including chemotherapy, anti-HER2 agents, cyclin-dependent kinase 4/6 inhibitors, PolyADP-ribose polymerase (PARP) inhibitors, antiangiogenic drugs and immunotherapy. We also focused our discussion on prevention, monitoring, treatment, and management of CV-AEs.

Cardiotoxicity from neoadjuvant targeted treatment for breast cancer prior to surgery

Cancer treatment has been gradually shifting from non-specific cytotoxic agents to molecularly targeted drugs. Breast cancer (BC), a malignant tumor with one of the highest incidence worldwide, has seen a rapid development in terms of targeted therapies, leading to a radical change in the treatment paradigm. However, the use of targeted drugs is accompanied by an increasing rate of deaths due to non-tumor-related causes in BC patients, with cardiovascular complications as the most common cause. Cardiovascular toxicity during antitumor therapy has become a high-risk factor for survival in BC patients. Targeted drug-induced cardiotoxicity exerts a wide range of effects on cardiac structure and function, including conduction disturbances, QT interval prolongation, impaired myocardial contractility, myocardial fibrosis, and hypertrophy, resulting in various clinical manifestations, e.g., arrhythmias, cardiomyopathy, heart failure, and even sudden death. In adult patients, the incidence of antitumor targeted drug-induced cardiotoxicity can reach 50%, and current preclinical evaluation tools are often insufficiently effective in predicting clinical cardiotoxicity. Herein, we reviewed the current status of the occurrence, causative mechanisms, monitoring methods, and progress in the prevention and treatment of cardiotoxicity associated with preoperative neoadjuvant targeted therapy for BC. It supplements the absence of relevant review on the latest research progress of preoperative neoadjuvant targeted therapy for cardiotoxicity, with a view to providing more reference for clinical treatment of BC patients.

Cardiovascular Diseases Following Breast Cancer: Towards a Case-by-Case Assessment Through a Prediction Risk Score Model in 943 Patients

OBJECTIVES

To identify patients at high risk of developing cardiovascular disease through the identification of risk factors among a large population of breast cancer women and to assess the performance of Abdel-Qadir risk prediction model score.

MATERIALS AND METHODS

The medical records and baseline characteristics of all patients/tumors diagnosed with breast cancer from 2010 to 2011 in a French comprehensive cancer center were collected. Cardiovascular events were defined as arterial and cardiac events, atrial fibrillation and venous thromboembolism occurring during the 5-year follow-up. Abdel-Qadir multivariable prediction model for major adverse cardiovascular events were used with the concordance index (c-index) score to assess calibration by comparing predicted risks to observed probabilities.

RESULTS

Among the 943 breast cancer patients included, 83 patients (8.8%) presented with at least one cardiovascular event, leading to a cumulative incidence of 0.07 at 5 years (95% confidence interval [CI], 0.055-0.088). The cumulative incidence of atrial fibrillation at 5 years was 0.01 (95% CI, 0.005-0.018). Factors associated with the occurrence of cardiovascular events were pre-existing cardiovascular diseases including high blood pressure (hazard ratio [HR]=1.78, 95% CI=1.07-2.97, P=0.028), acute coronary syndrome (HR=5.28, 95% CI: 2.16-12.88, P<0.05) and grade 3 Scarff-Blool-Richardson (HR=1.95, 95% CI: 1.21-3.15, P=0.006). With a c-index inferior to 0.7, the Abdel-Qadir score was not fully validated in our population.

CONCLUSION

These findings call for the assessment of the performance of risk prediction models such as Abdel-Qadir score coupled with other factors such as Scarff Bloom and Richardson grading in order to identify patients at high risk of experiencing cardiotoxicity.

Cardiac Toxicity From Adjuvant Targeting Treatment for Breast Cancer Post-Surgery

Breast cancer is one of the most prevalent types of cancers worldwide, especially for females. Surgery is the preferred treatment for breast cancer, and various postoperative adjuvant therapies can be reasonably used according to different pathological characteristics, especially traditional radiotherapy, chemotherapy, and endocrine therapy. In recent years, targeting agent therapy has also become one of the selective breast cancer treatment strategies, including anti-HER-2 drugs, CDK4/6 inhibitor, poly ADP-ribose polymerase inhibitor, PI3K/AKT/mTOR pathway inhibitor, ER targeting drugs, and aromatase inhibitor. Because of the different pathologic mechanisms of these adjuvant therapies, each of the strategies may cause cardiotoxicity in clinic. The cardiac adverse events of traditional endocrine therapy, radiotherapy, and chemotherapy for breast cancer have been widely detected in clinic; however, the targeting therapy agents have been paid more attention with the extension of application. This review will summarize the cardiac toxicity of various adjuvant therapies for breast cancer, especially for targeting drug therapy.

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.

Study on Medication Rules of Traditional Chinese Medicine against Antineoplastic Drug-Induced Cardiotoxicity Based on Network Pharmacology and Data Mining

Methods

The targets of antineoplastic drugs with cardiotoxicity were obtained from the National Center for Biotechnology Information (NCBI) database, China national knowledge infrastructure (CNKI) database, and Swiss Target Prediction platform. Then, the cardiotoxicity-related targets were derived from the Gene Cards, Disgenet, OMIM, and DrugBank databases, as well as the drug of current clinical guidelines. The targets both in these two sets were regarded as potential targets to alleviate ADIC. Then, candidate compounds and herbs were matched via Traditional Chinese Medicine Systems Pharmacology (TCMSP) platform. Cytoscape3.7.1 was used to set up the target-compound-herb network. Molecular docking between core targets and compounds was performed with AutodockVina1.1.2. The rules of herbs were summarized by analyzing their property, flavor, and channel tropism.

Results

Twenty-one potential targets, 332 candidate compounds, and 400 kinds of herbs were obtained. Five core targets including potassium voltage-gated channel subfamily H member 2 (KCNH2), cyclin-dependent kinase 1 (CDK1), matrix metalloproteinase 2 (MMP2), mitogen-activated protein kinase1 (MAPK1), and tumor protein p53 (TP53) and 29 core compounds (beta-sitosterol, quercetin, kaempferol, etc.) were collected. Five core herbs (Yanhusuo, Gouteng, Huangbai, Lianqiao, and Gancao) were identified. Also, the TCM against ADIC were mainly bitter and acrid in taste, warm in property, and distributed to the liver and lung meridians.

Conclusion

TCM against ADIC has great potential. Our study provides a new method and ideas for clinical applications of integrated Chinese and western medicine in treating ADIC.

Exploring treatment with Ribociclib alone or in sequence/combination with Everolimus in ER+HER2-Rb wild-type and knock-down in breast cancer cell lines

Background

Breast cancer (BC) is the second most common type of cancer worldwide. Among targeted therapies for Hormone Receptor-positive (HR⁺) and Human Epidermal growth factor Receptor 2-negative (HER2⁻) BC, the Cyclin-Dependent Kinases (CDK4/6) are targeted by inhibitors such as Ribociclib (Rib); however, resistance to CDK4/6 inhibitors frequently develops. The aim of this work is to assess in vitro activity of Rib and Everolimus (Eve) in HR⁺HER2⁻ MCF-7 and HR⁻HER2⁻BT-549 BC cell lines.

Methods

HR⁺HER2⁻ MCF-7 and HR⁻HER2⁻ BT-549 BC cell lines were treated with increasing concentration of Rib and Eve (up to 80 μg/mL) for 48–72 h. Subsequently, HR⁺HER2⁻ MCF-7 cells were silenced for Retinoblastoma (Rb) gene, and thus, the effect of Rib in sequential or concurrent schedule with Eve for the treatment of both Rb wild type or Rb knock-down MCF-7 in vitro was evaluated. Cell viability of HR⁺HER2⁻ MCF-7cells treated with sequential and concurrent dosing schedule was analyzed by MTT assay. Moreover, cell cycle phases, cell death and senescence were evaluated by cytofluorimetric analysis after treatment with Rib or Eve alone or in combination.

Results

The sequential treatment didn’t produce a significant increase of cytotoxicity, compared to Rib alone. Instead, the cotreatment synergized to increase the cytotoxicity compared to Rib alone. The cotreatment reduced the percentage of cells in S and G2/M phases and induced apoptosis. Rib triggered senescence and Eve completely reversed this effect in Rb wild type BC cells. Rib also showed Rb-independent effects as shown by results in Rb knock-down MCF-7.

Conclusion

Overall, the Rib/Eve concurrent therapy augmented the in vitro cytotoxic effect, compared to Rib/Eve sequential therapy or single treatments.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-020-07619-1.

Characterization of the Synergistic Inhibition of IK(erg) and IK(DR) by Ribociclib, a Cyclin-Dependent Kinase 4/6 Inhibitor

Ribociclib (RIB, LE011, Kisqali^®), an orally administered inhibitor of cyclin-dependent kinase-4/6 (CDK-4/6) complex, is clinically effective for the treatment of several malignancies, including advanced breast cancer. However, information regarding the effects of RIB on membrane ion currents is limited. In this study, the addition of RIB to pituitary tumor (GH₃) cells decreased the peak amplitude of erg-mediated K⁺ current (I_K(erg)), which was accompanied by a slowed deactivation rate of the current. The IC₅₀ value for RIB-perturbed inhibition of deactivating I_K(erg) in these cells was 2.7 μM. In continued presence of μM RIB, neither the subsequent addition of 17β-estradiol (30 μM), phorbol 12-myristate 13-acetate (10 μM), or transforming growth factor-β (1 μM) counteracted the inhibition of deactivating I_K(erg). Its presence affected the decrease in the degree of voltage-dependent hysteresis for I_K(erg) elicitation by long-duration triangular ramp voltage commands. The presence of RIB differentially inhibited the peak or sustained component of delayed rectifier K⁺ current (I_K(DR)) with an effective IC₅₀ of 28.7 or 11.4 μM, respectively, while it concentration-dependently decreased the amplitude of M-type K⁺ current with IC₅₀ of 13.3 μM. Upon 10-s long membrane depolarization, RIB elicited a decrease in the I_K(DR) amplitude, which was concomitant with an accelerated inactivation time course. However, the inability of RIB (10 μM) to modify the magnitude of the hyperpolarization-activated cation current was disclosed. The mean current–voltage relationship of I_K(erg) present in HL-1 atrial cardiomyocytes was inhibited in the presence of RIB (10 μM). Collectively, the hyperpolarization-activated cation current was observed. RIB-mediated perturbations in ionic currents presented herein are upstream of its suppressive action on cytosolic CDK-4/6 activities and partly participates in its modulatory effects on the functional activities of pituitary tumor cells (e.g., GH₃ cells) or cardiac myocytes (e.g., HL-1 cells).

Bullous Skin Rash: A Rare Case of Palbociclib-Induced Dermatological Toxicity

Palbociclib is an FDA-approved cyclin-dependent kinase inhibitor to treat hormone-positive, HER2-negative metastatic breast cancer. Severe skin toxicities are rare but important adverse events associated with these agents. Early detection of severe forms of skin lesions is crucial to permit the immediate discontinuation of palbociclib in order to avoid unacceptable risk level in the form of severe cutaneous toxicities like Steven-Johnson Syndrome. In such cases, palbociclib should be abruptly discontinued and an early aggressive support should be initiated. We here present a case of 50-year-old Caucasian female, who developed acute onset blistering skin lesions one to two weeks after she was started on palbociclib. We sought to report this case given the unusual toxicity and to emphasize the importance of identifying the acute onset of blistering skin lesions, regardless of their extension, should prompt awareness of their potential severity.