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Hsieh CT, Lee WC, Chiang CJ, Wang CC, Hsu HY, Lin HJ, Yeh TL, Tsai MC, Jhuang JR, Hsiao BY, Chien KL. The Risk of Cancer-Associated and Radiotherapy-Associated Cardiovascular Diseases among Patients with Breast Cancer. Clin Breast Cancer 2024; 24:131-141.e3. [PMID: 38052665 DOI: 10.1016/j.clbc.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 10/17/2023] [Accepted: 11/10/2023] [Indexed: 12/07/2023]
Abstract
BACKGROUND The cardio-related issues should be emphasized as the survival rates of breast cancer increased. We investigated the risk of coronary artery disease (CAD) and stroke due to breast cancer or radiotherapy. METHODS In this retrospective cohort study, breast cancer patients diagnosed between 2007 and 2016 were recruited from Taiwan Cancer Registry Database and were followed until the end of 2018 by linking with the Taiwan National Health Insurance Database. The general population was randomly selected from the whole population in 2007. Standardized incidence ratios (SIR) were calculated to compare the risk of CAD and stroke between patients and the general population. Within the cohort, we included the patients diagnosed between 2011 and 2016. Cox proportional hazards model and subdistribution hazard function were used to investigate the associations of radiotherapy with the risk of CAD and stroke. RESULTS Overall SIR of CAD was 0.82 (95% confidence interval [CI]: 0.78-0.86), while were 1.43 and 1.08 (95% CI: 1.30-1.55 and 1.00-1.16) 1 and 2 years after diagnosis, respectively. Overall SIR of stroke was 0.63 (95% CI: 0.60-0.67), the results were similar after considering the time since diagnosis. The adjusted hazard ratios (HR) for the associations of radiotherapy with CAD and stroke risk were 0.91 (95% [CI] = 0.76-1.09) and 0.84 (95% CI = 0.68-1.04), respectively. The results were similar by using subdistribution hazard function. CONCLUSIONS The risk of CAD was higher within the first 2 years of breast cancer diagnosis. We found no association between radiotherapy and the risk of CAD and stroke.
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Affiliation(s)
- Cheng-Tzu Hsieh
- Department of Epidemiology, University of California, Los Angeles, CA
| | - Wen-Chung Lee
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei City, Taiwan; Taiwan Cancer Registry, Taipei City, Taiwan
| | - Chun-Ju Chiang
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei City, Taiwan; Taiwan Cancer Registry, Taipei City, Taiwan
| | - Chia-Chun Wang
- Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital, Taipei City, Taiwan
| | - Hsin-Yin Hsu
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei City, Taiwan; Department of Family Medicine, Taipei MacKay Memorial Hospital, Taipei City, Taiwan; Department of Medicine, Mackay Medical Collage, New Taipei City, Taiwan
| | - Hung-Ju Lin
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei City, Taiwan; Department of Internal Medicine, National Taiwan University Hospital, Taipei City, Taiwan
| | - Tzu-Lin Yeh
- Department of Family Medicine, Hsinchu MacKay Memorial Hospital, Hsinchu City, Taiwan; Department of Medicine, Mackay Medical Collage, New Taipei City, Taiwan
| | - Ming-Chieh Tsai
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei City, Taiwan; Department of Endocrinology, Department of Internal Medicine, Taipei Mackay Memorial Hospital, Taipei City, Taiwan,; Department of Medicine, Mackay Medical Collage, New Taipei City, Taiwan
| | - Jing-Rong Jhuang
- Institute of Statistical Science, Academia Sinica, Taipei, Taiwan
| | - Bo-Yu Hsiao
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei City, Taiwan
| | - Kuo-Liong Chien
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei City, Taiwan; Department of Internal Medicine, National Taiwan University Hospital, Taipei City, Taiwan; Population Health Research Center, National Taiwan University.
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Sutton AL, Felix AS, Wahl S, Franco RL, Leicht Z, Williams KP, Hundley WG, Sheppard VB. Racial disparities in treatment-related cardiovascular toxicities amongst women with breast cancer: a scoping review. J Cancer Surviv 2023; 17:1596-1605. [PMID: 35420375 DOI: 10.1007/s11764-022-01210-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 04/01/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Black women often experience poorer breast cancer-related outcomes and higher mortality than white women. A contributor to this disparity may relate to the disproportionate burden of cancer treatment-related cardiovascular (CV) toxicities. The objective of this review is to identify studies that report racial differences in CV toxicity risk. METHODS Medline and Embase were searched for studies that assessed CV toxicities as the outcome(s) and included Black and White women with breast cancer. Studies were selected based on inclusion/exclusion criteria and through the use of multiple reviewers. RESULTS The review included 13 studies following a review of 409 citations and 49 full-text articles. All studies were retrospective and 8/13 utilized data from the Surveillance, Epidemiology, and End Results-Medicare linked database. Trastuzumab was the most frequently studied treatment. The proportion of Black women in these studies ranged from 5.5 to 63%. A majority of studies reported a higher risk of CV toxicity amongst Black women when compared to white women (93%). Black women had up to a two times higher risk of CV toxicity (HR, 2.73 (CI, 1.24 to 6.01)) compared to white women. Only one study evaluated the role of socioeconomic factors in explaining racial differences in CV toxicity; however, the disparity remained even after adjusting for these factors. CONCLUSIONS There is a critical need for more longitudinal studies that evaluate multilevel factors (e.g., psychosocial, biological) that may help to explain this disparity. IMPLICATIONS FOR CANCER SURVIVORS Black cancer survivors may require additional surveillance and mitigation strategies to decrease disproportionate burden of CV toxicities.
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Affiliation(s)
- Arnethea L Sutton
- Department of Health Behavior and Policy, School of Medicine, Virginia Commonwealth University, P.O. Box 980149, Richmond, VA, 23219, USA.
| | - Ashley S Felix
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH, USA
| | - Stacey Wahl
- Health Sciences Library, Virginia Commonwealth University, Richmond, VA, USA
| | - R Lee Franco
- Department of Kinesiology and Health Sciences, College of Humanities and Sciences, Virginia Commonwealth University, Richmond, VA, USA
| | - Zachary Leicht
- Department of Kinesiology, School of Education and Human Development, University of Virginia, Charlottesvile, VA, USA
| | | | - W Gregory Hundley
- Pauley Heart Center, Virginia Commonwealth University Health Sciences, Richmond, VA, USA
| | - Vanessa B Sheppard
- Department of Health Behavior and Policy, School of Medicine, Virginia Commonwealth University, P.O. Box 980149, Richmond, VA, 23219, USA
- Office of Health Equity and Disparities Research, Massey Cancer Center, Richmond, VA, USA
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Halpern MT, McNeel TS, Kozono D, Mollica MA. Association of Patient Experience of Care and Radiation Therapy Initiation Among Women With Early-Stage Breast Cancer. Pract Radiat Oncol 2023; 13:434-443. [PMID: 37150319 PMCID: PMC10524855 DOI: 10.1016/j.prro.2023.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 04/11/2023] [Accepted: 04/21/2023] [Indexed: 05/09/2023]
Abstract
PURPOSE For women diagnosed with early-stage breast cancer, lumpectomy followed by radiation therapy (RT) has been a guideline-recommended treatment. However, lumpectomy followed by hormonal therapy is also an approved treatment for certain women. It is unclear what patient-driven factors are related to decisions to receive RT. This study examined relationships between patient-reported experience of care, an important dimension of health care quality, and receipt of RT after lumpectomy. METHODS AND MATERIALS We used National Cancer Institute Surveillance, Epidemiology, and End Results data linked to the CMS Medicare Consumer Assessment of Healthcare Providers and Systems patient surveys (SEER-CAHPS) to examine experiences of care among women diagnosed with local/regional stage breast cancer 2000 to 2017 who received lumpectomy, were enrolled in fee-for-service Medicare, completed a CAHPS survey ≤18 months after diagnosis, and survived for this study period. Experience of care was assessed by patient-provided scores for physicians, doctor communication, care coordination, and other aspects of care. Multivariable logistic regression models assessed associations of receipt of external beam RT with care experience and patient sociodemographic and clinical characteristics. RESULTS The study population included 824 women; 655 (79%) received RT. Women with higher experience of care scores for their personal doctor were significantly more likely to have received any RT (odds ratio [OR], 1.18; P = .033). Nonsignificant trends were observed for associations of increased RT with higher CAHPS measures of doctor communications (OR, 1.15; P = .055) and care coordination (OR, 1.24; P = .051). In contrast, women reporting higher scores for Part D prescription drug plans were significantly less likely to have received RT (OR, 0.78; P = .030). CONCLUSIONS Patient experience of care was significantly associated with receipt of RT after lumpectomy among women with breast cancer. Health care organization leaders may want to consider incorporating experience of care into quality improvement initiatives and other activities that aim to improve patient decision-making, care, and outcomes.
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Affiliation(s)
- Michael T Halpern
- Division of Cancer Control and Populations Sciences, National Cancer Institute, Bethesda, Maryland.
| | | | - David Kozono
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Michelle A Mollica
- Division of Cancer Control and Populations Sciences, National Cancer Institute, Bethesda, Maryland
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Jacobs JEJ, L'Hoyes W, Lauwens L, Yu Y, Brusselmans M, Weltens C, Voigt J, Wildiers H, Neven P, Herrmann J, Thijs L, Staessen JA, Janssens S, Van Aelst LNL. Mortality and Major Adverse Cardiac Events in Patients With Breast Cancer Receiving Radiotherapy: The First Decade. J Am Heart Assoc 2023; 12:e027855. [PMID: 37026536 PMCID: PMC10227262 DOI: 10.1161/jaha.122.027855] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 02/09/2023] [Indexed: 04/08/2023]
Abstract
Background Treatment for breast cancer (BC) frequently involves radiotherapy. Guidelines recommend screening for cardiac adverse events starting 10 years after radiotherapy. The rationale for this interval is unclear. Methods and Results We aimed to study cardiovascular event rates in the first decade following curative radiotherapy for BC. We compared mortality and cardiovascular event rates with an age- and risk factor-matched control population. We included 1095 patients with BC (mean age 56±12 years). Two hundred and eighteen (19.9%) women died. Cancer and cardiovascular mortality caused 107 (49.1%) and 22 (10.1%) deaths, respectively. A total of 904 cases were matched to female FLEMENGHO (Flemish Study on Environment, Genes and Health Outcomes) participants. Coronary artery disease incidence was similar (risk ratio [RR], 0.75 [95% CI, 0.48-1.18]), yet heart failure (RR, 1.97 [95% CI, 1.19-3.25]) and atrial fibrillation/flutter (RR, 1.82 [95% CI, 1.07-3.08]) occurred more often in patients with BC. Age (hazard ratio [HR], 1.033 [95% CI, 1.006-1.061], P=0.016), tumor grade (HR, 1.739 [95% CI, 1.166-2.591], P=0.007), and neoadjuvant treatment setting (HR, 2.782 [95% CI, 1.304-5.936], P=0.008) were risk factors for mortality. Risk factors for major adverse cardiac events were age (HR, 1.053 [95% CI, 1.013-1.093]; P=0.008), mean heart dose (HR, 1.093 [95% CI, 1.025-1.167]; P=0.007), history of cardiovascular disease (HR, 2.386 [95% CI, 1.096-6.197]; P=0.029) and Mayo Clinic Cardiotoxicity Risk Score (HR, 2.664 [95% CI, 1.625-4.367]; P<0.001). Conclusions Ten-year mortality following curative treatment for unilateral BC was mainly cancer related, but heart failure and atrial fibrillation/flutter were already common in the first decade following irradiation. Mean heart dose, pre-existing cardiovascular diseases, and Mayo Clinic Cardiotoxicity Risk Score were risk factors for cardiac adverse events. These results suggest a need for early dedicated cardio-oncological follow-up after radiotherapy.
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Affiliation(s)
- Johanna E. J. Jacobs
- Department of Cardiovascular DiseasesUniversity Hospitals (UZ) LeuvenLeuvenBelgium
| | - Wouter L'Hoyes
- Department of Cardiovascular DiseasesUniversity Hospitals (UZ) LeuvenLeuvenBelgium
| | - Lieselotte Lauwens
- Department of Radiation OncologyUniversity Hospitals (UZ) LeuvenLeuvenBelgium
| | - Yu‐Ling Yu
- Research Unit Environment and Health, KU Leuven Department of Public Health and Primary CareUniversity of LeuvenLeuvenBelgium
- Non‐Profit Research Association Alliance for the Promotion of Preventive Medicine (APPREMED)MechelenBelgium
| | - Marius Brusselmans
- Leuven Biostatistics and Statistical Bioinformatics Centre (L‐Biostat)LeuvenBelgium
| | - Caroline Weltens
- Department of Radiation OncologyUniversity Hospitals (UZ) LeuvenLeuvenBelgium
| | - Jens‐Uwe Voigt
- Department of Cardiovascular DiseasesUniversity Hospitals (UZ) LeuvenLeuvenBelgium
| | - Hans Wildiers
- Department of Medical OncologyUniversity Hospitals (UZ) LeuvenLeuvenBelgium
| | - Patrick Neven
- Department of GynaecologyUniversity Hospitals (UZ) LeuvenLeuvenBelgium
| | | | - Lutgarde Thijs
- Department of Cardiovascular DiseasesUniversity Hospitals (UZ) LeuvenLeuvenBelgium
| | - Jan A. Staessen
- Non‐Profit Research Association Alliance for the Promotion of Preventive Medicine (APPREMED)MechelenBelgium
- Biomedical Science Group, Faculty of MedicineUniversity of LeuvenLeuvenBelgium
| | - Stefan Janssens
- Department of Cardiovascular DiseasesUniversity Hospitals (UZ) LeuvenLeuvenBelgium
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5
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A retrospective study in tumour characteristics and clinical outcomes of overweight and obese women with breast cancer. Breast Cancer Res Treat 2023; 198:89-101. [PMID: 36576677 PMCID: PMC9883351 DOI: 10.1007/s10549-022-06836-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 12/02/2022] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Obesity and breast cancer are two major pathologies closely associated with increasing incidence and mortality rates, especially amongst women. The association between both diseases have been thoroughly discussed but much is still to uncover. AIM The aim of this study is to analyse tumour characteristics and clinical outcomes of overweight and obese women to disclosure potential associations and better understand the impact of obesity in breast cancer. MATERIALS AND METHODS Clinicopathological information of 2246 women were extracted from the institutional database of comprehensive cancer centre in Portugal diagnosed between 2012 and 2016. Women were stratified according to body mass index as normal, overweight, and obese. Patients' demographic information and tumour features (age, family history, topographic localization, laterality, histological type, and receptor status) were taken as independent variables and overall survival, tumour stage, differentiation grade and bilaterality were considered clinical outcomes. RESULTS The main results reveal that overweight and obesity are predominantly associated with worse outcomes in breast cancer patients. Obese patients present larger (p-value: 0.002; OR 1.422; 95% CI 1.134-1.783) and more poorly differentiated tumours (p-value: 0.002; OR 1.480; 95% CI 1.154-1.898) and tend to have lower overall survival although without statistical significance (p-value: 0.117; OR 1.309; 95% CI 0.934-1.833). Overweighted women are more likely to have bilateral breast cancer (p-value: 0.017; OR 3.076; 95% CI 1.225-7.722) than obese women. The results also reveal that overweight women present less distant metastasis (p-value: 0.024; OR 0.525; 95%CI 0.299-0.920). Topographic localization and laterality did not achieve statistical significance.
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Abdelkarem OAI, Choudhury A, Burnet NG, Summersgill HR, West CML. Effect of Race and Ethnicity on Risk of Radiotherapy Toxicity and Implications for Radiogenomics. Clin Oncol (R Coll Radiol) 2022; 34:653-669. [PMID: 35431121 DOI: 10.1016/j.clon.2022.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 02/21/2022] [Accepted: 03/16/2022] [Indexed: 11/03/2022]
Abstract
AIMS Patient factors affect the risk of radiotherapy toxicity, but many are poorly defined. Studies have shown that race affects cancer incidence, survival, drug response, molecular pathways and epigenetics. Effects on radiosensitivity and radiotherapy toxicity are not well studied. The aim of the present study was to identify the effects of race and ethnicity on the risk of radiotherapy toxicity. MATERIALS AND METHODS A systematic review was carried out of PubMed, Ovid Medline and Ovid Embase with no year limit. PRISMA 2020 guidelines were followed. Two independent assessors reviewed papers. RESULTS Of 607 papers screened, 46 fulfilled the inclusion criteria. Papers were published between 1996 and 2021 and involved 30-28,354 individuals (median 433). Most involved patients with prostate (33%), breast (26%) and lung (9%) cancer. Both early and late toxicities were studied. Some studies reported a higher risk of toxicity in White men with prostate cancer compared with other races and ethnicities. For breast cancer patients, some reported an increased risk of toxicity in White women compared with other race and ethnic groups. In general, it was difficult to draw conclusions due to insufficient reporting and analysis of race and ethnicity in published literature. CONCLUSIONS Reporting of race and ethnicity in radiotherapy studies must be harmonised and improved and frameworks are needed to improve the quality of reporting. Further research is needed to understand how ancestral heritage might affect radiosensitivity and risk of radiotherapy toxicity.
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Affiliation(s)
- O A I Abdelkarem
- Chemical Pathology Department, Medical Research Institute, Alexandria University, Alexandria, Egypt; Translational Radiobiology Group, Division of Cancer Sciences, Manchester Academic Health Science Centre, The University of Manchester, Christie Hospital NHS Foundation Trust, Manchester, UK
| | - A Choudhury
- Proton Beam Therapy Centre, The Christie NHS Foundation Trust, Manchester, UK
| | - N G Burnet
- Proton Beam Therapy Centre, The Christie NHS Foundation Trust, Manchester, UK
| | - H R Summersgill
- Translational Radiobiology Group, Division of Cancer Sciences, Manchester Academic Health Science Centre, The University of Manchester, Christie Hospital NHS Foundation Trust, Manchester, UK
| | - C M L West
- Translational Radiobiology Group, Division of Cancer Sciences, Manchester Academic Health Science Centre, The University of Manchester, Christie Hospital NHS Foundation Trust, Manchester, UK.
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Koric A, Chang CP, Mark B, Rowe K, Snyder J, Dodson M, Deshmukh VG, Newman MG, Fraser AM, Smith KR, Date AP, Gren LH, Porucznik CA, Haaland BA, Henry NL, Hashibe M. Cardiovascular disease risk in long-term breast cancer survivors: A population-based cohort study. Cancer 2022; 128:2826-2835. [PMID: 35561317 PMCID: PMC9991862 DOI: 10.1002/cncr.34224] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 02/22/2022] [Accepted: 03/03/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Breast cancer survival is increasing, making late effects such as cardiovascular disease (CVD) more relevant. The purpose of this study was to evaluate incident CVD following breast cancer diagnosis among long-term survivors and to investigate possible risk factors for CVD. METHODS A population-based cohort of 6641 breast cancer survivors diagnosed between 1997 and 2009 who survived at least 10 years was identified within the Utah Cancer Registry. In addition, 36,612 cancer-free women from the general population, matched by birth year and state, were identified within the Utah Population Database. Cox proportional hazards models were used to calculate CVD hazard ratios (HRs) for >10 to 15 and >15 years. RESULTS Long-term breast cancer survivors had an increased risk of newly diagnosed diseases of the circulatory system (HR, 1.32; 99% confidence interval [CI], 1.00-1.75) from 10 to 15 years following cancer diagnosis compared with the general population. No increased CVD risks were observed after 15 years. Breast cancer survivors with Charlson Comorbidity Index score ≥2 had a significantly higher risk of diseases of the circulatory system (HR, 2.64; 95% CI, 1.08-6.45) beyond 10 years following breast cancer diagnosis. Similarly, older age, obesity, lower education, and family history of CVD and breast cancer were risk factors for heart and circulatory system diseases among long-term breast cancer survivors. CONCLUSION Risk of CVD compared to the general population was moderate among this cohort of long-term breast cancer survivors between 10 to 15 years since cancer diagnosis. Awareness of CVD risks is important for breast cancer survivors.
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Affiliation(s)
- Alzina Koric
- Huntsman Cancer Institute, Salt Lake City, Utah.,Division of Public Health, Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Chun-Pin Chang
- Huntsman Cancer Institute, Salt Lake City, Utah.,Division of Public Health, Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Bayarmaa Mark
- Huntsman Cancer Institute, Salt Lake City, Utah.,Division of Public Health, Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Kerry Rowe
- Intermountain Healthcare, Salt Lake City, Utah
| | - John Snyder
- Intermountain Healthcare, Salt Lake City, Utah
| | - Mark Dodson
- Intermountain Healthcare, Salt Lake City, Utah
| | | | - Michael G Newman
- Huntsman Cancer Institute, Salt Lake City, Utah.,University of Utah Health Sciences Center, Salt Lake City, Utah
| | - Alison M Fraser
- Pedigree and Population Resource, Population Sciences, Huntsman Cancer Institute, Salt Lake City, Utah
| | - Ken R Smith
- Pedigree and Population Resource, Population Sciences, Huntsman Cancer Institute, Salt Lake City, Utah
| | - Ankita P Date
- Pedigree and Population Resource, Population Sciences, Huntsman Cancer Institute, Salt Lake City, Utah
| | - Lisa H Gren
- Division of Public Health, Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Christina A Porucznik
- Division of Public Health, Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Benjamin A Haaland
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah
| | - N Lynn Henry
- Division of Hematology and Oncology, University of Michigan Medical School, University of Michigan Rogel Cancer Center, Ann Arbor, Michigan
| | - Mia Hashibe
- Huntsman Cancer Institute, Salt Lake City, Utah.,Division of Public Health, Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, Utah
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8
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Lin H, Dong L, Jimenez RB. Emerging Technologies in Mitigating the Risks of Cardiac Toxicity From Breast Radiotherapy. Semin Radiat Oncol 2022; 32:270-281. [DOI: 10.1016/j.semradonc.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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9
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Cardiac late effects after modern 3D-conformal radiotherapy in breast cancer patients: a retrospective cohort study in Germany (ESCaRa). Breast Cancer Res Treat 2021; 191:147-157. [PMID: 34626275 PMCID: PMC8758608 DOI: 10.1007/s10549-021-06412-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 09/30/2021] [Indexed: 11/28/2022]
Abstract
Purpose Radiotherapy (RT) was identified as a risk factor for long-term cardiac effects in breast cancer patients treated until the 1990s. However, modern techniques reduce radiation exposure of the heart, but some exposure remains unavoidable. In a retrospective cohort study, we investigated cardiac mortality and morbidity of breast cancer survivors treated with recent RT in Germany. Methods A total of 11,982 breast cancer patients treated between 1998 and 2008 were included. A mortality follow-up was conducted until 06/2018. In order to assess cardiac morbidity occurring after breast cancer treatment, a questionnaire was sent out in 2014 and 2019. The effect of breast cancer laterality on cardiac mortality and morbidity was investigated as a proxy for radiation exposure. We used Cox Proportional Hazards regression analysis, taking potential confounders into account. Results After a median follow-up time of 11.1 years, there was no significant association of tumor laterality with cardiac mortality in irradiated patients (hazard ratio (HR) for left-sided versus right-sided tumor 1.09; 95% confidence interval (CI) 0.85–1.41). Furthermore, tumor laterality was not identified as a significant risk factor for cardiac morbidity (HR = 1.05; 95%CI 0.88–1.25). Conclusions Even though RT for left-sided breast cancer on average incurs higher radiation dose to the heart than RT for right-sided tumors, we found no evidence that laterality is a strong risk factor for cardiac disease after contemporary RT. However, larger sample sizes, longer follow-up, detailed information on individual risk factors and heart dose are needed to assess clinically manifest late effects of current cancer therapy. Supplementary Information The online version contains supplementary material available at 10.1007/s10549-021-06412-3.
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10
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Yousefi Kashi AS, Karimi M, Rakhsha A, Javadzadegan A, Taghizadeh-Hesary F. The Troponin-I Release in Patients with Left-Sided Early-Stage Breast Cancer Undergoing Adjuvant Whole Breast Radiotherapy: An Iranian Experience. INTERNATIONAL JOURNAL OF CANCER MANAGEMENT 2020; 13. [DOI: 10.5812/ijcm.107043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/08/2020] [Accepted: 07/11/2020] [Indexed: 08/30/2023]
Abstract
Background: Breast cancer is the most frequent cancer among women. In line with the survival improvement of patients with cancer, the issue of treatment-induced toxicities becomes more important. Objectives: This study aimed at evaluating acute radiation-induced cardiac damage. Methods: Between 2016 and 2019, women with histologically-confirmed early-stage left-sided breast cancer or ductal carcinoma in-situ (DCIS) without prior chemotherapy, who were candidates for adjuvant whole breast radiotherapy, entered the study. The radiation-induced cardiotoxicity was assessed, using a rise in high-sensitivity cardiac troponin I (hscTnI) over the radiotherapy. Likewise, the association between the percentage of heart receiving at least 25Gy (V25Gy) and the rise in hscTnI was evaluated as the secondary endpoint. Results: A total of 22 women were included in this study. Mean ± standard deviation (SD) hscTnI for the whole study population was 12 ± 2 ng/L before and 15 ± 2 ng/L after radiotherapy. The median (interquartile range [IQR]) V25Gy was 8.05% (6.95% - 8.95%). The difference between hscTnI levels before and after radiotherapy was significant (P = 0.001). There was no correlation between V25Gy and the rise in hscTnI (P = 0.18). Conclusions: hscTnI is a sensitive marker to detect early radiation-induced cardiotoxicity. There is no association between V25Gy and the rise in hscTnI over radiotherapy.
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11
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Chopra I, Mattes MD, Findley P, Tan X, Dwibedi N, Sambamoorthi U. Impact of Incident Cancer on Short-Term Coronary Artery Disease-Related Healthcare Expenditures Among Medicare Beneficiaries. J Natl Compr Canc Netw 2020; 17:149-158. [PMID: 30787128 DOI: 10.6004/jnccn.2018.7078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 08/20/2018] [Indexed: 01/09/2023]
Abstract
Background: Healthcare spending for coronary artery disease (CAD)-related services is higher than for other chronic conditions. Diagnosis of incident cancer may impede management of CAD, thereby increasing the risk of CAD-related complications and associated healthcare expenditures. This study examined the relationship between incident cancer and CAD-related expenditures among elderly Medicare beneficiaries. Patients and Methods: A retrospective longitudinal study was conducted using the SEER-Medicare linked registries and a 5% noncancer random sample of Medicare beneficiaries. Elderly fee-for-service Medicare beneficiaries with preexisting CAD and with incident breast, colorectal, or prostate cancer (N=12,095) or no cancer (N=34,237) were included. CAD-related healthcare expenditures comprised Medicare payments for inpatient, home healthcare, and outpatient services. Expenditures were measured every 120 days during the 1-year preindex and 1-year postindex periods. Adjusted relationship between incident cancer and expenditures was analyzed using the generalized linear mixed models. Results: Overall, CAD-related mean healthcare expenditures in the preindex period accounted for approximately 32.6% to 39.5% of total expenditures among women and 41.5% to 46.8% among men. All incident cancer groups had significantly higher CAD-related expenditures compared with noncancer groups (P<.0001). Men and women with colorectal cancer (CRC) had 166% and 153% higher expenditures, respectively, compared with their noncancer counterparts. Furthermore, men and women with CRC had 57% and 55% higher expenditures compared with those with prostate or breast cancer, respectively. Conclusions: CAD-related expenditures were higher for elderly Medicare beneficiaries with incident cancer, specifically for those with CRC. This warrants the need for effective programs and policies to reduce CAD-related expenditures. Close monitoring of patients with a cancer diagnosis and preexisting CAD may prevent CAD-related events and expenditures.
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Affiliation(s)
- Ishveen Chopra
- aDepartment of Pharmaceutical Systems and Policy, West Virginia University, and
| | - Malcolm D Mattes
- bDepartment of Medical Education, WVU School of Medicine, Morgantown, West Virginia; and
| | - Patricia Findley
- cSchool of Social Work, Rutgers University, New Brunswick, New Jersey
| | - Xi Tan
- aDepartment of Pharmaceutical Systems and Policy, West Virginia University, and
| | - Nilanjana Dwibedi
- aDepartment of Pharmaceutical Systems and Policy, West Virginia University, and
| | - Usha Sambamoorthi
- aDepartment of Pharmaceutical Systems and Policy, West Virginia University, and
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12
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Ricco A, Slade A, Canada JM, Grizzard J, Dana F, Rezai Gharai L, Neiderer K, Vera A, Abbate A, Weiss E. Cardiac MRI utilizing late gadolinium enhancement (LGE) and T1 mapping in the detection of radiation induced heart disease. CARDIO-ONCOLOGY 2020; 6:6. [PMID: 32626602 PMCID: PMC7329507 DOI: 10.1186/s40959-020-00061-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 06/21/2020] [Indexed: 12/18/2022]
Abstract
Background and purpose Radiotherapy has been associated with late dose-dependent cardiovascular toxicity. In this cross-sectional pilot study, radiation dose distributions were correlated with areas of localized and diffuse myocardial fibrosis as measured by novel cardiac MRI (CMR) sequences including late gadolinium enhancement (LGE) and T1 mapping with the goal to identify early markers of myocardial damage. Materials and methods Twenty-eight patients with chest tumors including lung, breast, esophagus, and lymphoma underwent CMR per study protocol on average 46.4 months (range 1.7–344.5) after radiotherapy. Patients without pretreatment cardiac history were included if the volume of heart receiving 5 Gy or more was at least 10% (V5Gy ≥ 10%). The association of LGE with cardiac dosimetric factors, clinical factors (e.g., tumor type, smoking history, BMI), and T1 values was analyzed. Results Cardiac maximum (Dmax) and mean dose (Dmean) equivalent to doses delivered in 2 Gy fractions (EQD2) were on average 50.9 Gy (range 6.2–108.0) and 8.2 Gy (range 1.0–35.7), respectively, compared to 60.8 Gy (40.8–108.0) and 6.8 Gy (1.8–21.8) among the 9 patients with LGE. Doses were not different between patients with and without LGE (p = 0.16 and 0.56, respectively). The average T1 value of the left ventricle myocardium was 1009 ms (range 933–1117). No significant correlation was seen for heart Dmax and Dmean and T1 values (p = 0.14 and 0.58, respectively). In addition, no significant association between clinical factors and the development of LGE was identified. Conclusions No relation between cardiac doses, the presence of LGE or T1 values was observed. Further study is needed to determine the benefit of CMR for detecting radiotherapy-related myocardial fibrosis.
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Affiliation(s)
- Anthony Ricco
- Department of Radiation Oncology, Virginia Commonwealth University Health System, 401 College Street, Richmond, VA 23298 USA
| | - Alexander Slade
- Department of Radiation Oncology, Virginia Commonwealth University Health System, 401 College Street, Richmond, VA 23298 USA
| | - Justin M Canada
- Department of Cardiology, Virginia Commonwealth University Health System, Richmond, VA USA.,Department of Kinesiology & Health Sciences, Virginia Commonwealth University Health System, Richmond, VA USA
| | - John Grizzard
- Department of Radiology, Virginia Commonwealth University Health System, Richmond, VA USA
| | - Franklin Dana
- Department of Radiology, Virginia Commonwealth University Health System, Richmond, VA USA
| | - Leila Rezai Gharai
- Department of Radiology, Virginia Commonwealth University Health System, Richmond, VA USA
| | - Keith Neiderer
- Department of Radiation Oncology, Virginia Commonwealth University Health System, 401 College Street, Richmond, VA 23298 USA
| | - Armando Vera
- Department of Radiation Oncology, Virginia Commonwealth University Health System, 401 College Street, Richmond, VA 23298 USA
| | - Antonio Abbate
- Department of Cardiology, Virginia Commonwealth University Health System, Richmond, VA USA
| | - Elisabeth Weiss
- Department of Radiation Oncology, Virginia Commonwealth University Health System, 401 College Street, Richmond, VA 23298 USA
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13
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Killander F, Wieslander E, Karlsson P, Holmberg E, Lundstedt D, Holmberg L, Werner L, Koul S, Haghanegi M, Kjellen E, Nilsson P, Malmström P. No Increased Cardiac Mortality or Morbidity of Radiation Therapy in Breast Cancer Patients After Breast-Conserving Surgery: 20-Year Follow-up of the Randomized SweBCGRT Trial. Int J Radiat Oncol Biol Phys 2020; 107:701-709. [PMID: 32302682 DOI: 10.1016/j.ijrobp.2020.04.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 04/02/2020] [Accepted: 04/04/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE Radiation therapy (RT) after breast-conserving surgery reduces locoregional recurrences and improves survival but may cause late side effects. The main purpose of this paper was to investigate long-term side effects after whole breast RT in a randomized clinical trial initiated in 1991 and to report dose-volume data based on individual 3-dimensional treatment plans for organs at risk. METHODS AND MATERIALS The trial included 1187 patients with T1-2 N0 breast cancer randomized to postoperative tangential whole breast RT or no further treatment. The prescription dose to the clinical target volume was 48 to 54 Gy. We present 20-year follow-up on survival, cause of death, morbidity, and later malignancies. For a cohort of patients (n = 157) with accessible computed tomography-based 3-dimensional treatment plans in Dicom-RT format, dose-volume descriptors for organs at risk were derived. In addition, these were compared with dose-volume data for a cohort of patients treated with contemporary RT techniques. RESULTS The cumulative incidence of cardiac mortality was 12.4% in the control group and 13.0% in the RT group (P = .8). There was an increase in stroke mortality: 3.4% in the control group versus 6.7% in the RT group (P = .018). Incidences of contralateral breast cancer and lung cancer were similar between groups. The median Dmean (range) heart dose for left-sided treatments was 3.0 Gy (1.1-8.1), and the corresponding value for patients treated in 2017 was 1.5 Gy (0.4-6.0). CONCLUSIONS In this trial, serious late side effects of whole breast RT were limited and less than previously reported in large meta-analyses. We observed no increase in cardiac mortality in irradiated patients. Doses to the heart were a median Dmean of 3.0 Gy for left-sided RT. The observed increase in stroke mortality may partly be secondary to cardiac side effects, complications to anticoagulant treatment, or to chance, rather than a direct side effect of tangential whole breast irradiation.
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Affiliation(s)
- Fredrika Killander
- Department of Clinical Sciences, Faculty of Medicine, Lund, Lund University, Sweden; Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden.
| | - Elinore Wieslander
- Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Per Karlsson
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Erik Holmberg
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Regional Oncologic Centre West, Gothenburg, Sweden
| | - Dan Lundstedt
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lars Holmberg
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden; Translational Oncology & Urology Research (TOUR), School of Cancer and Pharmaceutical Sciences, Kingś College London, London, United Kingdom
| | - Linda Werner
- Department of Clinical Sciences, Faculty of Medicine, Lund, Lund University, Sweden
| | - Sasha Koul
- Department of Cardiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Mahnaz Haghanegi
- Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Elisabeth Kjellen
- Department of Clinical Sciences, Faculty of Medicine, Lund, Lund University, Sweden; Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Per Nilsson
- Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden; Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Per Malmström
- Department of Clinical Sciences, Faculty of Medicine, Lund, Lund University, Sweden; Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
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14
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Abstract
Patients with a current diagnosis of breast cancer are enjoying dramatic cure rates and survivorship secondary to an increase in awareness, earlier detection, and more effective therapies. Although strategies such as Breast Cancer Awareness Month in October focus on early detection, lifestyle changes are seldom discussed other than dietary concerns and physical activity. Lifestyle modifications centered on diet and exercise have been demonstrated to affect overall disease-free survival in breast cancer. Since the early 2000s, the role of the human gut microbiota and its relation to breast cancer has become a major area of interest in the scientific and medical community. We live and survive owing to the symbiotic relationship with the microorganisms within us: the human microbiota. Scientific advances have identified a subset of the gut microbiota: the estrobolome, those bacteria that have the genetic capability to metabolize estrogen, which plays a key role in most breast cancers. Recent research provides evidence that the gut microbiome plays a substantial role in estrogen regulation. Gut microbiota diversity appears to be an essential component of overall health, including breast health. Future research attention should include a more extensive focus on the role of the human gut microbiota in breast cancer.
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Affiliation(s)
- Balazs I Bodai
- The Breast Cancer Survivorship Institute, Kaiser Permanente, Sacramento, CA
| | - Therese E Nakata
- The Breast Cancer Survivorship Institute, Kaiser Permanente, Sacramento, CA
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15
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Soumarová R, Rušinová L. Cardiotoxicity of breast cancer radiotherapy - overview of current results. Rep Pract Oncol Radiother 2019; 25:182-186. [PMID: 32021574 DOI: 10.1016/j.rpor.2019.12.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 07/31/2019] [Accepted: 12/06/2019] [Indexed: 10/25/2022] Open
Abstract
Adjuvant radiotherapy after breast cancer surgery is an important part of breast cancer treatment improving local control and overall survival. However, a higher risk of cardiac mortality was observed when conventional radiotherapy techniques were used. Cardiac morbidity and mortality after radiation therapy have been studied in many meta-analyses. In those focused on modern radiotherapy techniques, cardiac morbidity and mortality were no longer presented. However, an extremely long follow-up period is required. Importantly, the cardiac morbidity rates vary depending not only on the dose delivered to the heart, but also on the systemic therapies administrated and the pre-existing cardiac disease. Systematic heart dose monitoring is of great importance, as are efforts to constantly decrease doses, using advanced radiotherapy techniques. Nowadays, it is essential to individualize treatment according to tumor characteristics and anatomical predispositions, and to consider the cost and benefits.
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Affiliation(s)
- R Soumarová
- Department of Radiotherapy and Oncology, Third Faculty of Medicine, Charles University and Královské Vinohrady University Hospital, Prague, Czech Republic
| | - L Rušinová
- Department of Radiotherapy and Oncology, Third Faculty of Medicine, Charles University and Královské Vinohrady University Hospital, Prague, Czech Republic
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16
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Findlay SG, Gill JH, Plummer R, DeSantis C, Plummer C. Chronic cardiovascular toxicity in the older oncology patient population. J Geriatr Oncol 2019; 10:685-689. [DOI: 10.1016/j.jgo.2019.01.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 01/21/2019] [Accepted: 01/24/2019] [Indexed: 12/28/2022]
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17
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Beaton L, Bergman A, Nichol A, Aparicio M, Wong G, Gondara L, Speers C, Weir L, Davis M, Tyldesley S. Cardiac death after breast radiotherapy and the QUANTEC cardiac guidelines. Clin Transl Radiat Oncol 2019; 19:39-45. [PMID: 31485490 PMCID: PMC6715791 DOI: 10.1016/j.ctro.2019.08.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 08/11/2019] [Indexed: 02/08/2023] Open
Abstract
Cardiovascular risk factors predict for cardiac death after breast radiotherapy. Cardiovascular risk factors should be modified in breast cancer patients. Radiation induced cardiac death at 10-years is low if mean heart dose is <3.3 Gy. Radiation induced cardiac death at 10-years is low if maximum LAD dose is <45.4 Gy. Studies are needed to evaluate heart and LAD constraints in the CT-planning era.
Background Breast/chest wall irradiation (RT) increases risk of cardiovascular death. International Quantitative Analysis of Normal Tissue Effects in the Clinic (QUANTEC) guidelines state for partial heart irradiation a “V25Gy <10% will be associated with a <1% probability of cardiac mortality” in long-term follow-up after RT. We assessed whether women treated with breast/chest wall RT 10-years ago who died of cardiovascular disease (CVD) violated QUANTEC guidelines. Materials/methods A population-based database identified all cardiovascular deaths in women with early-stage breast cancer <80 years, treated with adjuvant breast/chest wall RT from 2002 to 2006. Ten-year rate of cardiovascular death was calculated using a Kaplan-Meier method. Patients were matched on a 2:1 basis with controls that did not die of CVD. For left-sided cases, the heart and left anterior descending (LAD) artery were retrospectively delineated. Dose-volume histograms were calculated, and heart V25Gy compared to QUANTEC guidelines. Results 5249 eligible patients received breast/chest wall RT from 2002 to 2006: 76 (1.4% at 10-years) died of CVD by June 2015. Forty-two patients received left-sided RT (1.7% CVD death at 10-years), 34 right-sided RT (1.3% at 10-years). Heart V25Gy did not exceed 10% in any left-sided cases. No cardiac dosimetry parameter distinguished left-sided cases from controls. Conclusions QUANTEC guidelines were not violated in any patient that died of CVD after left-sided RT. The risk of radiation induced cardiac death at 10-years appears to be very low if MHD is <3.3 Gy and maximum LAD dose (EQD23 Gy) is <45.4 Gy. Further studies are needed to evaluate heart and LAD constraints in the CT-planning era.
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Affiliation(s)
- Laura Beaton
- Department of Radiation Oncology, BC Cancer Agency, Vancouver Centre, Vancouver, British Columbia, Canada
| | - Alanah Bergman
- Department of Medical Physics, BC Cancer Agency, Vancouver Centre, Vancouver, British Columbia, Canada
| | - Alan Nichol
- Department of Radiation Oncology, BC Cancer Agency, Vancouver Centre, Vancouver, British Columbia, Canada.,Breast Cancer Outcomes Unit, BC Cancer Agency, Vancouver Centre, Vancouver, British Columbia, Canada.,Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Maria Aparicio
- Department of Radiation Oncology, BC Cancer Agency, Vancouver Centre, Vancouver, British Columbia, Canada
| | - Graham Wong
- Department of Cardiology, Vancouver General Hospital, Vancouver, British Columbia, Canada.,Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lovedeep Gondara
- Breast Cancer Outcomes Unit, BC Cancer Agency, Vancouver Centre, Vancouver, British Columbia, Canada
| | - Caroline Speers
- Breast Cancer Outcomes Unit, BC Cancer Agency, Vancouver Centre, Vancouver, British Columbia, Canada
| | - Lorna Weir
- Department of Radiation Oncology, BC Cancer Agency, Vancouver Centre, Vancouver, British Columbia, Canada.,Breast Cancer Outcomes Unit, BC Cancer Agency, Vancouver Centre, Vancouver, British Columbia, Canada.,Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Margot Davis
- Department of Cardiology, Vancouver General Hospital, Vancouver, British Columbia, Canada.,Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Scott Tyldesley
- Department of Radiation Oncology, BC Cancer Agency, Vancouver Centre, Vancouver, British Columbia, Canada.,Breast Cancer Outcomes Unit, BC Cancer Agency, Vancouver Centre, Vancouver, British Columbia, Canada.,Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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18
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Risk of cardiotoxicity induced by adjuvant anthracycline-based chemotherapy and radiotherapy in young and old Asian women with breast cancer. Strahlenther Onkol 2019; 195:629-639. [PMID: 30690687 DOI: 10.1007/s00066-019-01428-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 12/24/2018] [Indexed: 12/13/2022]
Abstract
PURPOSE The risk of cardiotoxicity induced by adjuvant anthracycline-based chemotherapy (CT) and radiotherapy (RT) is yet to be investigated in a large-scale randomized controlled trial with an adequate sample size of young and old women with breast cancer. PATIENTS AND METHODS To compare the occurrence of major heart events (heart failure and coronary artery disease) in patients with breast cancer, 3489 women who underwent surgical resection of the breast tumor were retrospectively selected from the Taiwan National Health Insurance Research Database. The patients were categorized into the following groups based on their treatment modalities: group 1 (n = 1113), no treatment; group 2 (n = 646), adjuvant RT alone; group 3 (n = 705), adjuvant anthracycline-based CT alone; and group 4 (n = 1025), combined adjuvant RT and anthracycline-based CT. RESULTS The mean patient age was 50.35 years. Subsequent coronary artery disease and heart failure were identified in 244 (7.0%) and 206 (5.9%) patients, respectively. All three adjuvant therapies were significant independent prognostic factors of major heart events (adjusted hazard ratio [95% confidence interval]: 1.47 [1.24-1.73]; 1.48 [1.25-1.75], and 1.92 [1.65-2.23] in groups 2, 3, and 4, respectively). In patients aged ≥50 years with breast cancer who underwent surgery, the log-rank p values of groups 2 and 3 after adjustment were 0.537 and 0.001, respectively. CONCLUSION Adjuvant RT can increase cardiotoxicity in patients with breast cancer, particularly when used in combination with anthracycline-based CT. Therefore, it should be offered with optimal heart-sparing techniques, particularly in younger patients with good prognosis and long life expectancy.
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Lozza L, Fariselli L, Sandri M, Rampa M, Pinzi V, De Santis MC, Franceschini M, Trecate G, Maugeri I, Fumagalli L, Bonfantini F, Bianchi G, Pignoli E, De Martin E, Agresti R. Partial breast irradiation with CyberKnife after breast conserving surgery: a pilot study in early breast cancer. Radiat Oncol 2018; 13:49. [PMID: 29566762 PMCID: PMC5865347 DOI: 10.1186/s13014-018-0991-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 03/06/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Local recurrences after breast conserving treatment are mainly close to the original tumor site, and as such shorter fractionation strategies focused on and nearest mammary gland, i.e. accelerated partial breast irradiation (APBI), have been developed. Stereotactic APBI has been attempted, although there is little experience using CyberKnife (CK) for early breast cancer. METHODS This pilot study was designed to assess the feasibility of CK-APBI on 20 evaluable patients of 29 eligible, followed for 2 years. The primary endpoint was acute/sub-acute toxicity; secondary endpoints were late toxicity and the cosmetic result. RESULTS Mean pathological tumor size was 10.5 mm (±4.3, range 3-18), 8 of these patients were classified as LumA-like, 11 as LumB-like, and 1 as LumB-HER2-enriched. Using CK-APBI with Iris, the treatment time was approximately 60 min (range~ 35 to ~ 120). All patients received 30 Gy in five fractions delivered to the PTV. The median number of beams was 180 (IQR 107-213; range:56-325) with a median PTV isodose prescription of 86.0% (IQR 85.0-88.5; range:82-94). The median PTV was 88.1 cm3 (IQR 63.8-108.6; range:32.3-238.8). The median breast V100 and V50 was 0.6 (IQR 0.1-1.5; range:0-13) and 18.6 (IQR 13.1-21.7; range:7.5-37), respectively. The median PTV minimum dose was 26.2 Gy (IQR 24.7-27.6; range 22.3-29.3). Mild side effects were recorded during the period of observation. Cosmetic evaluations were performed by three observers from the start of radiotherapy up to 2 years. Patients' evaluation progressively increase from 60% to 85% of excellent rating; this trend was similar to that of external observer. CONCLUSIONS These preliminary results showed the safe feasibility of CK-APBI in early breast cancer, with mild acute and late toxicity and very good cosmetic results. TRIAL REGISTRATION The present study is registered at Clinicaltrial.gov ( NCT02896322 ). Retrospectively egistered August 4, 2016.
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Affiliation(s)
- Laura Lozza
- Radiotherapy Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Laura Fariselli
- Health Department, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Marco Sandri
- Molecular Targeting Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Mario Rampa
- Breast Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Valentina Pinzi
- Health Department, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | | | - Marzia Franceschini
- Radiotherapy Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Giovanna Trecate
- Radiology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Ilaria Maugeri
- Breast Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Luisa Fumagalli
- Health Department, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Francesca Bonfantini
- Medical Physics Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Giulia Bianchi
- Medical Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Emanuele Pignoli
- Medical Physics Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Elena De Martin
- Health Department, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Roberto Agresti
- Breast Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
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20
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Gulati M, Mulvagh SL. The connection between the breast and heart in a woman: Breast cancer and cardiovascular disease. Clin Cardiol 2018; 41:253-257. [PMID: 29446841 DOI: 10.1002/clc.22886] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 01/03/2018] [Indexed: 12/24/2022] Open
Abstract
Cardiovascular disease remains the leading cause of death in women in the United States and is a major public health issue for all women, but it is of increasing concern to breast cancer survivors. Advancements in early detection and breast cancer therapy have resulted in over 90% of women surviving 5 years past their diagnosis of breast cancer. Nonetheless, with increased survivorship from breast cancer, there has been an increase in cardiovascular disease in these women. The consequences of the treatments for breast cancer may increase the risk for cardiovascular disease. Additionally, there is an overlap of risk factors common to both breast cancer and cardiovascular disease. The increased risk of cardiovascular disease in women who survive breast cancer must be recognized, with a focus on the prevention and early detection of cardiovascular disease.
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Affiliation(s)
- Martha Gulati
- Division of Cardiology, University of Arizona-Phoenix, Phoenix, Arizona
| | - Sharon L Mulvagh
- Division of Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
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21
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Obi N, Eulenburg C, Seibold P, Eilber U, Thöne K, Behrens S, Chang-Claude J, Flesch-Janys D. Associations between adjuvant radiotherapy and different causes of death in a German breast cancer cohort. Breast 2018; 38:75-80. [PMID: 29248876 DOI: 10.1016/j.breast.2017.12.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 11/24/2017] [Accepted: 12/04/2017] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Studies of cohorts of breast cancer (BC) patients diagnosed before 1990 showed radiotherapy (RT) to be associated with increased cardiovascular (CVD) and lung cancer mortality many years after diagnosis. In the late 1990s, improvements in RT planning techniques reduced radiation doses to normal tissues. Recent studies did not consistently report higher RT-related mortality for CVD and second cancers. Aim of the study was to analyze specific causes of death after 3D-conformal RT in a recent BC cohort. METHODS Stage I-III BC patients diagnosed 2001-2005 and enrolled in the population based MARIEplus study were followed-up for 11.9 years (median). Associations between adjuvant RT and cause-specific mortality were analyzed by using competing risks models, yielding subdistribution hazard ratios (SHR) for RT directly related to cumulative incidences. Models were adjusted for differences in baseline characteristics applying inverse-probability-of-treatment-weighting (IPTW). RESULTS Of the 2951 patients, 2439 (83.0%) received RT. No significant association of RT with lung cancer mortality (SHRIPTW 0.88, 0.35-2.12), other cancer mortality (SHRIPTW 1.04, 95% CI 0.62-1.73) or cardiac mortality was observed (SHRIPTW 1.57, 0.75-3.29). Mortality from lung and other diseases were significantly lower in irradiated women (SHRIPTW 0.39, 95% CI 0.17-0.90 and SHRIPTW 0.58, 95% CI 0.34-0.97, respectively). CONCLUSION In line with recent studies, 3D-conformal RT did not significantly increase mortality from non-BC causes in the German MARIEplus cohort. Since long-term data are still sparse and event rates low in BC-cohorts, who received modern RT, investigation of possible late RT effects on mortality beyond 14 years of follow-up is warranted.
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Affiliation(s)
- Nadia Obi
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany.
| | - Christine Eulenburg
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany; Medical Statistics and Decision Making, Department for Epidemiology, University of Groningen, PO Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Petra Seibold
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 581, 69120 Heidelberg, Germany
| | - Ursula Eilber
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 581, 69120 Heidelberg, Germany
| | - Kathrin Thöne
- Department of Cancer Epidemiology/Clinical Cancer Registry, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Sabine Behrens
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 581, 69120 Heidelberg, Germany
| | - Jenny Chang-Claude
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 581, 69120 Heidelberg, Germany; Genetic Tumor Epidemiology Group, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Dieter Flesch-Janys
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany; Department of Cancer Epidemiology/Clinical Cancer Registry, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
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Sadek I, Keaton M, Maihle NJ, Tang SC. Anti-HER-2 therapy following severe trastuzumab-induced cardiac toxicity. Genes Dis 2017; 4:159-162. [PMID: 30258918 PMCID: PMC6147109 DOI: 10.1016/j.gendis.2017.07.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 07/25/2017] [Indexed: 01/05/2023] Open
Abstract
The human epidermal growth factor receptor 2 (HER2) is overexpressed in 25%-30% of breast cancer patients. Anti-HER2 therapies have changed the aggressive course of HER2+ breast cancer. In spite of the therapeutic benefits, their cardiotoxicities are major concerns, especially when used concurrently with anthracyclines. Here we present an elderly patient with relapsed HER2+ breast cancer. Her presentation for relapsed disease was unusual for the physical finding as well as the history of trastuzumab-induced severe cardiotoxicity while requiring additional anti-HER2 therapy. She received neoadjuvant anti-HER2 treatment for stage III breast caner. Due to severe reduction of cardiac ejection fraction (EF), she only received five doses of adjuvant transtuzumab. Unfortunately her disease relapsed one year later with chest wall lesions and a persistent low EF. We treated the patient with lapatinib combined with capecitabine which resulted rapid resolution of her chest wall lesion. More importantly, the patient had one year of disease control without deterioration in her ejection fraction. We discussed the management of recurrent HER2+ breast cancer with chest wall disease and the choice of anti-HER2 therapy in patients with a history of transtuzumab-induced cardiac dysfunction.
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Affiliation(s)
- Ibrahim Sadek
- Georgia Cancer Center, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
| | - Mark Keaton
- Georgia Cancer Center, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
| | - Nita J. Maihle
- Georgia Cancer Center, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
| | - Shou-Ching Tang
- Georgia Cancer Center, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
- Tianjin Medical University Cancer Institute and Hospital, Huanhuxi Road, Hexi District, Tianjin 300060, China
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Miyashita M, Tada H, Suzuki A, Watanabe G, Hirakawa H, Amari M, Kakugawa Y, Kawai M, Furuta A, Sato K, Yoshida R, Ebata A, Sasano H, Jingu K, Ohuchi N, Ishida T. Minimal impact of postmastectomy radiation therapy on locoregional recurrence for breast cancer patients with 1 to 3 positive lymph nodes in the modern treatment era. Surg Oncol 2017; 26:163-170. [DOI: 10.1016/j.suronc.2017.03.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 01/31/2017] [Accepted: 03/12/2017] [Indexed: 01/01/2023]
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Cheng YJ, Nie XY, Ji CC, Lin XX, Liu LJ, Chen XM, Yao H, Wu SH. Long-Term Cardiovascular Risk After Radiotherapy in Women With Breast Cancer. J Am Heart Assoc 2017; 6:JAHA.117.005633. [PMID: 28529208 PMCID: PMC5524103 DOI: 10.1161/jaha.117.005633] [Citation(s) in RCA: 131] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background Radiotherapy for breast cancer often involves some incidental exposure of the heart to ionizing radiation. The effect of this exposure on the subsequent risk of heart disease is uncertain. We performed a meta‐analysis to investigate the link between radiotherapy and long‐term cardiovascular morbidity and mortality in patients with breast cancer. Methods and Results We performed a literature search using MEDLINE (January 1966 to January 2015) and EMBASE (January 1980 to January 2015) with no restrictions. Studies that reported relative risk (RR) estimates with 95%CIs for the associations of interest were included. Pooled effect estimates were obtained by using random‐effects meta‐analysis. Thirty‐nine studies involving 1 191 371 participants were identified. Patients who received left‐sided radiotherapy, as compared with those receiving right‐sided radiotherapy, experienced increased risks of developing coronary heart disease (RR 1.29, 95%CI 1.13‐1.48), cardiac death (RR 1.22, 95%CI 1.08‐1.37) and death from any cause (RR 1.05, 95%CI 1.01‐1.10). In a comparison of patients with radiotherapy and without radiotherapy, the RRs were 1.30 (95%CI 1.13‐1.49) for coronary heart disease and 1.38 (95%CI 1.18‐1.62) for cardiac mortality. Radiotherapy for breast cancer was associated with an absolute risk increase of 76.4 (95%CI 36.8‐130.5) cases of coronary heart disease and 125.5 (95%CI 98.8‐157.9) cases of cardiac death per 100 000 person‐years. The risk started to increase within the first decade for coronary heart disease and from the second decade for cardiac mortality. Conclusions Exposure of the heart to ionizing radiation during radiotherapy for breast cancer increases the subsequent risk of coronary heart disease and cardiac mortality.
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Affiliation(s)
- Yun-Jiu Cheng
- Department of Cardiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Xiao-Ying Nie
- Outpatient Department, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Cheng-Cheng Ji
- Department of Cardiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Xiao-Xiong Lin
- Department of Cardiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Li-Juan Liu
- Department of Cardiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Xu-Miao Chen
- Department of Cardiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Hao Yao
- Department of Cardiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Su-Hua Wu
- Department of Cardiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
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Recht A. Radiation-Induced Heart Disease After Breast Cancer Treatment: How Big a Problem, and How Much Can—and Should—We Try to Reduce It? J Clin Oncol 2017; 35:1146-1148. [DOI: 10.1200/jco.2016.71.4113] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Abram Recht
- Abram Recht, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
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Wollschläger D, Merzenich H, Schwentner L, Janni W, Wiegel T, Bartkowiak D, Wöckel A, Schmidt M, Schmidberger H, Blettner M. Self-reported long-term cardiac morbidity in breast cancer patients: a retrospective cohort study in Germany (PASSOS Heart Study). Breast Cancer Res Treat 2017; 163:595-604. [DOI: 10.1007/s10549-017-4215-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 03/21/2017] [Indexed: 10/19/2022]
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Takx RAP, Vliegenthart R, Schoepf UJ, Pilz LR, Schoenberg SO, Morris PB, Henzler T, Apfaltrer P. Coronary artery calcium in breast cancer survivors after radiation therapy. Int J Cardiovasc Imaging 2017; 33:1425-1431. [DOI: 10.1007/s10554-017-1119-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 03/18/2017] [Indexed: 11/25/2022]
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Abstract
BACKGROUND Cardiovascular disease (CVD) is of increasing concern among breast cancer survivors. However, the burden of this comorbidity in this group relative to the general population, and its temporal pattern, remains unknown. METHODS We compared deaths due to CVD in a population-based sample of 1,413 women with incident breast cancer diagnosed in 1996-1997, and 1,411 age-matched women without breast cancer. Date and cause of death through December 31, 2009 were assessed through the national death index and covariate data was gathered through structured interviews and medical record abstraction. Hazard ratios (HR) and 95% confidence intervals were calculated using Cox regression for overall mortality (HR) and CVD-specific death (cause-specific HR). Subdistribution HRs for CVD death were estimated from the Fine-Gray model. RESULTS Risk of death was greater among breast cancer survivors compared with women without breast cancer (HR: 1.8 [1.5, 2.1]). An increase in CVD-related death among breast cancer survivors was evident only 7 years after diagnosis (years 0-7, cause-specific HR: 0.80 [0.53, 1.2], subdistribution HR: 0.59 [0.40, 0.87]); years 7+, cause-specific HR: 1.8 [1.3, 2.5], subdistribution HR: 1.9 [1.4, 2.7]; P interaction: 0.001). An increase in CVD-related mortality was observed among breast cancer survivors receiving chemotherapy. CONCLUSIONS Breast cancer survivors are at greater risk for CVD-related mortality compared with women without breast cancer and this increase in risk is manifested approximately 7 years after diagnosis. Efforts should be made to identify risk factors and interventions that can be employed during this brief window to reduce the excess burden of CVD in this vulnerable population.
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Headon H, Kasem A, Almukbel R, Mokbel K. Improvement of survival with postmastectomy radiotherapy in patients with 1-3 positive axillary lymph nodes: A systematic review and meta-analysis of the current literature. Mol Clin Oncol 2016; 5:429-436. [PMID: 27699038 DOI: 10.3892/mco.2016.971] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 03/21/2016] [Indexed: 11/06/2022] Open
Abstract
In breast cancer with >4 positive axillary lymph nodes, it is common practice to deliver radiotherapy to the affected site following mastectomy. However, less is known regarding the benefits this may confer on women with 1-3 positive lymph nodes. In this meta-analysis, we aimed to assess whether post-mastectomy radiotherapy (PMRT) was beneficial for such patients. A literature review was conducted using the PubMed and Ovid databases. Selected studies were analysed and data regarding overall survival (OS) and locoregional recurrence (LRR) rates were extracted. Statistical analysis was then conducted in order to develop a combined risk ratio (RR) for both OS and LRR in the setting of PMRT in women with breast cancer with 1-3 positive lymph nodes. PMRT in women with 1-3 positive lymph nodes significantly reduced the risk of LRR, with a RR of 0.3 [95% confidence interval (CI): 0.23-0.38] and also showed a minor benefit in terms of OS (RR=1.03, 95% CI: 1.00-1.07). Therefore, in breast cancer patients with 1-3 positive lymph nodes, PMRT significantly reduced the risk of LRR and was associated with a minor OS benefit. Until the results of ongoing randomised controlled trials are published, PMRT should be recommended in this group of patients following a careful multidisciplinary discussion.
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Affiliation(s)
- Hannah Headon
- The London Breast Institute, The Princess Grace Hospital, W1U 5NY London, UK
| | - Abdul Kasem
- The London Breast Institute, The Princess Grace Hospital, W1U 5NY London, UK
| | - Reham Almukbel
- The London Breast Institute, The Princess Grace Hospital, W1U 5NY London, UK
| | - Kefah Mokbel
- The London Breast Institute, The Princess Grace Hospital, W1U 5NY London, UK
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Nilsson G, Witt Nyström P, Isacsson U, Garmo H, Duvernoy O, Sjögren I, Lagerqvist B, Holmberg L, Blomqvist C. Radiation dose distribution in coronary arteries in breast cancer radiotherapy. Acta Oncol 2016; 55:959-63. [PMID: 27230730 DOI: 10.1080/0284186x.2016.1182209] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Women irradiated for left-sided breast cancer (BC) have an increased risk of coronary artery disease compared to women with right-sided BC. We describe the distribution of radiation dose in segments of coronary arteries in women receiving adjuvant radiotherapy (RT) for left- or right-sided BC. MATERIAL AND METHODS Fifteen women with BC, seven left-sided and eight right-sided, who had received three-dimensional conformal radiotherapy (3DCRT), constituted the study base. The heart and the segments of the coronary arteries were defined as separate organs at risk (OAR), and the mean and maximum radiation doses were calculated for each OAR. RESULTS In women with left-sided BC, irrespective of if regional lymph node RT was given or not, maximum dose in mid and distal left anterior descending artery (mdLAD) was approximately 50 Gy in 6/7 patients, whereas women with right-sided BC mainly received low doses of radiation. In women with left-sided BC, 6/7 patients had substantially higher mean dose to the distal LAD than to the heart, ranging from 30 to 55 Gy and 3 to13 Gy, respectively. CONCLUSION We found a pronounced difference of radiation dose distribution in the coronary arteries between women with left- and right-sided BC. Women with left-sided BC had almost full treatment dose in parts of mdLAD, regardless of if regional lymph node irradiation was given or not, while women with right-sided BC mainly received low doses to the coronary arteries.
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Affiliation(s)
- Greger Nilsson
- Department of Immunology, Genetics and Pathology, Section of Experimental and Clinical Oncology, Uppsala University, University Hospital, Uppsala, Sweden
- Department of Oncology, Gävle Hospital, Gävle, Sweden
- Section of Oncology, Visby Hospital, Visby, Sweden
| | - Petra Witt Nyström
- Department of Immunology, Genetics and Pathology, Section of Experimental and Clinical Oncology, Uppsala University, University Hospital, Uppsala, Sweden
| | - Ulf Isacsson
- Department of Immunology, Genetics and Pathology, Section of Medical Radiation Science, Uppsala University, University Hospital, Uppsala, Sweden
| | - Hans Garmo
- King's College London, Faculty of Life Sciences and Medicine, Division of Cancer Studies, Guy's Campus, London, UK
- Regional Cancer Center, Uppsala University, University Hospital, Uppsala, Sweden
| | - Olov Duvernoy
- Department of Surgical Sciences, Section of Radiology, Uppsala University, University Hospital, Uppsala, Sweden
| | - Iwar Sjögren
- Department of Cardiology, Falu Hospital, Falun, Sweden
| | - Bo Lagerqvist
- Department of Medical Sciences, Section of Cardiology, Uppsala University; jUppsala Clinical Research Centre, Uppsala University, University Hospital, Uppsala, Sweden; , Uppsala University, University Hospital, Uppsala, Sweden
- Uppsala Clinical Research Centre, Uppsala University, University Hospital, Uppsala, Sweden
| | - Lars Holmberg
- King's College London, Faculty of Life Sciences and Medicine, Division of Cancer Studies, Guy's Campus, London, UK
- Department of Surgical Sciences, Section of Endocrine Surgery, Uppsala University, University Hospital, Uppsala, Sweden
| | - Carl Blomqvist
- Department of Oncology, Örebro University, University Hospital, Örebro, Sweden
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Becker-Schiebe M, Stockhammer M, Hoffmann W, Wetzel F, Franz H. Does mean heart dose sufficiently reflect coronary artery exposure in left-sided breast cancer radiotherapy? : Influence of respiratory gating. Strahlenther Onkol 2016; 192:624-31. [PMID: 27389036 DOI: 10.1007/s00066-016-1011-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 06/08/2016] [Indexed: 12/25/2022]
Abstract
PURPOSE With extensive use of systemic treatment, the issue of cardiac mortality after breast cancer radiation (RT) is still important. The aim of our analysis was to clarify whether the dose to one surrogate parameter (e. g., mean heart dose, as used in most studies) reflects the dose to the other cardiovascular structures especially the left anterior descending artery depending on breathing-adapted RT. PATIENTS AND METHODS A total of 130 patients who underwent adjuvant RT (50.4 Gy plus boost 9-16 Gy) were evaluated. In all, 71 patients were treated with free-breathing and 59 patients using respiratory monitoring (gated RT). Dosimetric associations were calculated. RESULTS The mean dose to the heart (Dmean heart) was reduced from 2.7 (0.8-5.2) Gy to 2.4 (1.1-4.6) Gy, the Dmean LAD (left anterior descending artery) decreased from 11.1 (1.3-28.6) Gy to 9.3 (2.2-19.9) Gy with gated RT (p = 0.04). A significant relationship was shown for Dmean heart-Dmean LAD, V25heart-Dmean LAD and Dmax heart-Dmax LAD for gated patients only (p < 0.01). For every 1 Gy increase in Dmean heart, mean LAD doses rose by 3.6 Gy, without gating V25 ≤5 % did not assure a benefit and resulted in Dmean LAD between 1.3 and 28.6 Gy. CONCLUSION A significant reduction and association of heart and coronary artery (LAD) doses using inspiratory gating was shown. However, in free-breathing plans commonly measured dose constraints do not allow precise estimation of the dose to the coronary arteries.
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Affiliation(s)
- Martina Becker-Schiebe
- Department of Radiotherapy and Radio-Oncology, Klinikum Braunschweig, Celler Straße 38, 38114, Braunschweig, Germany. .,Radiation Oncology, Hannover Medical School, Hannover, Germany.
| | - Maxi Stockhammer
- Department of Gynecology and Obstetrics, Klinikum Braunschweig, Braunschweig, Germany
| | - Wolfgang Hoffmann
- Department of Radiotherapy and Radio-Oncology, Klinikum Braunschweig, Celler Straße 38, 38114, Braunschweig, Germany
| | - Fabian Wetzel
- Department of Radiotherapy and Radio-Oncology, Klinikum Braunschweig, Celler Straße 38, 38114, Braunschweig, Germany
| | - Heiko Franz
- Department of Gynecology and Obstetrics, Klinikum Braunschweig, Braunschweig, Germany
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Vourch S, Miglierini P, Miranda O, Malhaire JP, Boussion N, Pradier O, Schick U. Bénéfices de la radiothérapie avec asservissement respiratoire dans le traitement du cancer du sein. Cancer Radiother 2016; 20:30-5. [DOI: 10.1016/j.canrad.2015.09.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Revised: 08/28/2015] [Accepted: 09/11/2015] [Indexed: 10/22/2022]
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Zhang Y, Feng Y, Ahmad M, Ming X, Zhou L, Deng J. Intermediate Megavoltage Photon Beams for Improved Lung Cancer Treatments. PLoS One 2015; 10:e0145117. [PMID: 26672752 PMCID: PMC4682946 DOI: 10.1371/journal.pone.0145117] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 11/28/2015] [Indexed: 02/05/2023] Open
Abstract
The goal of this study is to evaluate the effects of intermediate megavoltage (3-MV) photon beams on SBRT lung cancer treatments. To start with, a 3-MV virtual beam was commissioned on a commercial treatment planning system based on Monte Carlo simulations. Three optimized plans (6-MV, 3-MV and dual energy of 3- and 6-MV) were generated for 31 lung cancer patients with identical beam configuration and optimization constraints for each patient. Dosimetric metrics were evaluated and compared among the three plans. Overall, planned dose conformity was comparable among three plans for all 31 patients. For 21 thin patients with average short effective path length (< 10 cm), the 3-MV plans showed better target coverage and homogeneity with dose spillage index R50% = 4.68±0.83 and homogeneity index = 1.26±0.06, as compared to 4.95±1.01 and 1.31±0.08 in the 6-MV plans (p < 0.001). Correspondingly, the average/maximum reductions of lung volumes receiving 20 Gy (V20Gy), 5 Gy (V5Gy), and mean lung dose (MLD) were 7%/20%, 9%/30% and 5%/10%, respectively in the 3-MV plans (p < 0.05). The doses to 5% volumes of the cord, esophagus, trachea and heart were reduced by 9.0%, 10.6%, 11.4% and 7.4%, respectively (p < 0.05). For 10 thick patients, dual energy plans can bring dosimetric benefits with comparable target coverage, integral dose and reduced dose to the critical structures, as compared to the 6-MV plans. In conclusion, our study indicated that 3-MV photon beams have potential dosimetric benefits in treating lung tumors in terms of improved tumor coverage and reduced doses to the adjacent critical structures, in comparison to 6-MV photon beams. Intermediate megavoltage photon beams (< 6-MV) may be considered and added into current treatment approaches to reduce the adjacent normal tissue doses while maintaining sufficient tumor dose coverage in lung cancer radiotherapy.
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Affiliation(s)
- Ying Zhang
- Department of Biomedical Engineering, Tianjin University, Tianjin, China
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Yuanming Feng
- Department of Biomedical Engineering, Tianjin University, Tianjin, China
| | - Munir Ahmad
- Department of Radiation Oncology, William W. Backus Hospital, Norwich, Connecticut, United States of America
| | - Xin Ming
- Department of Biomedical Engineering, Tianjin University, Tianjin, China
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Li Zhou
- Center for Radiation Physics and Technology, West China Hospital Cancer Center, Sichuan University, Chengdu, China
| | - Jun Deng
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut, United States of America
- * E-mail:
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Paul Wright G, Drinane JJ, Sobel HL, Chung MH. Left-Sided Breast Irradiation does not Result in Increased Long-Term Cardiac-Related Mortality Among Women Treated with Breast-Conserving Surgery. Ann Surg Oncol 2015; 23:1117-22. [DOI: 10.1245/s10434-015-4949-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Indexed: 01/31/2023]
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Poortmans PM, Collette S, Kirkove C, Van Limbergen E, Budach V, Struikmans H, Collette L, Fourquet A, Maingon P, Valli M, De Winter K, Marnitz S, Barillot I, Scandolaro L, Vonk E, Rodenhuis C, Marsiglia H, Weidner N, van Tienhoven G, Glanzmann C, Kuten A, Arriagada R, Bartelink H, Van den Bogaert W. Internal Mammary and Medial Supraclavicular Irradiation in Breast Cancer. N Engl J Med 2015. [PMID: 26200978 DOI: 10.1056/nejmoa1415369] [Citation(s) in RCA: 705] [Impact Index Per Article: 78.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The effect of internal mammary and medial supraclavicular lymph-node irradiation (regional nodal irradiation) added to whole-breast or thoracic-wall irradiation after surgery on survival among women with early-stage breast cancer is unknown. METHODS We randomly assigned women who had a centrally or medially located primary tumor, irrespective of axillary involvement, or an externally located tumor with axillary involvement to undergo either whole-breast or thoracic-wall irradiation in addition to regional nodal irradiation (nodal-irradiation group) or whole-breast or thoracic-wall irradiation alone (control group). The primary end point was overall survival. Secondary end points were the rates of disease-free survival, survival free from distant disease, and death from breast cancer. RESULTS Between 1996 and 2004, a total of 4004 patients underwent randomization. The majority of patients (76.1%) underwent breast-conserving surgery. After mastectomy, 73.4% of the patients in both groups underwent chest-wall irradiation. Nearly all patients with node-positive disease (99.0%) and 66.3% of patients with node-negative disease received adjuvant systemic treatment. At a median follow-up of 10.9 years, 811 patients had died. At 10 years, overall survival was 82.3% in the nodal-irradiation group and 80.7% in the control group (hazard ratio for death with nodal irradiation, 0.87; 95% confidence interval [CI], 0.76 to 1.00; P=0.06). The rate of disease-free survival was 72.1% in the nodal-irradiation group and 69.1% in the control group (hazard ratio for disease progression or death, 0.89; 95% CI, 0.80 to 1.00; P=0.04), the rate of distant disease-free survival was 78.0% versus 75.0% (hazard ratio, 0.86; 95% CI, 0.76 to 0.98; P=0.02), and breast-cancer mortality was 12.5% versus 14.4% (hazard ratio, 0.82; 95% CI, 0.70 to 0.97; P=0.02). Acute side effects of regional nodal irradiation were modest. CONCLUSIONS In patients with early-stage breast cancer, irradiation of the regional nodes had a marginal effect on overall survival. Disease-free survival and distant disease-free survival were improved, and breast-cancer mortality was reduced. (Funded by Fonds Cancer; ClinicalTrials.gov number, NCT00002851.).
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Affiliation(s)
- Philip M Poortmans
- From the Department of Radiation Oncology, Radboud University Medical Center, Nijmegen (P.M.P.), Department of Radiation Oncology, Institute Verbeeten, Tilburg (P.M.P., K.D.W.), Department of Radiation Oncology, Medisch Centrum Haaglanden, The Hague (H.S.), Department of Radiation Oncology, University Medical Center Utrecht, Utrecht (H.S., C.R.), Department of Radiation Oncology, Institute for Radiation Oncology Radiotherapeutisch Instituut Stedendriehoek en Omstreken, Deventer (E.V.), Department of Radiation Oncology, Academic Medical Center (G.T.), and Department of Radiation Oncology, the Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital (H.B.), Amsterdam - all in the Netherlands; European Organization for Research and Treatment of Cancer (EORTC) Headquarters (S.C., L.C.) and Department of Radiation Oncology, University Hospital Saint-Luc, Université Catholique de Louvain (C.K.), Brussels, and Department of Radiation Oncology, University Hospital Gasthuisberg, Leuven (E.V.L., W.V.B.) - all in Belgium; Department of Radiation Oncology, Charité University Medicine Berlin, Berlin (V.B., S.M.), and Department of Radiation Oncology, University Hospital, Tübingen (N.W.) - both in Germany; Department of Radiation Oncology, Institut Curie, Paris (A.F.), Department of Radiation Oncology, Centre Georges-François Leclerc, Dijon (P.M., I.B.), Department of Radiation Oncology, Université François Rabelais, Tours (I.B.), and Department of Radiation Oncology, Gustave Roussy Cancer Center, Villejuif (H.M.) - all in France; Department of Radiation Oncology, Ospedale Regionale di Bellinzona e Valli, Bellinzona (M.V.), and Department of Radiation Oncology, University Hospital Zurich (C.G.) - both in Switzerland; Department of Radiation Oncology, Sant'Anna Hospital, Como, Italy (M.V., L.S.); Department of Radiation Oncology, Rambam Medical Center, Haifa, Israel (A.K.); and Grupo Oncológico Cooperativo Chileno de Investigación, Santiago, Chile (R.A.)
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Alam A, Mukhopadhyay ND, Ning Y, Reshko LB, Cardnell RJG, Alam O, Rabender CS, Yakovlev VA, Walker L, Anscher MS, Mikkelsen RB. A Preliminary Study on Racial Differences in HMOX1, NFE2L2, and TGFβ1 Gene Polymorphisms and Radiation-Induced Late Normal Tissue Toxicity. Int J Radiat Oncol Biol Phys 2015; 93:436-43. [PMID: 26238954 DOI: 10.1016/j.ijrobp.2015.05.049] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 05/14/2015] [Accepted: 05/27/2015] [Indexed: 02/06/2023]
Abstract
PURPOSE This study tested whether racial differences in genetic polymorphisms of 4 genes involved in wound repair and response to radiation can be used to predict the occurrence of normal tissue late effects of radiation therapy and indicate potential therapeutic targets. METHODS AND MATERIALS This prospective study examined genetic polymorphisms that modulate the expression of 4 genes involved in inflammation and fibrosis and response to radiation (HMOX1, NFE2L2, NOS3, and TGFβ1). DNA from blood samples of 179 patients (∼ 80% breast and head and neck) collected at the time of diagnosis by their radiation oncologist as exhibiting late normal tissue toxicity was used for the analysis. Patient demographics were as follows: 56% white, 43% African American, 1% other. Allelic frequencies of the different polymorphisms of the participants were compared with those of the general American population stratified by race. Twenty-six additional patients treated with radiation, but without toxicity at 3 months or later after therapy, were also analyzed. RESULTS Increased frequency of a long GT repeat in the HMOX1 promoter was associated with late effects in both African American and white populations. The single nucleotide polymorphisms (SNP) rs1800469 in the TGFβ1 promoter and the rs6721961 SNP in the NFE2L2 promoter were also found to significantly associate with late effects in African Americans but not whites. A combined analysis of these polymorphisms revealed that >90% of African American patients with late effects had at least 1 of these minor alleles, and 58% had 2 or more. No statistical significance was found relating the studied NOS3 polymorphisms and normal tissue toxicity. CONCLUSIONS These results support a strong association between wound repair and late toxicities of radiation. The presence of these genetic risk factors can vary significantly among different ethnic groups, as demonstrated for some of the SNPs. Future studies should account for the possibility of such ethnic heterogeneity in the late toxicities of radiation.
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Affiliation(s)
- Asim Alam
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia
| | - Nitai D Mukhopadhyay
- Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia
| | - Yi Ning
- Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia
| | - Leonid B Reshko
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia
| | - Robert J G Cardnell
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia
| | - Omair Alam
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia
| | | | - Vasily A Yakovlev
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia
| | - Linda Walker
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia
| | - Mitchell S Anscher
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia
| | - Ross B Mikkelsen
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia.
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Nonrandomized Comparison between Concomitant and Sequential Chemoradiotherapy with Anthracyclines in Breast Cancer. TUMORI JOURNAL 2015; 101:64-71. [DOI: 10.5301/tj.5000218] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2014] [Indexed: 11/20/2022]
Abstract
Purpose To evaluate the tolerance of concomitant administration of anthracycline-based chemotherapy (CHT) and 3-dimensional conformal radiotherapy (RT) after breast-conserving surgery. Methods and Materials Sixty-seven patients, treated with conservative surgery followed by 3-dimensional whole breast RT and concomitant CHT regimens including “Canadian modified” CEF (5-fluorouracil, epirubicin, cyclophosphamide) or AC (doxorubicin, cyclophosphamide) were evaluated for toxicity. They were compared in terms in compliance and acute toxicity with 67 patients irradiated sequentially after having received anthracyclines. Results Acute grade ≥2 skin toxicity was significantly higher in the concomitant group compared to the sequential group, although the incidence of Grade 3 desquamation showed no statistical difference (9% vs. 3%, p = 0.14). Haematological toxicity represented the main cause of treatment discontinuation, reporting higher rate of grade 3-4 leuco-neutropenia in the concomitant group (20.9% vs. 6%, p = 0.01). Mean RT duration was longer in the concomitant group (51 days vs. 45 days) owing to RT breaks. Late toxicity was acceptable. No symptomatic lung and heart events were reported. Radiological lung hyperdensity was detected in 27.7% of the patients in the concomitant group. Post-treatment left ventricular ejection fraction significantly decreased compared with baseline, but cardiac function remained within the normal range, without any difference between left or right-sided RT. Conclusions Although there was more acute grade ≥2 skin toxicity in the concomitant group, the rate of grade 3 dermatitis was lower than expected, suggesting some advantages of 3-D CRT over older techniques. Haematological toxicity exerted a significant impact on both RT and CHT delivery.
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Chen T, Reyhan M, Yue N, Metaxas DN, Haffty BG, Goyal S. Tagged MRI based cardiac motion modeling and toxicity evaluation in breast cancer radiotherapy. Front Oncol 2015; 5:9. [PMID: 25692095 PMCID: PMC4315014 DOI: 10.3389/fonc.2015.00009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 01/11/2015] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ting Chen
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Meral Reyhan
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Ning Yue
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | | | - Bruce G. Haffty
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Sharad Goyal
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
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Onwudiwe NC, Kwok Y, Onukwugha E, Sorkin JD, Zuckerman IH, Shaya FT, Daniel Mullins C. Cardiovascular event-free survival after adjuvant radiation therapy in breast cancer patients stratified by cardiovascular risk. Cancer Med 2014; 3:1342-52. [PMID: 25044867 PMCID: PMC4302684 DOI: 10.1002/cam4.283] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Revised: 04/23/2014] [Accepted: 04/24/2014] [Indexed: 11/11/2022] Open
Abstract
The objective of this study was to estimate the risk of a cardiovascular event or death associated with modern radiation in a population of elderly female breast cancer patients with varying baseline cardiovascular risk. The data used for this analysis are from the linked Surveillance, Epidemiology, and End-Results (SEER)-Medicare database. The retrospective cohort study included women aged 66 years and older with stage 0–III breast cancer diagnosed between 2000 and 2005. Women were grouped as low, intermediate, or high cardiovascular risk based on the presence of certain clinical diagnoses. The risk for the combined outcome of a hospitalization for a cardiovascular event or death within 6 months and 24 months of diagnosis was estimated using a multivariable Cox model. The median follow-up time was 24 months. Among the 91,612 women with American Joint Committee on Cancer (AJCC) stage 0–III breast cancer: 39,555 (43.2%) were treated with radiation therapy and 52,057 (56.8%) were not. The receipt of radiation therapy in the first 6 months was associated with a statistically significant increased risk for the combined outcome in women categorized as high risk (HR = 1.510; 95% CI, 1.396–1.634) or intermediate risk (HR = 1.415; 95% CI, 1.188–1.686) but not low risk (HR = 1.027; 95% CI, 0.798–1.321). Women with a prior medical history of cardiovascular disease treated with radiation therapy are at increased risk for an event and should be monitored for at least 6 months following treatment with radiation therapy.
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Affiliation(s)
- Nneka C Onwudiwe
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, Maryland
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Mackenzie P, Fyles A, Wang W, Chung C. Advanced radiotherapy techniques for breast cancer to minimize cardiovascular risk. BREAST CANCER MANAGEMENT 2014. [DOI: 10.2217/bmt.14.7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
SUMMARY Radiotherapy plays an integral role in the management of breast cancer and has been demonstrated to reduce the risk of recurrence and improve overall survival. Recent reports in the literature have suggested a dose-dependent risk of cardiovascular disease following radiation treatment for breast cancer. This article highlights new advances in radiotherapy for breast cancer that may help minimize radiotherapy doses to the heart.
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Affiliation(s)
- Penny Mackenzie
- Department of Radiation Oncology, Princess Margaret Cancer Centre, 610 University Avenue, Toronto, Ontario, M5V 2V1, Canada
| | - Anthony Fyles
- Department of Radiation Oncology, Princess Margaret Cancer Centre, 610 University Avenue, Toronto, Ontario, M5V 2V1, Canada
| | - Wei Wang
- Westmead Cancer Centre, Sydney, Australia
| | - Caroline Chung
- Department of Radiation Oncology, Princess Margaret Cancer Centre, 610 University Avenue, Toronto, Ontario, M5V 2V1, Canada
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Bao J, Yu KD, Jiang YZ, Shao ZM, Di GH. The effect of laterality and primary tumor site on cancer-specific mortality in breast cancer: a SEER population-based study. PLoS One 2014; 9:e94815. [PMID: 24740002 PMCID: PMC3989248 DOI: 10.1371/journal.pone.0094815] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Accepted: 03/20/2014] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Reduced overall survival has been observed in patients with left-sided versus right-sided breast cancer due to cardiac toxicity after radiotherapy. However, the effect of laterality and primary tumor site on breast cancer-specific mortality (BCSM) remains unclear. PATIENTS AND METHODS We analyzed data from 305,443 women ages 20- to 79-years-old diagnosed with breast cancer between 1990 and 2009. The data were obtained from the population-based Surveillance, Epidemiology, and End Results (SEER) program of the U.S. National Cancer Institute. The survival outcomes with regard to laterality and primary tumor site were compared using univariate and multivariate (Cox proportional hazards regression model) methods. RESULTS In the multivariate analysis, BCSM was affected by the primary tumor site (P<0.0001) but not laterality (P = 0.331). The combined effect was piecewise: using the left upper-outer quadrant as the reference, the BCSM hazard ratio (HR) was not significant in the right upper quadrant (P = 0.755) and the right central portion (P = 0.329). The BCSM HR was slightly increased in the left central portion as well as the left and right lower-outer quadrants (HRs from 1.136 to 1.145; P<0.0001). The BCSM HR was significantly increased in the upper-inner and lower-inner quadrants (HRs from 1.242 to 1.372; P<0.0001) on both sides. Laterality only impacted BCSM in patients with breast cancer located in the central portion (HR, 1.100; P = 0.013, using the right side as the reference). CONCLUSION Patients with tumors in the upper-outer quadrant of both sides and the right central portion have a better prognosis than patients with tumors at other locations. Laterality is not regarded as a prognostic factor in breast cancer.
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Affiliation(s)
- Jing Bao
- Department of Breast Surgery, Cancer Center and Cancer Institute, Shanghai Medical College, Fudan University, Shanghai, P. R. China
| | - Ke-Da Yu
- Department of Breast Surgery, Cancer Center and Cancer Institute, Shanghai Medical College, Fudan University, Shanghai, P. R. China
- * E-mail: ;
| | - Yi-Zhou Jiang
- Department of Breast Surgery, Cancer Center and Cancer Institute, Shanghai Medical College, Fudan University, Shanghai, P. R. China
| | - Zhi-Ming Shao
- Department of Breast Surgery, Cancer Center and Cancer Institute, Shanghai Medical College, Fudan University, Shanghai, P. R. China
| | - Gen-Hong Di
- Department of Breast Surgery, Cancer Center and Cancer Institute, Shanghai Medical College, Fudan University, Shanghai, P. R. China
- * E-mail: ;
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Adjuvant Hypofractionated Versus Conventional Whole Breast Radiation Therapy for Early-Stage Breast Cancer: Long-Term Hospital-Related Morbidity From Cardiac Causes. Int J Radiat Oncol Biol Phys 2014; 88:786-92. [DOI: 10.1016/j.ijrobp.2013.11.243] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 11/20/2013] [Accepted: 11/25/2013] [Indexed: 11/16/2022]
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Steingart RM, Yadav N, Manrique C, Carver JR, Liu J. Cancer Survivorship: Cardiotoxic Therapy in the Adult Cancer Patient; Cardiac Outcomes With Recommendations for Patient Management. Semin Oncol 2013; 40:690-708. [DOI: 10.1053/j.seminoncol.2013.09.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Mutaf YD, Zhang J, Yu CX, Yi BY, Prado K, D'Souza WD, Regine WF, Feigenberg SJ. Dosimetric and geometric evaluation of a novel stereotactic radiotherapy device for breast cancer: the GammaPod™. Med Phys 2013; 40:041722. [PMID: 23556892 DOI: 10.1118/1.4794477] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE A dedicated stereotactic gamma irradiation device, the GammaPod™ from Xcision Medical Systems, was developed specifically to treat small breast cancers. This study presents the first evaluation of dosimetric and geometric characteristics from the initial prototype installed at University of Maryland Radiation Oncology Department. METHODS The GammaPod™ stereotactic radiotherapy device is an assembly of a hemi-spherical source carrier containing 36 (60)Co sources, a tungsten collimator, a dynamically controlled patient support table, and the breast immobilization system which also functions as a stereotactic frame. The source carrier contains the sources in six columns spaced longitudinally at 60° intervals and it rotates together with the variable-size collimator to form 36 noncoplanar, concentric arcs focused at the isocenter. The patient support table enables motion in three dimensions to position the patient tumor at the focal point of the irradiation. The table moves continuously in three cardinal dimensions during treatment to provide dynamic shaping of the dose distribution. The breast is immobilized using a breast cup applying a small negative pressure, where the immobilization cup is embedded with fiducials also functioning as the stereotactic frame for the breast. Geometric and dosimetric evaluations of the system as well as a protocol for absorbed dose calibration are provided. Dosimetric verifications of dynamically delivered patient plans are performed for seven patients using radiochromic films in hypothetical preop, postop, and target-in-target treatment scenarios. RESULTS Loaded with 36 (60)Co sources with cumulative activity of 4320 Ci, the prototype GammaPod™ unit delivers 5.31 Gy/min at the isocenter using the largest 2.5 cm diameter collimator. Due to the noncoplanar beam arrangement and dynamic dose shaping features, the GammaPod™ device is found to deliver uniform doses to targets with good conformity. The spatial accuracy of the device to locate the radiation isocenter is determined to be less than 1 mm. Single shot profiles with 2.5 cm collimator are measured with radiochromic film and found to be in good agreement with respect to the Monte Carlo based calculations (congruence of FWHM less than 1 mm). Dosimetric verifications corresponding to all hypothetical treatment plans corresponding to three target scenarios for each of the seven patients demonstrated good agreement with gamma index pass rates of better than 97% (99.0% ± 0.7%). CONCLUSIONS Dosimetric evaluation of the first GammaPod™ stereotactic breast radiotherapy unit was performed and the dosimetric and spatial accuracy of this novel technology is found to be feasible with respect to clinical radiotherapy standards. The observed level of agreement between the treatment planning system calculations and dosimetric measurements has confirmed that the system can deliver highly complex treatment plans with remarkable geometric and dosimetric accuracy.
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Affiliation(s)
- Yildirim D Mutaf
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA
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Tjessem KH, Johansen S, Malinen E, Reinertsen KV, Danielsen T, Fosså SD, Fosså A. Long-term cardiac mortality after hypofractionated radiation therapy in breast cancer. Int J Radiat Oncol Biol Phys 2013; 87:337-43. [PMID: 23886416 DOI: 10.1016/j.ijrobp.2013.05.038] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Revised: 05/12/2013] [Accepted: 05/21/2013] [Indexed: 11/19/2022]
Abstract
PURPOSE To explore very-long-term mortality from ischemic heart disease (IHD) after locoregional radiation therapy of breast cancer (BC) in relation to degree of hypofractionation and other treatment variables. METHODS AND MATERIALS Two hypofractionated regimens used for locoregional radiation therapy for BC from 1975 to 1991 were considered. Patients received 4.3 Gy × 2/week (10 fractions; target dose 43 Gy; n=1107) or 2.5 Gy × 5/week (20 fractions; target dose 50 Gy; n=459). To estimate cardiac doses, radiation fields were reconstructed in a planning system. Time to death from IHD was the endpoint, comparing the groups with each other and with age-matched, cancer-free control individuals, modeled with the Cox proportional hazards model. RESULTS Patients given 4.3 Gy × 10 had an increased risk of dying of IHD compared with both the 2.5 Gy group (hazard ratio [HR] = 2.37; 95% confidence interval [CI]: 1.06-5.32; P=.036) and the control group (HR = 1.59; 95% CI: 1.13-2.23; P=.008). Photon beams for parasternal fields gave an increased risk of dying of IHD compared with electron beams (HR = 2.56; 95% CI: 1.12-5.84; P=.025). Multivariate analysis gave an increased risk for the 4.3-Gy versus 2.5-Gy regimen with borderline significance (HR = 2.90; 95% CI: 0.97-8.79; P=.057) but not for parasternal irradiation. CONCLUSIONS The degree of hypofractionation and parasternal photon beams contributed to increased cardiac mortality in this patient cohort. Differences emerged after 12 to 15 years, indicating the need of more studies with observation time of 2 decades.
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Affiliation(s)
- Kristin Holm Tjessem
- Department of Oncology, Oslo University Hospital, National Resource Centre for Late Effects after Cancer Treatment, Oslo, Norway.
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Riihimäki M, Thomsen H, Brandt A, Sundquist J, Hemminki K. Death causes in breast cancer patients. Ann Oncol 2012; 23:604-610. [PMID: 21586686 DOI: 10.1093/annonc/mdr160] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Due to improved outcomes in breast cancer (BCa), the proportion of affected women dying of other causes has increased. Thus, a better survival of BCa requires knowledge of other causes of death. MATERIALS AND METHODS Data on the population, cancers, and causes of death were gathered from the nationwide Swedish Family-Cancer Database, enrolling ∼3.68 million Swedish women. A Cox regression model, comparing BCa patients against all other women, was applied. Cause-of-death-specific hazard ratios (HRs) were calculated for both underlying and multiple causes of death. RESULTS Among 641 000 deaths from 1987 to 2006, 48,000 were BCa patients. For underlying causes except BCa, the highest cause-specific HRs were found for diseases of pulmonary circulation {1.51 [95% confidence interval (CI) 1.36-1.68]}, suicide [1.39 (1.19-1.63)], and heart failure [1.29 (1.22-1.37)]. For specific multiple causes, the highest ratios were found for external causes [1.86 (1.80-1.91)] and gastrointestinal disease [1.68 (1.62-1.74)]. CONCLUSIONS Diagnosis of BCa is associated with increased risks of dying of various causes, including external causes, heart failure, diseases of pulmonary circulation, and gastrointestinal disease. The study fulfills the gap in knowledge of death causes in BCa patients and suggests to draw more attention to comorbidities.
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Affiliation(s)
- M Riihimäki
- Division of Molecular Genetic Epidemiology, German Cancer Research Center, Heidelberg, Germany; Center for Primary Care Research, Lund University, Malmö, Sweden
| | - H Thomsen
- Division of Molecular Genetic Epidemiology, German Cancer Research Center, Heidelberg, Germany.
| | - A Brandt
- Division of Molecular Genetic Epidemiology, German Cancer Research Center, Heidelberg, Germany
| | - J Sundquist
- Center for Primary Care Research, Lund University, Malmö, Sweden; Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, USA
| | - K Hemminki
- Division of Molecular Genetic Epidemiology, German Cancer Research Center, Heidelberg, Germany; Center for Primary Care Research, Lund University, Malmö, Sweden
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D’Errico MP, Grimaldi L, Petruzzelli MF, Gianicolo EA, Tramacere F, Monetti A, Placella R, Pili G, Andreassi MG, Sicari R, Picano E, Portaluri M. N-Terminal Pro-B–Type Natriuretic Peptide Plasma Levels as a Potential Biomarker for Cardiac Damage After Radiotherapy in Patients With Left-Sided Breast Cancer. Int J Radiat Oncol Biol Phys 2012; 82:e239-46. [DOI: 10.1016/j.ijrobp.2011.03.058] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Revised: 03/15/2011] [Accepted: 03/31/2011] [Indexed: 10/18/2022]
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McGale P, Darby SC, Hall P, Adolfsson J, Bengtsson NO, Bennet AM, Fornander T, Gigante B, Jensen MB, Peto R, Rahimi K, Taylor CW, Ewertz M. Incidence of heart disease in 35,000 women treated with radiotherapy for breast cancer in Denmark and Sweden. Radiother Oncol 2011; 100:167-75. [PMID: 21752480 DOI: 10.1016/j.radonc.2011.06.016] [Citation(s) in RCA: 323] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2010] [Revised: 06/08/2011] [Accepted: 06/08/2011] [Indexed: 12/15/2022]
Abstract
PURPOSE To study incidence of radiation-related heart disease in a large population of breast cancer patients followed for up to 30 years. MATERIAL AND METHODS 72,134 women diagnosed with breast cancer in Denmark or Sweden during 1976-2006 and followed prospectively. Radiation-related risk was studied by comparing women with left-sided and right-sided tumours. RESULTS 34,825 women (48%) received radiotherapy. Among unirradiated women tumour laterality had little relevance to heart disease. Among irradiated women mean dose to the whole heart was 6.3 Gy for left-sided tumours and 2.7 Gy for right-sided tumours. Mortality was similar in irradiated women with left-sided and right-sided tumours, but incidence ratios, left-sided versus right-sided, were raised: acute myocardial infarction 1.22 (95% CI 1.06-1.42), angina 1.25 (1.05-1.49), pericarditis 1.61 (1.06-2.43), valvular heart disease 1.54 (1.11-2.13). Incidence ratios for all heart disease were as high for women irradiated since 1990 (1.09 [1.00-1.19]) as for women irradiated during 1976-1989 (1.08 [0.99-1.17]), and were higher for women diagnosed with ischaemic heart disease prior to breast cancer than for other women (1.58 [1.19-2.10] versus 1.08 [1.01-1.15], p for difference=0.01). CONCLUSIONS Breast cancer radiotherapy has, at least until recently, increased the risk of developing ischaemic heart disease, pericarditis and valvular disease. Women with ischaemic heart disease before breast cancer diagnosis may have incurred higher risks than others.
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Affiliation(s)
- Paul McGale
- Clinical Trial Service Unit, University of Oxford, UK
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