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Jiang W, Jin WL, Xu AM. Cholesterol metabolism in tumor microenvironment: cancer hallmarks and therapeutic opportunities. Int J Biol Sci 2024; 20:2044-2071. [PMID: 38617549 PMCID: PMC11008265 DOI: 10.7150/ijbs.92274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 02/27/2024] [Indexed: 04/16/2024] Open
Abstract
Cholesterol is crucial for cell survival and growth, and dysregulation of cholesterol homeostasis has been linked to the development of cancer. The tumor microenvironment (TME) facilitates tumor cell survival and growth, and crosstalk between cholesterol metabolism and the TME contributes to tumorigenesis and tumor progression. Targeting cholesterol metabolism has demonstrated significant antitumor effects in preclinical and clinical studies. In this review, we discuss the regulatory mechanisms of cholesterol homeostasis and the impact of its dysregulation on the hallmarks of cancer. We also describe how cholesterol metabolism reprograms the TME across seven specialized microenvironments. Furthermore, we discuss the potential of targeting cholesterol metabolism as a therapeutic strategy for tumors. This approach not only exerts antitumor effects in monotherapy and combination therapy but also mitigates the adverse effects associated with conventional tumor therapy. Finally, we outline the unresolved questions and suggest potential avenues for future investigations on cholesterol metabolism in relation to cancer.
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Affiliation(s)
- Wen Jiang
- Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, P. R. China
| | - Wei-Lin Jin
- Institute of Cancer Neuroscience, Medical Frontier Innovation Research Center, The First Hospital of Lanzhou University, Lanzhou 730000, P. R. China
| | - A-Man Xu
- Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, P. R. China
- Anhui Public Health Clinical Center, Hefei 230022, P. R. China
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2
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Wernhart S, Rassaf T. Exercise, cancer, and the cardiovascular system: clinical effects and mechanistic insights. Basic Res Cardiol 2024:10.1007/s00395-024-01034-4. [PMID: 38353711 DOI: 10.1007/s00395-024-01034-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/21/2024] [Accepted: 01/21/2024] [Indexed: 03/05/2024]
Abstract
Cardiovascular diseases and cancer are the leading causes of death in the Western world and share common risk factors. Reduced cardiorespiratory fitness (CRF) is a major determinant of cardiovascular morbidity and cancer survival. In this review we discuss cancer- induced disturbances of parenchymal, cellular, and mitochondrial function, which limit CRF and may be antagonized and attenuated through exercise training. We show the impact of CRF on cancer survival and its attenuating effects on cardiotoxicity of cancer-related treatment. Tailored exercise programs are not yet available for each tumor entity as several trials were performed in heterogeneous populations without adequate cardiopulmonary exercise testing (CPET) prior to exercise prescription and with a wide variation of exercise modalities. There is emerging evidence that exercise may be a crucial pillar in cancer treatment and a tool to mitigate cardiotoxic treatment effects. We discuss modalities of aerobic exercise and resistance training and their potential to improve CRF in cancer patients and provide an example of a periodization model for exercise training in cancer.
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Affiliation(s)
- Simon Wernhart
- West German Heart- and Vascular Center, Department of Cardiology and Vascular Medicine, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany.
| | - Tienush Rassaf
- West German Heart- and Vascular Center, Department of Cardiology and Vascular Medicine, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
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Park Y, Farhat Z, Liao LM, Inoue-Choi M, Loftfield E. Multivitamin use and all-cause and cause-specific mortality in cancer survivors. Br J Cancer 2024; 130:82-87. [PMID: 38017130 PMCID: PMC10781735 DOI: 10.1038/s41416-023-02421-9] [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: 12/21/2022] [Revised: 08/23/2023] [Accepted: 08/30/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND Despite no sufficient evidence on benefits and harms of multivitamin use, cancer survivors use multivitamins as a self-care strategy to improve or maintain health. We examined if multivitamin use was associated with mortality in cancer survivors. METHODS 15,936 male and 7026 female cancer survivors in the NIH-AARP Diet and Health Study were included in the analysis. Types and frequency of multivitamin use at on average 4.6 years after cancer diagnosis were assessed. Multivariable-adjusted relative risks (RR) and 95% confidence intervals (CI) were estimated using Cox proportional hazards regression models. RESULTS Multivitamin use was not associated with lower all-cause mortality risk in all female (RR = 0.94, 95% CI:0.87-1.01 daily vs. no use) or male cancer survivors (RR = 0.96, 95% CI:0.91-1.00); however, a modest inverse association for CVD mortality was observed in female survivors of reproductive cancers (RR = 0.75, 95% CI:0.61-0.92) and male survivors of non-reproductive cancers (RR = 0.81, 95% CI:0.70-0.94). Multivitamin use was also associated with a lower risk of cancer-specific mortality in survivors of skin (RR = 0.65, 95% CI:0.48-0.88) and breast (RR = 0.79, 95% CI:0.65-0.95) cancer. DISCUSSION Multivitamin use may provide a modest survival benefit to some cancer survivors. Cancer care providers should talk with cancer survivors about potential benefits and harms of multivitamin use.
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Affiliation(s)
- Yikyung Park
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA.
| | - Zeinab Farhat
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Linda M Liao
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Maki Inoue-Choi
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Erikka Loftfield
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
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Galimzhanov A, Istanbuly S, Tun HN, Ozbay B, Alasnag M, Ky B, Lyon AR, Kayikcioglu M, Tenekecioglu E, Panagioti M, Kontopantelis E, Abdel-Qadir H, Mamas MA. Cardiovascular outcomes in breast cancer survivors: a systematic review and meta-analysis. Eur J Prev Cardiol 2023; 30:2018-2031. [PMID: 37499186 DOI: 10.1093/eurjpc/zwad243] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 06/19/2023] [Accepted: 07/21/2023] [Indexed: 07/29/2023]
Abstract
AIMS It is unclear whether the future risk of cardiovascular events in breast cancer (Bc) survivors is greater than in the general population. This meta-analysis quantifies the risk of cardiovascular disease development in Bc patients, compared to the risk in a general matched cancer-free population, and reports the incidence of cardiovascular events in patients with Bc. METHODS AND RESULTS We searched PubMed, Scopus, and Web of Science databases (up to 23 March 2022) for observational studies and post hoc analyses of randomized controlled trials. Cardiovascular death, heart failure (HF), atrial fibrillation (AF), coronary artery disease (CAD), myocardial infarction (MI), and stroke were the individual endpoints for our meta-analysis. We pooled incidence rates (IRs) and risk in hazard ratios (HRs), using random-effects meta-analyses. Heterogeneity was reported through the I2 statistic, and publication bias was examined using funnel plots and Egger's test in the meta-analysis of risk. One hundred and forty-two studies were identified in total, 26 (836 301 patients) relevant to the relative risk and 116 (2 111 882 patients) relevant to IRs. Compared to matched cancer-free controls, Bc patients had higher risk for cardiovascular death within 5 years of cancer diagnosis [HR = 1.09; 95% confidence interval (CI): 1.07, 1.11], HF within 10 years (HR = 1.21; 95% CI: 1.1, 1.33), and AF within 3 years (HR = 1.13; 95% CI: 1.05, 1.21). The pooled IR for cardiovascular death was 1.73 (95% CI 1.18, 2.53), 4.44 (95% CI 3.33, 5.92) for HF, 4.29 (95% CI 3.09, 5.94) for CAD, 1.98 (95% CI 1.24, 3.16) for MI, 4.33 (95% CI 2.97, 6.30) for stroke of any type, and 2.64 (95% CI 2.97, 6.30) for ischaemic stroke. CONCLUSION Breast cancer exposure was associated with the increased risk for cardiovascular death, HF, and AF. The pooled incidence for cardiovascular endpoints varied depending on population characteristics and endpoint studied. REGISTRATION CRD42022298741.
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Affiliation(s)
- Akhmetzhan Galimzhanov
- Department of Propedeutics of Internal Disease, Semey Medical University, Semey, Kazakhstan
- Keele Cardiovascular Research Group, Center for Prognosis Research, Keele University, Stoke on Trent, Keele, UK
| | - Sedralmontaha Istanbuly
- Keele Cardiovascular Research Group, Center for Prognosis Research, Keele University, Stoke on Trent, Keele, UK
- Faculty of Medicine, University of Aleppo, Aleppo, Syrian Arab Republic
| | - Han Naung Tun
- Larner College of Medicine, University of Vermont, Burlington, VT, USA
| | - Benay Ozbay
- Basaksehir Cam and Sakura State Hospital Department of Cardiology, Istanbul, Turkey
- Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Bonnie Ky
- Division of Cardiology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Alexander R Lyon
- Cardio-Oncology Service, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, London, UK
| | - Meral Kayikcioglu
- Department of Cardiology, Faculty of Medicine, 60521 Ege University, Izmir, Turkey
| | - Erhan Tenekecioglu
- Department of Cardiology, Bursa Yuksek İhtisas Training and Research Hospital, Health Sciences University, Bursa, Turkey
- Department of Cardiology, Erasmus MC, Thorax Center, Erasmus University, Rotterdam, The Netherlands
| | - Maria Panagioti
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, National Institute for Health Research School for Primary Care Research, University of Manchester, Manchester, UK
| | - Evangelos Kontopantelis
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, National Institute for Health Research School for Primary Care Research, University of Manchester, Manchester, UK
| | - Husam Abdel-Qadir
- Department of Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Canada
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Center for Prognosis Research, Keele University, Stoke on Trent, Keele, UK
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Yu AF, Lin I, Jorgensen J, Copeland‐Halperin R, Feldman S, Ibtida I, Assefa A, Johnson MN, Dang CT, Liu JE, Steingart RM. Nomogram for Predicting Risk of Cancer Therapy-Related Cardiac Dysfunction in Patients With Human Epidermal Growth Factor Receptor 2-Positive Breast Cancer. J Am Heart Assoc 2023; 12:e029465. [PMID: 37750581 PMCID: PMC10727240 DOI: 10.1161/jaha.123.029465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 07/06/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Cancer therapy-related cardiac dysfunction (CTRCD) is an important treatment-limiting toxicity for patients with human epidermal growth factor receptor 2 (HER2)-positive breast cancer that adversely affects cancer and cardiovascular outcomes. Easy-to-use tools that incorporate readily accessible clinical variables for individual estimation of CTRCD risk are needed. METHODS AND RESULTS From 2004 to 2013, 1440 patients with stage I to III HER2-positive breast cancer treated with trastuzumab-based therapy were identified. A multivariable Cox proportional hazards model was constructed to identify risk factors for CTRCD and included the 1377 patients in whom data were complete. Nine clinical variables, including age, race, body mass index, left ventricular ejection fraction, systolic blood pressure, coronary artery disease, diabetes, arrhythmia, and anthracycline exposure were built into a nomogram estimating risk of CTRCD at 1 year. The nomogram was validated for calibration and discrimination using bootstrap resampling. A total of 177 CTRCD events occurred within 1 year of HER2-targeted treatment. The nomogram for prediction of 1-year CTRCD probability demonstrated good discrimination, with a concordance index of 0.687. The predicted and observed probabilities of CTRCD were similar, demonstrating good model calibration. CONCLUSIONS A nomogram composed of 9 readily accessible clinical variables provides an individualized 1-year risk estimate of CTRCD among women with HER2-positive breast cancer receiving HER2-targeted therapy. This nomogram represents a simple-to-use tool for clinicians and patients that can inform clinical decision-making on breast cancer treatment options, optimal frequency of cardiac surveillance, and role of cardioprotective strategies.
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Affiliation(s)
- Anthony F. Yu
- Department of MedicineMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
- Weill Cornell Medical CollegeNew YorkNYUSA
| | - I‐Hsin Lin
- Department of Epidemiology and BiostatisticsMemorial Sloan Kettering CancerNew YorkNYUSA
| | - Justine Jorgensen
- Department of MedicineMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | | | - Stephanie Feldman
- Department of Medicine, Division of CardiologyRutgers New Jersey Medical SchoolNewarkNJUSA
| | - Ishmam Ibtida
- Department of MedicineMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | - Amare Assefa
- Department of MedicineMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | - Michelle N. Johnson
- Department of MedicineMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
- Weill Cornell Medical CollegeNew YorkNYUSA
| | - Chau T. Dang
- Department of MedicineMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
- Weill Cornell Medical CollegeNew YorkNYUSA
| | - Jennifer E. Liu
- Department of MedicineMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
- Weill Cornell Medical CollegeNew YorkNYUSA
| | - Richard M. Steingart
- Department of MedicineMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
- Weill Cornell Medical CollegeNew YorkNYUSA
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Thavendiranathan P, Houbois C, Marwick TH, Kei T, Saha S, Runeckles K, Huang F, Shalmon T, Thorpe KE, Pezo RC, Prica A, Maze D, Abdel-Qadir H, Connelly KA, Chan J, Billia F, Power C, Hanneman K, Wintersperger BJ, Brezden-Masley C, Amir E. Statins to prevent early cardiac dysfunction in cancer patients at increased cardiotoxicity risk receiving anthracyclines. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2023; 9:515-525. [PMID: 37120736 PMCID: PMC10509566 DOI: 10.1093/ehjcvp/pvad031] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 04/12/2023] [Accepted: 04/28/2023] [Indexed: 05/01/2023]
Abstract
BACKGROUND AND AIMS Anthracyclines can cause cancer therapy-related cardiac dysfunction (CTRCD). We aimed to assess whether statins prevent decline in left ventricular ejection fraction (LVEF) in anthracycline-treated patients at increased risk for CTRCD. METHODS In this multicenter double-blinded, placebo-controlled trial, patients with cancer at increased risk of anthracycline-related CTRCD (per ASCO guidelines) were randomly assigned to atorvastatin 40 mg or placebo once-daily. Cardiovascular magnetic resonance (CMR) imaging was performed before and within 4 weeks after anthracyclines. Blood biomarkers were measured at every cycle. The primary outcome was post-anthracycline LVEF, adjusted for baseline. CTRCD was defined as a fall in LVEF by >10% to <53%. Secondary endpoints included left ventricular (LV) volumes, CTRCD, CMR tissue characterization, high sensitivity troponin I (hsTnI), and B-type natriuretic peptide (BNP). RESULTS We randomized 112 patients (56.9 ± 13.6 years, 87 female, and 73 with breast cancer): 54 to atorvastatin and 58 to placebo. Post-anthracycline CMR was performed 22 (13-27) days from last anthracycline dose. Post-anthracycline LVEF did not differ between the atorvastatin and placebo groups (57.3 ± 5.8% and 55.9 ± 7.4%, respectively) when adjusted for baseline LVEF (P = 0.34). There were no significant between-group differences in post-anthracycline LV end-diastolic (P = 0.20) or end-systolic volume (P = 0.12), CMR myocardial edema and/or fibrosis (P = 0.06-0.47), or peak hsTnI (P ≥ 0.99) and BNP (P = 0.23). CTRCD incidence was similar (4% versus 4%, P ≥ 0.99). There was no difference in adverse events. CONCLUSIONS In patients at increased risk of CTRCD, primary prevention with atorvastatin during anthracycline therapy did not ameliorate early LVEF decline, LV remodeling, CTRCD, change in serum cardiac biomarkers, or CMR myocardial tissue changes. TRIAL REGISTRATION NCT03186404.
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Affiliation(s)
- Paaladinesh Thavendiranathan
- Department of Medicine, Division of Cardiology, Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Christian Houbois
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - Thomas H Marwick
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Baker Department of Cardiometabolic Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Tiffanie Kei
- Department of Medicine, Division of Cardiology, Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Sudipta Saha
- Rogers Computational Program, Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Kyle Runeckles
- Rogers Computational Program, Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Flora Huang
- Department of Medicine, Division of Cardiology, Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Tamar Shalmon
- Department of Medicine, Division of Cardiology, Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Kevin E Thorpe
- Dalla Lana School of Public Health, University of Toronto and Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Rossanna C Pezo
- Department of Medicine, Division of Medical Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Anca Prica
- Department of Medicine, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Dawn Maze
- Department of Medicine, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Husam Abdel-Qadir
- Department of Medicine, Division of Cardiology, Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
- Women's College Hospital (WCH), Toronto, ON, Canada
| | - Kim A Connelly
- Keenan Research Centre, Li Ka Shing Knowledge Institute, Division of Cardiology, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Joyce Chan
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Filio Billia
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Coleen Power
- Department of Medicine, Division of Cardiology, Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Kate Hanneman
- Joint Department of Medical Imaging, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - Bernd J Wintersperger
- Joint Department of Medical Imaging, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - Christine Brezden-Masley
- Department of Medicine, Division of Medical Oncology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Eitan Amir
- Department of Medicine, Division of Medical Oncology, Program, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada
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Chi K, Luo Z, Zhao H, Li Y, Liang Y, Xiao Z, He Y, Zhang H, Ma Z, Zeng L, Zhou R, Feng M, Li W, Rao H, Yi M. The impact of tumor characteristics on cardiovascular disease death in breast cancer patients with CT or RT: a population-based study. Front Cardiovasc Med 2023; 10:1149633. [PMID: 37229229 PMCID: PMC10203988 DOI: 10.3389/fcvm.2023.1149633] [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: 01/22/2023] [Accepted: 04/24/2023] [Indexed: 05/27/2023] Open
Abstract
Background Previous studies focused on the impact of cardiovascular diseases (CVD) risk factors in breast cancer patients with chemotherapy (CT) or radiotherapy (RT). This study aimed to identify the impact of tumor characteristics on CVD death in these patients. Methods Data of female breast cancer patients with CT or RT between 2004 and 2016 were included. The risk factors of CVD death were identified using Cox regression analyses. A nomogram was constructed to evaluate the predicted value of tumor characteristics, and then validated by the concordance indexes (C-index) and calibration curves. Result A total of 28,539 patients were included with an average follow-up of 6.1 years. Tumor size > 45 mm (adjusted HR = 1.431, 95% CI = 1.116-1.836, P = 0.005), regional (adjusted HR = 1.278, 95% CI = 1.048-1.560, P = 0.015) and distant stage (adjusted HR = 2.240, 95% CI = 1.444-3.474, P < 0.001) were risk factors of CVD death for breast cancer patients with CT or RT. The prediction nomogram of tumor characteristics (tumor size and stage) on CVD survival was established. The C-index of internal and external validation were 0.780 (95% Cl = 0.751-0.809), and 0.809 (95% Cl = 0.768-0.850), respectively. The calibration curves showed consistency between the actual observation and nomogram. The risk stratification was also significant distinction (P < 0.05). Conclusion Tumor size and stage were related to the risk of CVD death for breast cancer patients with CT or RT. The management of CVD death risk in breast cancer patients with CT or RT should focus not only on CVD risk factors but also on tumor size and stage.
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Affiliation(s)
- Kaiyi Chi
- Department of Endocrinology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Department of Clinical Medicine, The Second Clinical College of Guangzhou Medical University, Guangzhou, China
- Cardiovascular Medicine and Cardio-Oncology Group, Medical Exploration and Translation Team, Guangzhou, China
| | - Zehao Luo
- Cardiovascular Medicine and Cardio-Oncology Group, Medical Exploration and Translation Team, Guangzhou, China
- Department of Clinical Medicine, The Sixth Clinical College of Guangzhou Medical University, Guangzhou, China
| | - Hongjun Zhao
- Cardiovascular Medicine and Cardio-Oncology Group, Medical Exploration and Translation Team, Guangzhou, China
- Department of Clinical Medicine, The Sixth Clinical College of Guangzhou Medical University, Guangzhou, China
| | - Yemin Li
- Cardiovascular Medicine and Cardio-Oncology Group, Medical Exploration and Translation Team, Guangzhou, China
- Department of Clinical Medicine, The First Clinical College of Guangzhou Medical University, Guangzhou, China
| | - Yinglan Liang
- Cardiovascular Medicine and Cardio-Oncology Group, Medical Exploration and Translation Team, Guangzhou, China
- Department of Anesthesiology, The Second Clinical College of Guangzhou Medical University, Guangzhou, China
| | - Zhaoling Xiao
- Department of Clinical Medicine, The Second Clinical College of Guangzhou Medical University, Guangzhou, China
- Cardiovascular Medicine and Cardio-Oncology Group, Medical Exploration and Translation Team, Guangzhou, China
| | - Yiru He
- Cardiovascular Medicine and Cardio-Oncology Group, Medical Exploration and Translation Team, Guangzhou, China
- Department of Clinical Medicine, The Third Clinical College of Guangzhou Medical University, Guangzhou, China
| | - Hanbin Zhang
- Cardiovascular Medicine and Cardio-Oncology Group, Medical Exploration and Translation Team, Guangzhou, China
- Department of Radiological Oncology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zaiying Ma
- Department of Clinical Medicine, The Second Clinical College of Guangzhou Medical University, Guangzhou, China
| | - Liangjia Zeng
- Cardiovascular Medicine and Cardio-Oncology Group, Medical Exploration and Translation Team, Guangzhou, China
- Department of Clinical Medicine, The First Clinical College of Guangzhou Medical University, Guangzhou, China
| | - Ruoyun Zhou
- Cardiovascular Medicine and Cardio-Oncology Group, Medical Exploration and Translation Team, Guangzhou, China
- Department of Clinical Medicine, The Third Clinical College of Guangzhou Medical University, Guangzhou, China
| | - Manting Feng
- Department of Clinical Medicine, The Second Clinical College of Guangzhou Medical University, Guangzhou, China
- Cardiovascular Medicine and Cardio-Oncology Group, Medical Exploration and Translation Team, Guangzhou, China
| | - Wangen Li
- Department of Endocrinology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Huying Rao
- Department of Endocrinology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Min Yi
- Department of Endocrinology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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Alfaris I, Asselah J, Aziz H, Bouganim N, Mousavi N. The Cardiovascular Risks Associated with Aromatase Inhibitors, Tamoxifen, and GnRH Agonists in Women with Breast Cancer. Curr Atheroscler Rep 2023; 25:145-154. [PMID: 36848014 DOI: 10.1007/s11883-023-01085-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2023] [Indexed: 03/01/2023]
Abstract
PURPOSE OF REVIEW Cardiovascular disease accounts for up to 10% of all-cause mortality in women with a diagnosis of breast cancer, and the causes for this are multifaceted. Many women at risk of or with a diagnosis of breast cancer are on endocrine-modulating therapies. It is therefore important to understand the effect of hormone therapies on cardiovascular outcomes in breast cancer patients to mitigate against any adverse effects and to identify those most at risk so that they can be proactively managed. Here we discuss the pathophysiology of these agents, their effect on the cardiovascular system, and the latest evidence on their cardiovascular risks association. RECENT FINDINGS Tamoxifen appears to be cardioprotective during treatment but not over the longer term, while the effect of AIs on cardiovascular outcomes remains controversial. Heart failure outcomes remain understudied, and the cardiovascular effects of gonadotrophin-releasing hormone agonists (GNRHa) in women need further research, especially since data from men with prostate cancer have indicated an increased risk of cardiac events in GNRHa users. There remains a need for a greater understanding of the effects of hormone therapies on cardiovascular outcomes in breast cancer patients. Further areas of research in this area include developing evidence to better define the optimal preventive and screening methods for cardiovascular effects and the risk factors for patients on hormonal therapies.
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Affiliation(s)
- Ibrahim Alfaris
- Division of Cardiology, Department of Medicine, McGill University Health Center, Montreal, Canada.
| | - Jamil Asselah
- Department of Oncology, McGill University Health Center, Montreal, Canada
| | - Haya Aziz
- Division of Cardiology, Department of Medicine, McGill University Health Center, Montreal, Canada
| | - Nathaniel Bouganim
- Department of Oncology, McGill University Health Center, Montreal, Canada
| | - Negareh Mousavi
- Division of Cardiology, Department of Medicine, McGill University Health Center, Montreal, Canada
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Lavín-Pérez AM, Collado-Mateo D, Hinojo González C, de Juan Ferré A, Ruisánchez Villar C, Mayo X, Jiménez A. High-intensity exercise prescription guided by heart rate variability in breast cancer patients: a study protocol for a randomized controlled trial. BMC Sports Sci Med Rehabil 2023; 15:28. [PMID: 36890601 PMCID: PMC9993392 DOI: 10.1186/s13102-023-00634-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 02/16/2023] [Indexed: 03/10/2023]
Abstract
BACKGROUND Breast cancer is a chronic disease with a large growth in its treatments, prognosis, improvements, side effects and rehabilitation therapies research. These advances have also highlighted the need to use physical exercise as a countermeasure to reduce the cardiotoxicity of pharmacological treatments, increase patients' strength and quality of life and improve body composition, physical condition and mental health. However, new investigations show the need for a closed exercise individualisation to produce higher physiological, physical and psychological benefits in remote exercise programs. To this end, the present study will use, in a novel way in this population, heart rate variability (HRV) as a measure for prescribing high-intensity training. Thus, the primary objective of this randomised clinical trial is to analyse the effects of a high-intensity exercise program daily guided by HRV, a preplanned moderate to high-intensity exercise intervention and a usual care group, in breast cancer patients after chemotherapy and radiotherapy treatments. METHODS For this purpose, a 16-week intervention will be carried out with 90 breast cancer patients distributed in 3 groups (a control group, a moderate to high-intensity preplanned exercise group and a high-intensity exercise group guided by HRV). Both physical exercise interventions will be developed remotely and supervised including strength and cardiovascular exercises. Physiological variables, such as cardiotoxicity, biomarkers, lipid profile, glucose, heart rate and blood pressure; physical measures like cardiorespiratory capacity, strength, flexibility, agility, balance and body composition; and psychosocial variables, as health-related quality of life, fatigue, functionality, self-esteem, movement fear, physical exercise level, anxiety and depression will be measure before, after the intervention and 3 and 6 months follow up. DISCUSSION Personalized high-intensity exercise could be a promising exercise intervention in contrast to moderate-intensity or usual care in breast cancer patients to reach higher clinical, physical and mental effects. In addition, the novelty of controlling HRV measures daily may reflect exercise effects and patients' adaptation in the preplanned exercise group and a new opportunity to adjust intensity. Moreover, findings may support the effectiveness and security of physical exercise remotely supervised, although with high-intensity exercise, to reach cardiotoxicity improvements and increase physical and psychosocial variables after breast cancer treatments. Trial registration ClinicalTrials.gov nº NCT05040867 ( https://clinicaltrials.gov/ct2/show/record/NCT05040867 ).
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Affiliation(s)
- Ana Myriam Lavín-Pérez
- Centre for Sport Studies, Rey Juan Carlos University, Madrid, Spain.,GO fitLAB, Ingesport, Madrid, Spain.,Program of Epidemiology and Public Health (Interuniversity), PhD International School of the Rey Juan Carlos University, Madrid, Spain
| | | | - Carmen Hinojo González
- Onchology Department, Hospital Universitario Marqués de Valdecilla and Instituto de Investigación Marqués de Valdecilla (IDIVAL)., Santander, Spain
| | - Ana de Juan Ferré
- Onchology Department, Hospital Universitario Marqués de Valdecilla and Instituto de Investigación Marqués de Valdecilla (IDIVAL)., Santander, Spain
| | - Cristina Ruisánchez Villar
- Cardiology Department, Hospital Universitario Marqués de Valdecilla and Instituto de Investigación Marqués de Valdecilla (IDIVAL)., Santander, Spain
| | - Xián Mayo
- Centre for Sport Studies, Rey Juan Carlos University, Madrid, Spain
| | - Alfonso Jiménez
- Centre for Sport Studies, Rey Juan Carlos University, Madrid, Spain.,GO fitLAB, Ingesport, Madrid, Spain.,Advanced Wellbeing Research Centre, College of Health, Wellbeing and Life Sciences, Sheffield Hallam University, Sheffield, UK
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10
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Viamonte SG, Joaquim A, Alves A, Vilela E, Capela A, Ferreira C, Costa AJ, Teixeira M, Duarte B, Rato N, Tavares A, Santos M, Ribeiro F. Adherence, safety, and satisfaction of a cardio-oncology rehabilitation program framework versus community exercise training for cancer survivors: findings from the CORE trial. Support Care Cancer 2023; 31:173. [PMID: 36800020 PMCID: PMC9936479 DOI: 10.1007/s00520-023-07638-1] [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: 10/28/2022] [Accepted: 02/08/2023] [Indexed: 02/18/2023]
Abstract
PURPOSE To assess safety, satisfaction, and overall adherence of a center-based cardiac rehabilitation (CBCR) program for cancer survivors at increased cardiovascular (CV) risk, compared to community-based exercise training (CBET). METHODS The CORE study was a single-center, prospective, randomized controlled trial enrolling cancer survivors exposed to cardiotoxic cancer treatment and/or with previous CV disease. Participants were randomized to an 8-week CBCR program or CBET, twice a week. Overall feasibility (consent, retention, and completion rates), intervention adherence (percentage of exercise sessions attended), and safety were assessed. Adverse events (AEs) were registered, and participants' satisfaction was measured at the end of the study. RESULTS Eighty out of 116 potentially eligible individuals were included; consent rate was 72.4%, and 77 (96.2%) started the study (retention rate 100% in CBCR vs 92.5% in CBET); completion rate was 92.5%. Intervention adherence was higher in CBCR (90.3 ± 11.8% vs 68.4 ± 22.1%, p < 0.001). Exercise-related AEs were mainly related to musculoskeletal conditions in both groups (7 in CBCR vs 20 in CBET, p < 0.001), accounting for exercise prescription modification in 47 sessions (18 (3.3%) in CBCR vs 29 (7.2%) in CBET, p = 0.006), none motivating exercise discontinuation. No participants reported major CV events. Overall, the satisfaction with the different aspects of the programs (e.g., expectations, monitoring) was higher in the CBCR. CONCLUSION This exploratory analysis of the CORE trial suggests that both exercise-based interventions are feasible and safe in this setting. The higher intervention adherence and patient satisfaction in CBCR suggest that this comprehensive approach could be of interest in this population.
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Affiliation(s)
- Sofia Gonçalves Viamonte
- North Rehabilitation Center, Centro Hospitalar Vila Nova de Gaia/Espinho, Avenida Infante Sagres 22, 4250-076, Vila Nova de Gaia, Portugal. .,ONCOMOVE® - Associação de Investigação de Cuidados de Suporte em Oncologia (AICSO), Vila Nova de Gaia, Portugal. .,Research Center in Sports Sciences, Health Sciences and Human Development, University of Maia, Maia, Portugal. .,Institute of Biomedicine (iBiMED), School of Health Sciences, University of Aveiro, Aveiro, Portugal.
| | - Ana Joaquim
- ONCOMOVE® - Associação de Investigação de Cuidados de Suporte em Oncologia (AICSO), Vila Nova de Gaia, Portugal.,Oncology Department, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Alberto Alves
- ONCOMOVE® - Associação de Investigação de Cuidados de Suporte em Oncologia (AICSO), Vila Nova de Gaia, Portugal.,Research Center in Sports Sciences, Health Sciences and Human Development, University of Maia, Maia, Portugal
| | - Eduardo Vilela
- ONCOMOVE® - Associação de Investigação de Cuidados de Suporte em Oncologia (AICSO), Vila Nova de Gaia, Portugal.,Cardiology Department, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Andreia Capela
- ONCOMOVE® - Associação de Investigação de Cuidados de Suporte em Oncologia (AICSO), Vila Nova de Gaia, Portugal.,Oncology Department, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Cristina Ferreira
- Hematology Department, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Ana João Costa
- North Rehabilitation Center, Centro Hospitalar Vila Nova de Gaia/Espinho, Avenida Infante Sagres 22, 4250-076, Vila Nova de Gaia, Portugal
| | - Madalena Teixeira
- Cardiology Department, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Barbara Duarte
- ONCOMOVE® - Associação de Investigação de Cuidados de Suporte em Oncologia (AICSO), Vila Nova de Gaia, Portugal
| | - Nuno Rato
- ONCOMOVE® - Associação de Investigação de Cuidados de Suporte em Oncologia (AICSO), Vila Nova de Gaia, Portugal.,Research Center in Sports Sciences, Health Sciences and Human Development, University of Maia, Maia, Portugal
| | - Aida Tavares
- Lisbon School of Economics and Management, ISEG, University of Lisbon, Lisbon, Portugal
| | - Mário Santos
- Cardiology Department, Centro Hospitalar Universitário Do Porto, Porto, Portugal.,Unit for Multidisciplinary Investigation in Biomedicine (UMIB), Institute for Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal
| | - Fernando Ribeiro
- Institute of Biomedicine (iBiMED), School of Health Sciences, University of Aveiro, Aveiro, Portugal
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11
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Foulkes SJ, Howden EJ, Haykowsky MJ, Antill Y, Salim A, Nightingale SS, Loi S, Claus P, Janssens K, Mitchell AM, Wright L, Costello BT, Lindqvist A, Burnham L, Wallace I, Daly RM, Fraser SF, La Gerche A. Exercise for the Prevention of Anthracycline-Induced Functional Disability and Cardiac Dysfunction: The BREXIT Study. Circulation 2023; 147:532-545. [PMID: 36342348 DOI: 10.1161/circulationaha.122.062814] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Breast cancer survivors treated with anthracycline-based chemotherapy (AC) have increased risk of functional limitation and cardiac dysfunction. We conducted a 12-month randomized controlled trial in 104 patients with early-stage breast cancer scheduled for AC to determine whether 12 months of exercise training (ExT) could attenuate functional disability (primary end point), improve cardiorespiratory fitness (VO2peak), and prevent cardiac dysfunction. METHODS Women 40 to 75 years of age with stage I to III breast cancer scheduled for AC were randomized to 3 to 4 days per week aerobic and resistance ExT for 12 months (n=52) or usual care (UC; n=52). Functional measures were performed at baseline, at 4 weeks after AC (4 months), and at 12 months, comprising: (1) cardiopulmonary exercise testing to quantify VO2peak and functional disability (VO2peak ≤18.0 mL·kg-1·min-1); (2) cardiac reserve (response from rest to peak exercise), quantified with exercise cardiac magnetic resonance measures to determine changes in left and right ventricular ejection fraction, cardiac output, and stroke volume; (3) standard-of-care echocardiography-derived resting left ventricular ejection fraction and global longitudinal strain; and (4) biochemistry (troponin and BNP [B-type natriuretic peptide]). RESULTS Among 104 participants randomized, greater study attrition was observed among UC participants (P=0.031), with 93 women assessed at 4 months (ExT, n=49; UC, n=44) and 87 women assessed at 12 months (ExT, n=49; UC, n=38). ExT attenuated functional disability at 4 months (odds ratio, 0.32 [95% CI, 0.11-0.94]; P=0.03) but not at 12 months (odds ratio, 0.27 [95% CI, 0.06-1.12]; P=0.07). In a per-protocol analysis, functional disability was prevented entirely at 12 months among participants adherent to ExT (ExT, 0% versus UC, 20%; P=0.005). Compared with UC at 12 months, ExT was associated with a net 3.5-mL·kg-1·min-1 improvement in VO2peak that coincided with greater cardiac output, stroke volume, and left and right ventricular ejection fraction reserve (P<0.001 for all). There was no effect of ExT on resting measures of left ventricular function. Postchemotherapy troponin increased less in ExT than in UC (8-fold versus 16-fold increase; P=0.002). There were no changes in BNP in either group. CONCLUSIONS In women with early-stage breast cancer undergoing AC, 12 months of ExT did not attenuate functional disability, but provided large, clinically meaningful benefits on VO2peak and cardiac reserve. REGISTRATION URL: https://www.anzctr.org.au/; Unique identifier: ACTRN12617001408370.
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Affiliation(s)
- Stephen J Foulkes
- Sports Cardiology (S.J.F., K.J., A.M.M., L.W., B.T.C., A.L., L.B., I.W., A.L.G.), Baker Heart and Diabetes Institute, Melbourne, VIC, Australia.,Faculty of Nursing, College of Health Sciences, University of Alberta, Edmonton, Canada (M.J.H., S.J.F.).,Baker Department of Cardiometabolic Health (S.J.F., E.J.H., A.L.G.), University of Melbourne, Parkville, VIC, Australia
| | - Erin J Howden
- Human Integrative Physiology (E.J.H., L.B., I.W.), Baker Heart and Diabetes Institute, Melbourne, VIC, Australia.,Baker Department of Cardiometabolic Health (S.J.F., E.J.H., A.L.G.), University of Melbourne, Parkville, VIC, Australia
| | - Mark J Haykowsky
- Faculty of Nursing, College of Health Sciences, University of Alberta, Edmonton, Canada (M.J.H., S.J.F.)
| | - Yoland Antill
- Cabrini Health, Melbourne, VIC, Australia (Y.A.).,Faculty of Medicine, Dentistry and Health Sciences, Monash University, Melbourne, VIC, Australia (Y.A.)
| | - Agus Salim
- Epidemiology (A.S.), Baker Heart and Diabetes Institute, Melbourne, VIC, Australia.,Melbourne School of Population and Global Health (A.S.), University of Melbourne, Parkville, VIC, Australia.,School of Mathematics and Statistics (A.S.), University of Melbourne, Parkville, VIC, Australia
| | | | - Sherene Loi
- Peter MacCallum Cancer Centre, Melbourne, VIC, Australia (S.S.N., S.L.)
| | - Piet Claus
- Department of Cardiovascular Sciences, KU Leuven, Belgium (P.C.)
| | - Kristel Janssens
- Sports Cardiology (S.J.F., K.J., A.M.M., L.W., B.T.C., A.L., L.B., I.W., A.L.G.), Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Amy M Mitchell
- Sports Cardiology (S.J.F., K.J., A.M.M., L.W., B.T.C., A.L., L.B., I.W., A.L.G.), Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Leah Wright
- Sports Cardiology (S.J.F., K.J., A.M.M., L.W., B.T.C., A.L., L.B., I.W., A.L.G.), Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Ben T Costello
- Sports Cardiology (S.J.F., K.J., A.M.M., L.W., B.T.C., A.L., L.B., I.W., A.L.G.), Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Anniina Lindqvist
- Sports Cardiology (S.J.F., K.J., A.M.M., L.W., B.T.C., A.L., L.B., I.W., A.L.G.), Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Lauren Burnham
- Human Integrative Physiology (E.J.H., L.B., I.W.), Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Imogen Wallace
- Sports Cardiology (S.J.F., K.J., A.M.M., L.W., B.T.C., A.L., L.B., I.W., A.L.G.), Baker Heart and Diabetes Institute, Melbourne, VIC, Australia.,Human Integrative Physiology (E.J.H., L.B., I.W.), Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Robin M Daly
- Institute for Physical Activity and Nutrition, Deakin University, Melbourne, VIC, Australia (R.M.D., S.F.F.)
| | - Steve F Fraser
- Institute for Physical Activity and Nutrition, Deakin University, Melbourne, VIC, Australia (R.M.D., S.F.F.)
| | - André La Gerche
- Sports Cardiology (S.J.F., K.J., A.M.M., L.W., B.T.C., A.L., L.B., I.W., A.L.G.), Baker Heart and Diabetes Institute, Melbourne, VIC, Australia.,Baker Department of Cardiometabolic Health (S.J.F., E.J.H., A.L.G.), University of Melbourne, Parkville, VIC, Australia.,Cardiology Department, St. Vincent's Hospital Melbourne, Fitzroy, VIC, Australia (A.L.G.)
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12
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Screening for Coronary Artery Disease in Cancer Survivors: JACC: CardioOncology State-of-the-Art Review. JACC CardioOncol 2023; 5:22-38. [PMID: 36875910 PMCID: PMC9982229 DOI: 10.1016/j.jaccao.2022.12.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 12/19/2022] [Accepted: 12/20/2022] [Indexed: 02/24/2023] Open
Abstract
Coronary artery disease (CAD) is an important contributor to the cardiovascular burden in cancer survivors. This review identifies features that could help guide decisions about the benefit of screening to assess the risk or presence of subclinical CAD. Screening may be appropriate in selected survivors based on risk factors and inflammatory burden. In cancer survivors who have undergone genetic testing, polygenic risk scores and clonal hematopoiesis markers may become useful CAD risk prediction tools in the future. The type of cancer (especially breast, hematological, gastrointestinal, and genitourinary) and the nature of treatment (radiotherapy, platinum agents, fluorouracil, hormonal therapy, tyrosine kinase inhibitors, endothelial growth factor inhibitors, and immune checkpoint inhibitors) are also important in determining risk. Therapeutic implications of positive screening include lifestyle and atherosclerosis interventions, and in specific instances, revascularization may be indicated.
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Key Words
- ACS, acute coronary syndrome
- AYA, adolescent and young adult
- CAC, coronary artery calcium
- CAD, coronary artery disease
- CHIP, clonal hematopoiesis of indeterminate potential
- CMR, cardiac magnetic resonance
- CTA, computed tomography angiography
- CVD, cardiovascular disease
- IGF, insulin-like growth factor
- LDL, low-density lipoprotein
- PCE, pooled cohort equations
- PCI, percutaneous coronary intervention
- PRS, polygenic risk score
- ROS, reactive oxygen species
- TKI, tyrosine kinase inhibitor
- VEGF, vascular endothelial growth factor
- calcification
- coronary artery calcium
- coronary artery disease
- prevention
- risk factor
- risk prediction
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13
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Impact of a COmprehensive cardiac REhabilitation framework among high cardiovascular risk cancer survivors: Protocol for the CORE trial. Int J Cardiol 2023; 371:384-390. [PMID: 36216089 DOI: 10.1016/j.ijcard.2022.09.075] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 08/30/2022] [Accepted: 09/29/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Cancer survivors are challenging patients, as they often present increased cardiovascular risk. In this background, cardio-oncology rehabilitation frameworks for specific cancer patients have been proposed. However, optimal program designs, as well as their overall safety and efficacy in different subsets of patients, are not fully ascertained. DESIGN Single-center, pragmatic, prospective, randomized controlled trial performed in Portugal aiming to evaluate the impact of a center-based cardiac rehabilitation program, consisting of exercise training, nutritional counselling, psychosocial management and lifestyle behavior change, compared to community-based exercise training, in cancer survivors. METHODS Adult cancer survivors (N = 80) exposed to cardiotoxic cancer treatment and/or with previous cardiovascular disease will be randomized (1:1) to receive either an eight-week cardiac rehabilitation program or community-based exercise training. Primary endpoint is cardiorespiratory fitness; secondary endpoints are physical activity, psychosocial parameters, blood pressure, body composition, lipids and inflammatory parameters. Physical function, quality of life, fatigue, health literacy, and feasibility will be assessed; a cost-effectiveness evaluation will also be performed. Between-group differences at baseline and in the change from baseline to the end of the study will be tested with unpaired t-tests or Mann-Whitney U test. Paired t-tests or Wilcoxon signed-rank test will be performed for within-group comparisons. CONCLUSION This trial will address the overall impact of a contemporary cardiac rehabilitation program framework in cancer survivors, as compared to a community-based exercise training. Given the higher cardiovascular risk in several groups of cancer patients, our results could provide novel insights into optimized preventive strategies in this complex patient population.
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14
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Kirkham AA, Jerzak KJ. Prevalence of Breast Cancer Survivors Among Canadian Women. J Natl Compr Canc Netw 2022; 20:1005-1011. [PMID: 36075384 DOI: 10.6004/jnccn.2022.7028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 05/03/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND The 49% decrease in breast cancer mortality since 1986 has increased the number of breast cancer survivors requiring survivorship care. The purpose of this analysis was to estimate the 2022 prevalence of breast cancer survivors diagnosed within the past 15 years among Canadian women. METHODS We extracted the projected female breast cancer cases from 2007 to 2021 and rates of net survival (competing noncancer causes of death removed) from the Canadian Cancer Society's statistical reports. Overall survival was extracted from published Ontario data. Using known survival rates for 1, 5, 10, and 15 years, we interpolated remaining years and applied the corresponding net and overall survival rates to the projected cases for each year from 2007 to 2021 to determine survivors in 2022. Prevalence for predefined age groups was also calculated. As an example of excess healthcare costs attributable to breast cancer, we calculated the excess costs of heart failure hospitalizations. RESULTS From 2007 to 2021, there were 370,756 breast cancer cases. Using net survival, 318,429 (85.9%) of these patients were projected to survive breast cancer by 2022, a prevalence of 2.1% of Canadian women. Using overall survival, prevalence was 1.8%. Prevalence increased with age group, from 0.01% of those aged 20 to 24 years to 12.7% of those aged ≥90 years, and from 1.0% among the working and/or child-raising (age 20-64 years) to 5.4% among elderly populations (age ≥65 years). Among these survivors, 24.9% of projected heart failure hospitalizations would be in excess of those among matched control subjects, with projected excess costs of $16.5 million CAD. Given the excess healthcare costs, potential for reduced contributions to the workforce, and reduced quality of life associated with long-term impairments and risk of excess non-breast cancer death, enhanced breast cancer survivorship care is warranted. CONCLUSIONS With an overall prevalence of 2% among Canadian women, breast cancer survivors represent an increasing segment of the working-age and elderly populations.
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Affiliation(s)
- Amy A Kirkham
- University of Toronto, Knowledge, Innovation, Talent and Everywhere (KITE), Toronto Rehabilitation Institute, University Health Network; and
| | - Katarzyna J Jerzak
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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15
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Han X, Liu F, Hidru TH, Yang X, Wang C, Xia Y. Postmenopausal Women with Breast, Endometrial, and Ovarian Cancers Have an Increased Risk for Cardiovascular Conditions prior to Active Endocrine Therapy. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:5104351. [PMID: 36046689 PMCID: PMC9423972 DOI: 10.1155/2022/5104351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 08/03/2022] [Indexed: 11/17/2022]
Abstract
Background Patients with active cancer have an increased risk of cardiovascular diseases (CVDs) among cancer patients receiving endocrine therapy. However, little research has explored the distribution of CVD comorbidities and cardiovascular risk factors (CVRFs) among postmenopause women with breast, endometrial, or ovarian cancer prior to active treatment with endocrine therapy. We aimed to explore the distribution of CVD comorbidities and associated CVRF in patients suffering from breast, endometrial, or ovarian cancer prior to the use of endocrine therapy and to assess whether there was compliance with existing hospital recommendations, particularly on the use of lipid-lowering agents to prevent the development of CVD comorbidities in postmenopause women. Methods A total of 10,731 postmenopause women with primary breast, endometrial, or ovarian cancer were enrolled between 30th May 2008 and 31st July 2021 from an electronic health record database at the first affiliated hospital of Dalian Medical University. Dyslipidemia was defined according to 2016 Chinese guidelines for adults. Multivariate logistic regression analysis was used to identify the independent predictors of CVD comorbidities in breast, endometrial, and ovarian cancers separately. Results Overall, 18.9% of the included women had at least one CVD record before endocrine therapy. The highest prevalence of CVD was identified for hypertension (16.5%), followed by coronary heart disease (4.5%), stroke (2.1%), heart failure (1.2%), and atrial fibrillation (1.1%). The most common CVRF among total cancer patients was dyslipidemia, with a remarkable prevalence of 62.8%, followed by diabetes mellitus (8.6%). Notably, only 11.1% of cancer patients were receiving lipid-lowering agents. Conclusion Cancer patients with potential eligibility for endocrine therapy use had an increased risk for CVD comorbidities. Dyslipidemia was the common CVRF. Compliance with recommendations for preventing and managing these comorbidities requires serious attention.
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Affiliation(s)
- Xu Han
- Health Management Center, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Fei Liu
- Department of Cardiology, Institute of Cardiovascular Diseases, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Tesfaldet H. Hidru
- Department of Cardiology, Institute of Cardiovascular Diseases, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Xiaolei Yang
- Department of Cardiology, Institute of Cardiovascular Diseases, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Chengfang Wang
- Health Management Center, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Yunlong Xia
- Department of Cardiology, Institute of Cardiovascular Diseases, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
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16
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Yu B, Mei Z, Yu H, Wang Y, Geng Q, Pu J. Risk of cardiovascular disease among cancer survivors: Protocol of a pooled analysis of population-based cohort studies. Front Cardiovasc Med 2022; 9:926218. [PMID: 35990968 PMCID: PMC9391087 DOI: 10.3389/fcvm.2022.926218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 07/18/2022] [Indexed: 01/10/2023] Open
Abstract
Introduction Cancer and cardiovascular disease remain leading causes of death and disability worldwide, which places a heavy burden on public health systems and causes widespread suffering. Because these entities have highly overlapping risk factors, including hyperlipidemia, hypertension, diabetes, obesity, smoking and other lifestyle factors, many studies have reported that they have similar etiological mechanisms. Accumulating evidence indicates that there is an increased risk of cardiovascular disease among cancer survivors compared with the general population. However, whether cancer is associated with an increased risk of cardiovascular disease remains controversial. Methods and analysis We will conduct and report the meta-analysis strictly based on the Cochrane Handbook for Systematic Reviews and the Meta-analysis of Observational Studies in Epidemiology guidelines combined with the Preferred Reporting Items for Systematic Reviews and Meta-analysis for Protocols (PRISM-P). This meta-analysis was registered with PROSPERO (registration number CRD42022307056). We will search for studies published from database inception to December 1, 2021, regardless of language or date, in three electronic databases (PubMed, EMBASE, and Cochrane Library) to identify and appraise cohort studies examining the relationship between cancer and subsequent cardiovascular disease risk. The literature screening, inclusion and data extraction will be conducted independently by two investigators using pre-designed standardized data extraction forms. A senior investigator will be consulted in cases of disagreement. We will assess risk of bias in the included cohort studies using the Newcastle–Ottawa Scale (NOS). Quantitative synthesis will be conducted using a random-effects model. To explore potential sources of heterogeneity, we will carry out multiple sensitivity analysis, meta-regression and subgroup analysis according to baseline characteristics. Publication bias will be evaluated through visual inspection of funnel plot asymmetry as well as by Begg's rank correlation test and Egger's weighted linear regression test.
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Affiliation(s)
- Botao Yu
- Emergency Department, The Second Affiliated Hospital of Medical College of Qingdao University, Qingdao, China
| | - Zubing Mei
- Anorectal Disease Institute of Shuguang Hospital, Shanghai, China
- Department of Anorectal Surgery, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Zubing Mei
| | - Hang Yu
- Emergency Department, Changhai Hospital, Naval Military Medical University, Shanghai, China
| | - Yan Wang
- The Second Department of Neurology, The Third Affiliated Hospital of Xinxiang Medical University, Xinxiang, China
- Yan Wang
| | - Qian Geng
- Special Clinic of Changhai Hospital, Naval Military Medical University, Shanghai, China
- Qian Geng
| | - Jin Pu
- Special Clinic of Changhai Hospital, Naval Military Medical University, Shanghai, China
- *Correspondence: Jin Pu
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17
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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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18
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Giskeødegård GF, Madssen TS, Sangermani M, Lundgren S, Wethal T, Andreassen T, Reidunsdatter RJ, Bathen TF. Longitudinal Changes in Circulating Metabolites and Lipoproteins After Breast Cancer Treatment. Front Oncol 2022; 12:919522. [PMID: 35785197 PMCID: PMC9245384 DOI: 10.3389/fonc.2022.919522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 05/05/2022] [Indexed: 02/06/2023] Open
Abstract
The multimodal treatment of breast cancer may induce long term effects on the metabolic profile and increase the risk of future cardiovascular disease. In this study, we characterized longitudinal changes in serum lipoprotein subfractions and metabolites after breast cancer treatment, aiming to determine the long-term effect of different treatment modalities. Further, we investigated the prognostic value of treatment-induced changes in breast cancer-specific and overall 10-year survival. In this study, serum samples from breast cancer patients (n = 250) were collected repeatedly before and after radiotherapy, and serum metabolites and lipoprotein subfractions were quantified by NMR spectroscopy. Longitudinal changes were assessed by univariate and multivariate data analysis methods applicable for repeated measures. Distinct changes were detectable in levels of lipoprotein subfractions and circulating metabolites during the first year, with similar changes despite large differences in treatment regimens. We detect increased free cholesterol and decreased esterified cholesterol levels of HDL subfractions, a switch towards larger LDL particles and higher total LDL-cholesterol, in addition to a switch in the glutamine-glutamate ratio. Non-survivors had different lipid profiles from survivors already at baseline. To conclude, our results show development towards an atherogenic lipid profile in breast cancer patients with different treatment regimens.
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Affiliation(s)
- Guro F. Giskeødegård
- K.G. Jebsen Center for Genetic Epidemiology, Department of Public Health and Nursing, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Clinic of Surgery, St. Olavs University Hospital, Trondheim, Norway
- *Correspondence: Guro F. Giskeødegård, ; orcid.org/0000-0003-2157-882
| | - Torfinn S. Madssen
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Matteo Sangermani
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Steinar Lundgren
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Torgeir Wethal
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Department of Medicine, Stroke Unit, St. Olavs University Hospital, Trondheim, Norway
| | - Trygve Andreassen
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Randi J. Reidunsdatter
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Tone F. Bathen
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
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19
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Kwan ML, Cheng RK, Iribarren C, Shen H, Laurent CA, Roh JM, Hershman DL, Kushi LH, Greenlee H, Rana JS. Risk of heart failure with preserved versus reduced ejection fraction in women with breast cancer. Breast Cancer Res Treat 2022; 193:669-675. [PMID: 35429322 PMCID: PMC10461432 DOI: 10.1007/s10549-022-06586-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 03/27/2022] [Indexed: 12/22/2022]
Abstract
PURPOSE While clinical heart failure (HF) is recognized as an adverse effect from breast cancer (BC) treatment, sparse data exist on specific HF phenotypes in affected BC survivors. We examined risk of HF by left ventricular ejection fraction (LVEF) status in women with a history of BC. METHODS 14,804 women diagnosed with all stages of invasive BC from 2005 to 2013 and with no history of HF were matched 1:5 to 74,034 women without BC on birth year, race, and ethnicity. LVEF values were extracted from echocardiography studies within 30 days before through 90 days after the HF clinical encounter. HF was stratified into HF with preserved ejection fraction (HFpEF, LVEF ≥ 45%) and HF with reduced ejection fraction (HFrEF, LVEF < 45%). Cumulative incidence rates (CIRs) were estimated with competing risk of overall death. Hazard ratios (HR) were calculated by multivariable Cox proportional hazards regression. RESULTS Mean time to HF diagnosis was 5.31 years (range 0.03-13.03) in cases and 5.25 years (range 0.01-12.94) in controls. 10-year CIRs were 1.2% and 0.9% for overall HF, 0.8% and 0.7% for HFpEF, and 0.4% and 0.2% for HFrEF in cases and controls, respectively. In fully adjusted models, an overall significant increased risk of HF in cases versus controls was observed (HR: 1.31, 95% CI 1.14, 1.51). The increased risk was seen for both HFrEF (HR: 1.59, 95% CI 1.22, 2.08) and HFpEF (HR: 1.22; 95% CI 1.03, 1.45). CONCLUSION BC survivors experienced higher risk of HF compared with women without BC, and the risk persisted across LVEF phenotypes. Systematic cardio-oncology surveillance should be considered to mitigate this risk in BC patients.
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Affiliation(s)
- Marilyn L Kwan
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA.
| | - Richard K Cheng
- University of Washington School of Medicine, Seattle, WA, USA
- Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Carlos Iribarren
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
| | - Hanjie Shen
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Cecile A Laurent
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
| | - Janise M Roh
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
| | - Dawn L Hershman
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY, USA
| | - Lawrence H Kushi
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
| | - Heather Greenlee
- University of Washington School of Medicine, Seattle, WA, USA
- Seattle Cancer Care Alliance, Seattle, WA, USA
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Jamal S Rana
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
- Department of Cardiology, Oakland Medical Center, Kaiser Permanente Northern California, Oakland, CA, USA
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20
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Hammond MM, Everitt IK, Khan SS. New strategies and therapies for the prevention of heart failure in high-risk patients. Clin Cardiol 2022; 45 Suppl 1:S13-S25. [PMID: 35789013 PMCID: PMC9254668 DOI: 10.1002/clc.23839] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 04/16/2022] [Accepted: 04/19/2022] [Indexed: 11/05/2022] Open
Abstract
Despite declines in total cardiovascular mortality rates in the United States, heart failure (HF) mortality rates as well as hospitalizations and readmissions have increased in the past decade. Increases have been relatively higher among young and middle-aged adults (<65 years). Therefore, identification of individuals HF at-risk (Stage A) or with pre-HF (Stage B) before the onset of overt clinical signs and symptoms (Stage C) is urgently needed. Multivariate risk models (e.g., Pooled Cohort Equations to Prevent Heart Failure [PCP-HF]) have been externally validated in diverse populations and endorsed by the 2022 HF Guidelines to apply a risk-based framework for the prevention of HF. However, traditional risk factors included in the PCP-HF model only account for half of an individual's lifetime risk of HF; novel risk factors (e.g., adverse pregnancy outcomes, impaired lung health, COVID-19) are emerging as important risk-enhancing factors that need to be accounted for in personalized approaches to prevention. In addition to determining the role of novel risk-enhancing factors, integration of social determinants of health (SDoH) in identifying and addressing HF risk is needed to transform the current clinical paradigm for the prevention of HF. Comprehensive strategies to prevent the progression of HF must incorporate pharmacotherapies (e.g., sodium glucose co-transporter-2 inhibitors that have also been termed the "statins" of HF prevention), intensive blood pressure lowering, and heart-healthy behaviors. Future directions include investigation of novel prediction models leveraging machine learning, integration of risk-enhancing factors and SDoH, and equitable approaches to interventions for risk-based prevention of HF.
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Affiliation(s)
- Michael M. Hammond
- Department of MedicineNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Ian K. Everitt
- Department of MedicineNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Sadiya S. Khan
- Department of MedicineNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
- Department of Preventive MedicineNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
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21
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Greenlee H, Iribarren C, Rana JS, Cheng R, Nguyen-Huynh M, Rillamas-Sun E, Shi Z, Laurent CA, Lee VS, Roh JM, Santiago-Torres M, Shen H, Hershman DL, Kushi LH, Neugebauer R, Kwan ML. Risk of Cardiovascular Disease in Women With and Without Breast Cancer: The Pathways Heart Study. J Clin Oncol 2022; 40:1647-1658. [PMID: 35385342 PMCID: PMC9113215 DOI: 10.1200/jco.21.01736] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE To examine cardiovascular disease (CVD) and mortality risk in women with breast cancer (BC) by cancer therapy received relative to women without BC. METHODS The study population comprised Kaiser Permanente Northern California members. Cases with invasive BC diagnosed from 2005 to 2013 were matched 1:5 to controls without BC on birth year and race/ethnicity. Cancer treatment, CVD outcomes, and covariate data were from electronic health records. Multivariable Cox proportional hazards models estimated hazard ratios (HRs) and 95% CIs of CVD incidence and mortality by receipt of chemotherapy treatment combinations, radiation therapy, and endocrine therapy. RESULTS A total of 13,642 women with BC were matched to 68,202 controls without BC. Over a 7-year average follow-up (range < 1-14 years), women who received anthracyclines and/or trastuzumab had high risk of heart failure/cardiomyopathy relative to controls, with the highest risk seen in women who received both anthracyclines and trastuzumab (HR, 3.68; 95% CI, 1.79 to 7.59). High risk of heart failure and/or cardiomyopathy was also observed in women with BC with a history of radiation therapy (HR, 1.38; 95% CI, 1.13 to 1.69) and aromatase inhibitor use (HR, 1.31; 95% CI, 1.07 to 1.60), relative to their controls. Elevated risks for stroke, arrhythmia, cardiac arrest, venous thromboembolic disease, CVD-related death, and death from any cause were also observed in women with BC on the basis of cancer treatment received. CONCLUSION Women with BC had increased incidence of CVD events, CVD-related mortality, and all-cause mortality compared with women without BC, and risks varied according to the history of cancer treatment received. Studies are needed to determine how women who received BC treatment should be cared for to improve cardiovascular outcomes.
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Affiliation(s)
- Heather Greenlee
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA,University of Washington School of Medicine, Seattle, WA,Seattle Cancer Care Alliance, Seattle, WA,Heather Greenlee, ND, PhD, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, M4-B402, Seattle, WA 98109; e-mail:
| | - Carlos Iribarren
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Jamal S. Rana
- Division of Research, Kaiser Permanente Northern California, Oakland, CA,Oakland Medical Center, Kaiser Permanente Northern California, Oakland, CA
| | - Richard Cheng
- University of Washington School of Medicine, Seattle, WA,Seattle Cancer Care Alliance, Seattle, WA
| | - Mai Nguyen-Huynh
- Division of Research, Kaiser Permanente Northern California, Oakland, CA,Walnut Creek Medical Center, Kaiser Permanente Northern California, Oakland, CA
| | - Eileen Rillamas-Sun
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Zaixing Shi
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA,School of Public Health, Xiamen University, Xiamen, China
| | - Cecile A. Laurent
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Valerie S. Lee
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Janise M. Roh
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | | | - Hanjie Shen
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Dawn L. Hershman
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY
| | - Lawrence H. Kushi
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Romain Neugebauer
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Marilyn L. Kwan
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
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22
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Evaluation of Risk Prediction Models to Identify Cancer Therapeutics Related Cardiac Dysfunction in Women with HER2+ Breast Cancer. J Clin Med 2022; 11:jcm11030847. [PMID: 35160296 PMCID: PMC8836544 DOI: 10.3390/jcm11030847] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/23/2022] [Accepted: 01/31/2022] [Indexed: 12/10/2022] Open
Abstract
Cancer-therapeutics-related cardiac dysfunction (CTRCD) is an important concern in women receiving trastuzumab therapy for HER2+ breast cancer. However, the ability to assess CTRCD risk remains limited. In this retrospective cohort study, we apply three published risk prediction models (Ezaz et al., NSABP-31 cardiac risk scores (CRS), and HFA-ICOS trastuzumab proforma) to 629 women (mean age 52.4 ± 10.9 years) with Stage I-III HER2+ breast cancer treated with trastuzumab ± anthracyclines to assess their performance to identify CTRCD during or immediately post treatment. Using these models, patients were classified into CTRCD risk categories according to the pre-treatment characteristics. With NSABP-31 CRS and HFA-ICOS proformas, patients in the highest risk category had a 1.7-to-2.4-fold higher relative risk of CTRCD than the low-risk category (p = 0.010 and 0.005, respectively). However, with all three risk models, those in the low-risk category had a high absolute risk of CTRCD (15.5–25.5%). The discrimination of the models for CTRCD (AUC 0.51–0.60) and their calibration was limited. NSAP-31 CRS and HFA-ICOS proformas can identify relative differences in CTRCD risk between patients, but when considering absolute risk, they are only able to identify the highest risk patients. There remains an ongoing need for accurate CTRCD risk prediction models in women with HER2+ breast cancer.
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23
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Cao Z, Xu C, Yang H, Li S, Wang Y. The Role of Healthy Lifestyle in Cancer Incidence and Temporal Transitions to Cardiometabolic Disease. JACC CardioOncol 2021; 3:663-674. [PMID: 34988474 PMCID: PMC8702801 DOI: 10.1016/j.jaccao.2021.09.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 09/12/2021] [Accepted: 09/15/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Cardiometabolic disease, including cardiovascular disease (CVD) and type 2 diabetes (T2D), can result in serious late effects in patients with cancer. Preventing long-term complications in this population is an increasingly important priority in public health and clinical practice. OBJECTIVES The aim of this study was to investigate the role of a healthy lifestyle in the transition from a healthy status to the development of cancer and subsequent CVD and T2D. METHODS The analysis was based on data from the UK Biobank and included 2 subsamples: a cancer-free cohort of 397,136 individuals in the general population and a cancer-prevalent cohort of 35,564 patients with cancer. All participants were 40 to 70 years of age and were free of CVD and T2D at recruitment. A healthy lifestyle that included no current smoking, regular physical activity, a healthy diet, and moderate alcohol consumption and sleep duration were included in a healthy lifestyle index (HLI). RESULTS In the cancer-free cohort, during a maximum follow-up period of 15 years, 6.38% and 4.18% of patients with cancer developed CVD and T2D, respectively. A healthy lifestyle significantly mitigated the risk for transition from cancer to subsequent CVD and T2D, with HRs per 1-point increment in HLI of 0.90 (95% CI: 0.86-0.94) and 0.84 (95% CI: 0.79-0.89), respectively. In the cancer-prevalent cohort, each 1-point increment in HLI was similarly associated with lower risk for CVD (HR: 0.90; 95% CI: 0.87-0.93) and T2D (HR: 0.87; 95% CI: 0.83-0.91) in cancer survivors. CONCLUSIONS A healthy lifestyle is associated with a slower transition from cancer development to the subsequent development of CVD and T2D. Moreover, among patients with cancer, a healthy lifestyle is associated with lower risk for CVD and T2D. This study highlights the practical benefits of adherence to a healthy lifestyle.
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Affiliation(s)
- Zhi Cao
- School of Public Health, Tianjin Medical University, Tianjin, China.,Department of Big Data in Health Science, School of Public Health, Zhejiang University School of Medicine, Hangzhou, China
| | - Chenjie Xu
- Department of Health Policy and Management, School of Public Health, Hangzhou Normal University, Hangzhou, China
| | - Hongxi Yang
- School of Public Health, Tianjin Medical University, Tianjin, China
| | - Shu Li
- School of Public Health, Tianjin Medical University, Tianjin, China
| | - Yaogang Wang
- School of Public Health, Tianjin Medical University, Tianjin, China
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24
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Jakobsen M, Kolodziejczyk C, Jensen MS, Poulsen PB, Khan H, Kümler T, Andersson M. Cardiovascular disease in women with breast cancer - a nationwide cohort study. BMC Cancer 2021; 21:1040. [PMID: 34537007 PMCID: PMC8449438 DOI: 10.1186/s12885-021-08716-5] [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: 11/11/2020] [Accepted: 08/23/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is increasing concern about cardiovascular disease (CVD) after breast cancer (BC). The aim of this study was to estimate the prevalence of different types of CVD in women diagnosed with BC compared to cancer-free controls as well as the incidence of CVD after BC diagnosis. METHODS We performed a cohort study based on data from national registries covering the entire Danish population. We followed 16,505 cancer-naïve BC patients diagnosed from 2003 to 2007 5 years before and up to 10 years after BC diagnosis compared to 165,042 cancer-free controls. RESULTS We found that 15.6% of BC patients were registered with at least one CVD diagnosis in hospital records before BC diagnosis. Overall, BC patients and controls were similar with regard to CVD comorbidity before BC diagnosis. After BC diagnosis, the incidence of all CVD diagnoses combined was significantly higher in BC patients than controls up to approximately 6 years after the index date (BC diagnosis). After 10 years, 28% of both BC patients and controls (without any CVD diagnosis up to 5 years before the index date) had at least one CVD diagnosis according to hospital records. However, the incidence of heart failure, thrombophlebitis/thrombosis and pulmonary heart disease including pulmonary embolism remained higher in BC patients than controls during the entire 10-year follow-up period. After 10 years, 2.7% of BC patients compared to 2.5% of controls were diagnosed with heart failure, 2.7% of BC patients compared to 1.5% of controls were diagnosed with thrombophlebitis/thrombosis, and 1.5% of BC patients compared to 1.0% of controls were diagnosed with pulmonary heart disease according to hospital records. Furthermore, we found that the risk of heart failure and thrombophlebitis/thrombosis was higher after chemotherapy. CONCLUSIONS Focus on CVD in BC patients is important to ensure optimum treatment with regard to BC as well as possible CVD. Strategies to minimise and manage the increased risk of heart failure, thrombophlebitis/thrombosis and pulmonary heart disease including pulmonary embolism in BC patients are especially important.
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Affiliation(s)
- Marie Jakobsen
- VIVE, The Danish Center for Social Science Research, Herluf Trolles Gade 11, DK-1152, Copenhagen K, Denmark.
| | - Christophe Kolodziejczyk
- VIVE, The Danish Center for Social Science Research, Herluf Trolles Gade 11, DK-1152, Copenhagen K, Denmark
| | - Morten Sall Jensen
- VIVE, The Danish Center for Social Science Research, Oluf Palmes Allé 22, DK-8200, Aarhus N, Denmark
| | | | - Humma Khan
- Pfizer Denmark, Lautrupvang 8, DK-2750, Ballerup, Denmark
| | - Thomas Kümler
- Department of Cardiology, Herlev-Gentofte University Hospital, Borgmester Ib Juuls Vej 1, DK-2730, Herlev, Denmark
| | - Michael Andersson
- Department of Oncology, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen Oe, Denmark
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25
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Boddicker NJ, Larson MC, Castellino A, Herrmann J, Inwards DJ, Thanarajasingam G, Maurer MJ, Allmer C, Witzig TE, Nowakowski GS, Habermann TM, Villarraga HR, Slager SL, Cerhan JR, Thompson CA. Anthracycline treatment, cardiovascular risk factors and the cumulative incidence of cardiovascular disease in a cohort of newly diagnosed lymphoma patients from the modern treatment era. Am J Hematol 2021; 96:979-988. [PMID: 33971040 DOI: 10.1002/ajh.26230] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 05/05/2021] [Indexed: 12/24/2022]
Abstract
The development of cardiovascular disease (CVD) in long-term survivors of lymphoma is of increasing importance. Here, we characterize the cumulative incidence and risk factors for CVD in lymphoma patients diagnosed in the current treatment era. From 2002-2015, newly diagnosed lymphoma patients (>18 years) were enrollment into a prospective cohort study that captured incident CVD, consisting of congestive heart failure (CHF), acute coronary syndrome (ACS), valvular heart disease (VHD), and arrhythmia. The cumulative incidence of CVD was calculated with death modeled as a competing risk. We estimated the association of treatment with anthracyclines or radiotherapy and traditional CVD risk factors with incidence of CVD using hazard ratios (HR) and 95% confidence intervals (CI) estimated from Cox regression. After excluding prevalent CVD at lymphoma diagnosis, the study consisted of 3063 patients with a median age of 59 years (range 18-95). The cumulative incidence of CVD at 10-years was 10.7% (95% CI, 9.5%-12.1%). In multivariable analysis, increasing age (HR = 1.05 per year, p < 0.001), male sex (HR = 1.36, p = 0.02), current smoker (HR = 2.10, p < 0.001), BMI > 30 kg/m2 (HR = 1.45, p = 0.01), and any anthracycline treatment (HR = 1.57, p < 0.001) were all significantly associated with risk of CVD. Anthracyclines were associated with increased risk of CHF (HR = 2.71, p < 0.001) and arrhythmia (HR = 1.61, p < 0.01), but not VHD (HR = 0.84, p = 0.58) or ACS (HR = 1.32, p = 0.24) after adjustment for CVD risk factors. Even in the modern treatment era, CVD remains common in lymphoma survivors and preventive efforts are required that address both treatment and CVD risk factors.
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Affiliation(s)
| | - Melissa C. Larson
- Department of Quantitative Health Sciences Mayo Clinic Rochester Minnesota USA
| | | | - Joerg Herrmann
- Department of Cardiovascular Medicine Mayo Clinic Rochester Minnesota USA
| | | | | | - Matthew J. Maurer
- Department of Quantitative Health Sciences Mayo Clinic Rochester Minnesota USA
| | - Cristine Allmer
- Department of Quantitative Health Sciences Mayo Clinic Rochester Minnesota USA
| | | | | | | | | | - Susan L. Slager
- Department of Quantitative Health Sciences Mayo Clinic Rochester Minnesota USA
| | - James R. Cerhan
- Department of Quantitative Health Sciences Mayo Clinic Rochester Minnesota USA
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Puckett LL, Saba SG, Henry S, Rosen S, Rooney E, Filosa SL, Gilbo P, Pappas K, Laxer A, Eacobacci K, Kapyur AN, Robeny J, Musial S, Chaudhry A, Chaudhry R, Lesser ML, Riegel A, Ramoutarpersaud S, Rahmani N, Shah A, Papas V, Dawodu T, Charlton J, Knisely JPS, Lee L. Cardiotoxicity screening of long-term, breast cancer survivors-The CAROLE (Cardiac-Related Oncologic Late Effects) Study. Cancer Med 2021; 10:5051-5061. [PMID: 34245128 PMCID: PMC8335805 DOI: 10.1002/cam4.4037] [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: 11/17/2020] [Revised: 05/04/2021] [Accepted: 05/06/2021] [Indexed: 01/11/2023] Open
Abstract
Background Long‐term breast cancer survivors are at risk for cardiotoxicity after treatment, but there is insufficient evidence to provide long‐term (~10 years) cardiovascular disease (CVD) screening recommendations. We sought to evaluate a tri‐modality CVD screening approach. Methods This single‐arm, feasibility study enrolled 201 breast cancer patients treated ≥6 years prior without CVD at diagnosis. Patients were sub‐grouped: cardiotoxic (left‐sided) radiation (RT), cardiotoxic (anthracycline‐based) chemotherapy, both cardiotoxic chemotherapy and RT, and neither cardiotoxic treatment. Patients underwent electrocardiogram (EKG), transthoracic echocardiogram with strain (TTE with GLS), and coronary artery calcium computed tomography (CAC CT). The primary endpoint was preclinical or clinical CVD. Results Median age was 50 (29–65) at diagnosis and 63 (37–77) at imaging; median interval was 11.5 years (6.7–14.5). Among sub‐groups, 44% had no cardiotoxic treatment, 31.5% had cardiotoxic RT, 16% had cardiotoxic chemotherapy, and 8.5% had both. Overall, 77.6% showed preclinical and/or clinical CVD and 51.5% showed clinical CVD. Per modality, rates of any CVD and clinical CVD were, respectively: 27.1%/10.0% on EKG, 50.0%/25.3% on TTE with GLS, and 50.8%/45.8% on CAC CT. No statistical difference was seen among the treatment subgroups (NS, χ2 test, p = 0.58/p = 0.15). Conclusion This study identified a high incidence of CVD in heterogenous long‐term breast cancer survivors, most >10 years post‐treatment. Over half had clinical CVD findings warranting follow‐up and/or intervention. Each imaging test independently contributed to the detection rate. This provides early evidence that long‐term cardiac screening may be of value to a wider group of breast cancer survivors than previously recognized.
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Affiliation(s)
- Lindsay L Puckett
- Department of Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Lake Success, NY, USA.,Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Shahryar G Saba
- Department of Cardiology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Manhasset, NY, USA
| | - Sonia Henry
- Department of Cardiology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Manhasset, NY, USA
| | - Stacey Rosen
- Department of Cardiology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Manhasset, NY, USA
| | - Elise Rooney
- Department of Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Lake Success, NY, USA
| | - Samaria L Filosa
- Department of Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Lake Success, NY, USA
| | - Philip Gilbo
- Department of Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Lake Success, NY, USA
| | - Karalyn Pappas
- Department of Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Lake Success, NY, USA
| | - Alison Laxer
- Department of Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Lake Success, NY, USA
| | - Katherine Eacobacci
- Department of Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Lake Success, NY, USA
| | - Amitha N Kapyur
- Department of Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Lake Success, NY, USA
| | - Justin Robeny
- Department of Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Lake Success, NY, USA
| | - Samantha Musial
- Department of Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Lake Success, NY, USA
| | - Anisha Chaudhry
- Department of Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Lake Success, NY, USA
| | - Rahul Chaudhry
- Department of Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Lake Success, NY, USA
| | - Martin L Lesser
- Department of Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Lake Success, NY, USA
| | - Adam Riegel
- Department of Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Lake Success, NY, USA
| | - Sariah Ramoutarpersaud
- Department of Cardiology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Manhasset, NY, USA
| | - Navid Rahmani
- Department of Diagnostic Radiology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Manhasset, NY, USA
| | - Amar Shah
- Department of Diagnostic Radiology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Manhasset, NY, USA
| | - Vivian Papas
- Department of Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Lake Success, NY, USA
| | - Toluwani Dawodu
- Department of Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Lake Success, NY, USA
| | - Jessica Charlton
- Department of Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Lake Success, NY, USA
| | | | - Lucille Lee
- Department of Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Lake Success, NY, USA
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Abdel-Qadir H, Tai F, Croxford R, Austin PC, Amir E, Calvillo-Argüelles O, Ross H, Lee DS, Thavendiranathan P. Characteristics and Outcomes of Women Developing Heart Failure After Early Stage Breast Cancer Chemotherapy: A Population-Based Matched Cohort Study. Circ Heart Fail 2021; 14:e008110. [PMID: 34187164 PMCID: PMC8288484 DOI: 10.1161/circheartfailure.120.008110] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 04/22/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND The prognosis of heart failure (HF) after early stage breast cancer (EBC) treatment with anthracyclines or trastuzumab is not well-characterized. METHODS Using administrative databases, women diagnosed with HF after receiving anthracyclines or trastuzumab for EBC in Ontario during 2007 to 2017 (the EBC-HF cohort) were categorized by cardiotoxic exposure (anthracycline alone, trastuzumab alone, sequential therapy with both agents) and matched on age with ≤3 cancer-free HF controls to compare baseline characteristics. To study prognosis after HF onset, we conducted a second match on age plus important HF prognostic factors. The cumulative incidence function was used to describe risk of hospitalization or emergency department visits (hospital presentations) for HF and cardiovascular death. RESULTS A total of 804 women with EBC developed HF after anthracyclines (n=312), trastuzumab (n=112), or sequential therapy (n=380); they had significantly fewer comorbidities than 2411 age-matched HF controls. After the second match, the anthracycline-HF cohort had a similar 5-year incidence of HF hospital presentations (16.5% [95% CI, 12.0%-21.7%]) as controls (17.1% [95% CI, 14.4%-20.1%]); the 5-year incidence was lower than matched controls for the trastuzumab-HF (9.7% [95% CI, 4.7%-16.9%]; controls 16.4% [95% CI, 12.1%-21.3%]; P=0.03) and sequential-HF cohorts (2.7% [95% CI, 1.4%-4.8%]; controls 10.8% [95% CI, 8.9%-13.0%]; P<0.001). At 5 years, the incidence of cardiovascular death was 2.9% (95% CI, 1.2%-5.9%) in the anthracycline-HF cohort vs. 9.5% (95% CI, 6.9%-12.6%) in controls, and 1.7% (0.6%-3.7%) for women developing HF after trastuzumab vs. 4.3% (95% CI, 3.1-5.8%) for controls. CONCLUSIONS Women developing HF after cardiotoxic EBC chemotherapy have fewer comorbidities than cancer-free women with HF; trastuzumab-treated women who develop HF have better prognosis than matched HF controls.
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Affiliation(s)
- Husam Abdel-Qadir
- Women’s College Hospital (H.A.-Q., F.T.), University of Toronto, ON, Canada
- Ted Rogers Program in Cardiotoxicity Prevention (H.A.-Q., O.C.-A., P.T.), University of Toronto, ON, Canada
- Division of Cardiology, Peter Munk Cardiac Center (H.A.-Q., O.C.-A., H.R., D.S.L., P.T.), University of Toronto, ON, Canada
- University Health Network, Institute of Health Policy Management and Evaluation (H.A.-Q., P.C.A., E.A., D.S.L.), University of Toronto, ON, Canada
- ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., R.C., P.C.A., D.S.L.)
| | - Felicia Tai
- Women’s College Hospital (H.A.-Q., F.T.), University of Toronto, ON, Canada
| | - Ruth Croxford
- ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., R.C., P.C.A., D.S.L.)
| | - Peter C. Austin
- University Health Network, Institute of Health Policy Management and Evaluation (H.A.-Q., P.C.A., E.A., D.S.L.), University of Toronto, ON, Canada
- ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., R.C., P.C.A., D.S.L.)
| | - Eitan Amir
- University Health Network, Institute of Health Policy Management and Evaluation (H.A.-Q., P.C.A., E.A., D.S.L.), University of Toronto, ON, Canada
- Division of Medical Oncology and Hematology, Department of Medicine, Princess Margaret Cancer Center (E.A.), University of Toronto, ON, Canada
| | - Oscar Calvillo-Argüelles
- Ted Rogers Program in Cardiotoxicity Prevention (H.A.-Q., O.C.-A., P.T.), University of Toronto, ON, Canada
- Division of Cardiology, Peter Munk Cardiac Center (H.A.-Q., O.C.-A., H.R., D.S.L., P.T.), University of Toronto, ON, Canada
| | - Heather Ross
- Division of Cardiology, Peter Munk Cardiac Center (H.A.-Q., O.C.-A., H.R., D.S.L., P.T.), University of Toronto, ON, Canada
| | - Douglas S. Lee
- Division of Cardiology, Peter Munk Cardiac Center (H.A.-Q., O.C.-A., H.R., D.S.L., P.T.), University of Toronto, ON, Canada
- Joint Department of Medical Imaging (D.S.L., P.T.), University of Toronto, ON, Canada
- University Health Network, Institute of Health Policy Management and Evaluation (H.A.-Q., P.C.A., E.A., D.S.L.), University of Toronto, ON, Canada
- ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., R.C., P.C.A., D.S.L.)
| | - Paaladinesh Thavendiranathan
- Ted Rogers Program in Cardiotoxicity Prevention (H.A.-Q., O.C.-A., P.T.), University of Toronto, ON, Canada
- Division of Cardiology, Peter Munk Cardiac Center (H.A.-Q., O.C.-A., H.R., D.S.L., P.T.), University of Toronto, ON, Canada
- Joint Department of Medical Imaging (D.S.L., P.T.), University of Toronto, ON, Canada
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Ramin C, Schaeffer ML, Zheng Z, Connor AE, Hoffman-Bolton J, Lau B, Visvanathan K. All-Cause and Cardiovascular Disease Mortality Among Breast Cancer Survivors in CLUE II, a Long-Standing Community-Based Cohort. J Natl Cancer Inst 2021; 113:137-145. [PMID: 32634223 DOI: 10.1093/jnci/djaa096] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 04/22/2020] [Accepted: 06/26/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND There is growing evidence that breast cancer survivors have higher cardiovascular disease (CVD) mortality relative to the general population. Information on temporal patterns for all-cause and CVD mortality among breast cancer survivors relative to cancer-free women is limited. METHODS All-cause and CVD-related mortality were compared in 628 women with breast cancer and 3140 age-matched cancer-free women within CLUE II, a prospective cohort. We calculated adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) using Cox proportional hazards regression for all-cause mortality, and Fine and Gray models for CVD-related mortality to account for competing risks. RESULTS Over 25 years of follow-up, 916 deaths occurred (249 CVD related). Breast cancer survivors had an overall higher risk of dying compared with cancer-free women (HR = 1.79, 95% CI = 1.53 to 2.09) irrespective of time since diagnosis, tumor stage, estrogen receptor status, and older age at diagnosis (≥70 years). Risk of death was greatest among older survivors at more than 15 years after diagnosis (HR = 2.69, 95% CI = 1.59 to 4.55). CVD (69.1% ischemic heart disease) was the leading cause of death among cancer-free women and the second among survivors. Survivors had an increase in CVD-related deaths compared with cancer-free women beginning at 8 years after diagnosis (HR = 1.65, 95% CI = 1.00 to 2.73), with the highest risk among older survivors (HR = 2.24, 95% CI = 1.29 to 3.88) and after estrogen receptor-positive disease (HR = 1.85, 95% CI = 1.06 to 3.20). CONCLUSIONS Breast cancer survivors continue to have an elevated mortality compared with the general population for many years after diagnosis. Preventing cardiac deaths, particularly among older breast cancer patients, could lead to reductions in mortality.
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Affiliation(s)
- Cody Ramin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Marcy L Schaeffer
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Zihe Zheng
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Avonne E Connor
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Judith Hoffman-Bolton
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Bryan Lau
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Kala Visvanathan
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Johns Hopkins School of Medicine, Baltimore, MD, USA.,Johns Hopkins Sidney Kimmel Cancer Center, Baltimore, MD, USA
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Abstract
PURPOSE OF REVIEW Coronary artery disease (CAD) is a common comorbidity in patients with cancer. We review shared risk factors between the two diseases and cancer treatments that increase the risk of CAD. We also discuss outcomes and management considerations of patients with cancer who develop CAD. RECENT FINDINGS Several traditional and novel risk factors promote the development of both CAD and cancer. Several cancer treatments further increase the risk of CAD. The presence of cancer is associated with a higher burden of comorbidities and thrombocytopenia, which predisposes patients to higher bleeding risks. Patients with cancer who develop acute coronary syndromes are less likely to receive timely revascularization or appropriate medical therapy, despite evidence showing that receipt of these interventions is associated with substantial benefit. Accordingly, a cancer diagnosis is associated with worse outcomes in patients with CAD. The risk-benefit balance of revascularization is becoming more favorable due to the improving prognosis of many cancers and safer revascularization strategies, including shorter requirements for dual antiplatelet therapy after revascularization. SUMMARY Several factors increase the complexity of managing CAD in patients with cancer. A multidisciplinary approach is recommended to guide treatment decisions in this high-risk and growing patient group.
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Carrasco R, Castillo RL, Gormaz JG, Carrillo M, Thavendiranathan P. Role of Oxidative Stress in the Mechanisms of Anthracycline-Induced Cardiotoxicity: Effects of Preventive Strategies. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2021; 2021:8863789. [PMID: 33574985 PMCID: PMC7857913 DOI: 10.1155/2021/8863789] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/29/2020] [Accepted: 12/31/2020] [Indexed: 12/15/2022]
Abstract
Anthracycline-induced cardiotoxicity (AIC) persists as a significant cause of morbidity and mortality in cancer survivors. Although many protective strategies have been evaluated, cardiotoxicity remains an ongoing threat. The mechanisms of AIC remain unclear; however, several pathways have been proposed, suggesting a multifactorial origin. When the central role of topoisomerase 2β in the pathophysiology of AIC was described some years ago, the classical reactive oxygen species (ROS) hypothesis shifted to a secondary position. However, new insights have reemphasized the importance of the role of oxidative stress-mediated signaling as a common pathway and a critical modulator of the different mechanisms involved in AIC. A better understanding of the mechanisms of cardiotoxicity is crucial for the development of treatment strategies. It has been suggested that the available therapeutic interventions for AIC could act on the modulation of oxidative balance, leading to a reduction in oxidative stress injury. These indirect antioxidant effects make them an option for the primary prevention of AIC. In this review, our objective is to provide an update of the accumulated knowledge on the role of oxidative stress in AIC and the modulation of the redox balance by potential preventive strategies.
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Affiliation(s)
- Rodrigo Carrasco
- Division of Cardiology, Peter Munk Cardiac Centre and the Ted Rogers Centre for Heart Research, University Health Network, Toronto, Ontario, Canada
| | - Rodrigo L. Castillo
- Medicine Department, East Division, Faculty of Medicine, University of Chile. Santiago, Chile; Critical Care Patient Unit, Hospital Salvador, Santiago, Chile
| | - Juan G. Gormaz
- Faculty of Medicine, University of Chile, Santiago, Chile
| | - Montserrat Carrillo
- Division of Cardiology, Peter Munk Cardiac Centre and the Ted Rogers Centre for Heart Research, University Health Network, Toronto, Ontario, Canada
| | - Paaladinesh Thavendiranathan
- Division of Cardiology, Peter Munk Cardiac Centre and the Ted Rogers Centre for Heart Research, University Health Network, Toronto, Ontario, Canada
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Abdel-Qadir H, Bobrowski D, Zhou L, Austin PC, Calvillo-Argüelles O, Amir E, Lee DS, Thavendiranathan P. Statin Exposure and Risk of Heart Failure After Anthracycline- or Trastuzumab-Based Chemotherapy for Early Breast Cancer: A Propensity Score‒Matched Cohort Study. J Am Heart Assoc 2021; 10:e018393. [PMID: 33401953 PMCID: PMC7955306 DOI: 10.1161/jaha.119.018393] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background Statins are hypothesized to reduce the risk of cardiotoxicity associated with anthracyclines and trastuzumab. Our aim was to study the association of statin exposure with hospitalization or emergency department visits (hospital presentations) for heart failure (HF) after anthracycline- and/or trastuzumab-containing chemotherapy for early breast cancer. Methods and Results Using linked administrative databases, we conducted a retrospective cohort study of women aged ≥66 years without prior HF who received anthracyclines or trastuzumab for newly diagnosed early breast cancer in Ontario between 2007 to 2017. Statin-exposed and unexposed women were matched 1:1 using propensity scores. Trastuzumab-treated women were also matched on anthracycline exposure. We matched 666 statin-discordant pairs of anthracycline-treated women and 390 pairs of trastuzumab-treated women (median age, 69 and 71 years, respectively). The 5-year cumulative incidence of HF hospital presentations after anthracyclines was 1.2% (95% CI, 0.5%-2.6%) in statin-exposed women and 2.9% (95% CI, 1.7%-4.6%) in unexposed women (P value, 0.01). The cause-specific hazard ratio associated with statins in the anthracycline cohort was 0.45 (95% CI, 0.24-0.85; P value, 0.01). After trastuzumab, the 5-year cumulative incidence of HF hospital presentations was 2.7% (95% CI, 1.2%-5.2%) in statin-exposed women and 3.7% (95% CI, 2.0%-6.2%) in unexposed women (P value 0.09). The cause-specific hazard ratio associated with statins in the trastuzumab cohort was 0.46 (95% CI, 0.20-1.07; P value, 0.07). Conclusions Statin-exposed women had a lower risk of HF hospital presentations after early breast cancer chemotherapy involving anthracyclines, with non-significant trends towards lower risk following trastuzumab. These findings support the development of randomized controlled trials of statins for prevention of cardiotoxicity.
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Affiliation(s)
- Husam Abdel-Qadir
- Division of Cardiology and Department of Medicine Women's College Hospital Toronto Ontario Canada.,Ted Rogers Centre for Heart Research and the Division of Cardiology Peter Munk Cardiac CenterUniversity Health Network Toronto Ontario Canada.,ICES (formerly the Institute for Clinical Evaluative Sciences) Toronto Ontario Canada.,Institute of Health Policy Management and EvaluationUniversity of Toronto Ontario Canada
| | - David Bobrowski
- Division of Cardiology and Department of Medicine Women's College Hospital Toronto Ontario Canada.,Ted Rogers Centre for Heart Research and the Division of Cardiology Peter Munk Cardiac CenterUniversity Health Network Toronto Ontario Canada
| | - Limei Zhou
- ICES (formerly the Institute for Clinical Evaluative Sciences) Toronto Ontario Canada
| | - Peter C Austin
- ICES (formerly the Institute for Clinical Evaluative Sciences) Toronto Ontario Canada.,Institute of Health Policy Management and EvaluationUniversity of Toronto Ontario Canada
| | - Oscar Calvillo-Argüelles
- Ted Rogers Centre for Heart Research and the Division of Cardiology Peter Munk Cardiac CenterUniversity Health Network Toronto Ontario Canada
| | - Eitan Amir
- Institute of Health Policy Management and EvaluationUniversity of Toronto Ontario Canada.,Department of Medicine Division of Medical Oncology and Hematology Princess Margaret Cancer Center Toronto Ontario Canada
| | - Douglas S Lee
- Ted Rogers Centre for Heart Research and the Division of Cardiology Peter Munk Cardiac CenterUniversity Health Network Toronto Ontario Canada.,ICES (formerly the Institute for Clinical Evaluative Sciences) Toronto Ontario Canada.,Institute of Health Policy Management and EvaluationUniversity of Toronto Ontario Canada.,Joint Department of Medical Imaging University Health Network Toronto Ontario Canada
| | - Paaladinesh Thavendiranathan
- Ted Rogers Centre for Heart Research and the Division of Cardiology Peter Munk Cardiac CenterUniversity Health Network Toronto Ontario Canada.,Joint Department of Medical Imaging University Health Network Toronto Ontario Canada
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Matthews AA, Peacock Hinton S, Stanway S, Lyon AR, Smeeth L, Bhaskaran K, Lund JL. Risk of Cardiovascular Diseases Among Older Breast Cancer Survivors in the United States: A Matched Cohort Study. J Natl Compr Canc Netw 2021; 19:275-284. [PMID: 33401236 DOI: 10.6004/jnccn.2020.7629] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 07/24/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND It has been suggested that cardiovascular risks are increased in breast cancer survivors, but few studies have quantified the risks of a range of specific clinically important cardiovascular outcomes in detail. PATIENTS AND METHODS Women aged >65 years with incident breast cancer from 2004 to 2013 in the SEER-Medicare linked database were matched with 5 cancer-free female counterparts (5:1 ratio). Prevalence of specific cardiovascular outcomes at baseline was measured, then Cox regression was used to calculate hazard ratios (HRs) and 95% confidence intervals for the risk of individual cardiovascular outcomes during follow-up. Modification of the effect was investigated by time since diagnosis, race/ethnicity, prior cardiovascular disease (CVD), and age. RESULTS In all, 91,473 women with breast cancer and 454,197 without breast cancer were included. Women with breast cancer had lower baseline prevalence of all CVDs. Compared with cancer-free controls, breast cancer survivors had substantially increased risks of deep vein thrombosis (adjusted HR, 1.67; 95% CI, 1.62-1.73; 386,484 person-years of follow-up) and pericarditis (HR, 1.43; 95% CI, 1.38-1.49; 390,776 person-years of follow-up); evidence of smaller increased risks of sudden cardiac arrest, arrhythmia, heart failure, and valvular heart disease (adjusted HRs ranging from 1.05-1.09, lower CI limits all ≥1); and evidence of lower risk of incident angina, myocardial infarction, revascularization, peripheral vascular disease, and stroke (adjusted HRs ranging from 0.89-0.98, upper CI limits all ≤1). Increased risks of arrhythmia, heart failure, pericarditis, and deep vein thrombosis persisted >5 years after cancer diagnosis. CONCLUSIONS Women with a history of breast cancer were at increased risk of several CVDs, persisting into survivorship. Monitoring and managing cardiovascular risk throughout the long-term follow-up of women diagnosed with breast cancer should be a priority.
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Affiliation(s)
- Anthony A Matthews
- 1Department of Non-Communicable Diseases Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom.,2Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,3Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden; and
| | - Sharon Peacock Hinton
- 2Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Alexander R Lyon
- 5National Heart and Lung Institute, Imperial College London, and.,6Royal Brompton Hospital, London, United Kingdom
| | - Liam Smeeth
- 1Department of Non-Communicable Diseases Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Krishnan Bhaskaran
- 1Department of Non-Communicable Diseases Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jennifer L Lund
- 2Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Temporal Associations and Outcomes of Breast Cancer and Heart Failure in Postmenopausal Women. JACC: CARDIOONCOLOGY 2020; 2:567-577. [PMID: 34396268 PMCID: PMC8352239 DOI: 10.1016/j.jaccao.2020.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 08/28/2020] [Accepted: 09/03/2020] [Indexed: 01/01/2023]
Abstract
Background Heart failure (HF) and breast cancer are 2 of the leading causes of death in postmenopausal women. The temporal association between HF and breast cancer in postmenopausal women has not been described. Objectives This study sought to examine the temporal association between HF and breast cancer. Methods Postmenopausal women within the WHI (Women's Health Initiative) cohort were studied. All prevalent HF and prevalent breast cancer at enrollment were self-reported. Incident hospitalized HF and breast cancer diagnoses were adjudicated through 2017. Results Among a cohort of 44,174 women (mean age 63 ± 7 years), 2,188 developed incident invasive breast cancer and 2,416 developed incident hospitalized HF over a median follow-up of 14 and 15 years, respectively. When compared with a breast cancer- and HF-free cohort, there was no association between prevalent HF and incident invasive breast cancer and similarly, there was no association between prevalent breast cancer and incident hospitalized HF. Across the entire cohort, the median survival after incident hospitalized HF was worse compared with an incident invasive breast cancer diagnosis (5 and 19 years, respectively). In women with incident invasive breast cancer, prevalent HF was associated with an increased risk of mortality (hazard ratio: 2.28; 95% confidence interval: 1.31 to 3.95). In women with incident hospitalized HF, prevalent breast cancer was associated with an increased risk of mortality (hazard ratio: 1.66; 95% confidence interval: 1.03 to 2.68). Cause of death after incident HF was different only in women with prevalent and interim breast cancer compared with those without prevalent and interim breast cancer. Conclusions In postmenopausal women, prevalent HF was not associated with a higher incidence of breast cancer and vice versa. However, the presence of incident invasive breast cancer or incident HF in those with prevalent HF or prevalent breast cancer, respectively, was associated with increased mortality.
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Mallard J, Hucteau E, Schott R, Petit T, Demarchi M, Belletier C, Ben Abdelghani M, Carinato H, Chiappa P, Fischbach C, Kalish-Weindling M, Bousinière A, Dufour S, Favret F, Pivot X, Hureau TJ, Pagano AF. Evolution of Physical Status From Diagnosis to the End of First-Line Treatment in Breast, Lung, and Colorectal Cancer Patients: The PROTECT-01 Cohort Study Protocol. Front Oncol 2020; 10:1304. [PMID: 32903594 PMCID: PMC7438727 DOI: 10.3389/fonc.2020.01304] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 06/23/2020] [Indexed: 01/06/2023] Open
Abstract
Background: Cancer cachexia and exacerbated fatigue represent two hallmarks in cancer patients, negatively impacting their exercise tolerance and ultimately their quality of life. However, the characterization of patients' physical status and exercise tolerance and, most importantly, their evolution throughout cancer treatment may represent the first step in efficiently counteracting their development with prescribed and tailored exercise training. In this context, the aim of the PROTECT-01 study will be to investigate the evolution of physical status, from diagnosis to the end of first-line treatment, of patients with one of the three most common cancers (i.e., lung, breast, and colorectal). Methods: The PROTECT-01 cohort study will include 300 patients equally divided between lung, breast and colorectal cancer. Patients will perform a series of assessments at three visits throughout the treatment: (1) between the date of diagnosis and the start of treatment, (2) 8 weeks after the start of treatment, and (3) after the completion of first-line treatment or at the 6-months mark, whichever occurs first. For each of the three visits, subjective and objective fatigue, maximal voluntary force, body composition, cachexia, physical activity level, quality of life, respiratory function, overall physical performance, and exercise tolerance will be assessed. Discussion: The present study is aimed at identifying the nature and severity of maladaptation related to exercise intolerance in the three most common cancers. Therefore, our results should contribute to the delineation of the needs of each group of patients and to the determination of the most valuable exercise interventions in order to counteract these maladaptations. This descriptive and comprehensive approach is a prerequisite in order to elaborate, through future interventional research projects, tailored exercise strategies to counteract specific symptoms that are potentially cancer type-dependent and, in fine, to improve the health and quality of life of cancer patients. Moreover, our concomitant focus on fatigue and cachexia will provide insightful information about two factors that may have substantial interaction but require further investigation. Trial registration: This prospective study has been registered at ClinicalTrials.gov (NCT03956641), May, 2019.
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Affiliation(s)
- Joris Mallard
- Institut de Cancérologie Strasbourg Europe (ICANS), Strasbourg, France.,EA 3072: Mitochondria, Oxidative Stress and Muscular Protection Laboratory, Faculty of Medicine, Faculty of Sports Sciences, University of Strasbourg, Strasbourg, France
| | - Elyse Hucteau
- Institut de Cancérologie Strasbourg Europe (ICANS), Strasbourg, France.,EA 3072: Mitochondria, Oxidative Stress and Muscular Protection Laboratory, Faculty of Medicine, Faculty of Sports Sciences, University of Strasbourg, Strasbourg, France
| | - Roland Schott
- Institut de Cancérologie Strasbourg Europe (ICANS), Strasbourg, France
| | - Thierry Petit
- Institut de Cancérologie Strasbourg Europe (ICANS), Strasbourg, France
| | - Martin Demarchi
- Institut de Cancérologie Strasbourg Europe (ICANS), Strasbourg, France
| | | | | | - Hélène Carinato
- Institut de Cancérologie Strasbourg Europe (ICANS), Strasbourg, France
| | - Pascale Chiappa
- Institut de Cancérologie Strasbourg Europe (ICANS), Strasbourg, France
| | - Cathie Fischbach
- Institut de Cancérologie Strasbourg Europe (ICANS), Strasbourg, France
| | | | - Audren Bousinière
- Institut de Cancérologie Strasbourg Europe (ICANS), Strasbourg, France
| | - Stéphane Dufour
- EA 3072: Mitochondria, Oxidative Stress and Muscular Protection Laboratory, Faculty of Medicine, Faculty of Sports Sciences, University of Strasbourg, Strasbourg, France
| | - Fabrice Favret
- EA 3072: Mitochondria, Oxidative Stress and Muscular Protection Laboratory, Faculty of Medicine, Faculty of Sports Sciences, University of Strasbourg, Strasbourg, France
| | - Xavier Pivot
- Institut de Cancérologie Strasbourg Europe (ICANS), Strasbourg, France
| | - Thomas J Hureau
- EA 3072: Mitochondria, Oxidative Stress and Muscular Protection Laboratory, Faculty of Medicine, Faculty of Sports Sciences, University of Strasbourg, Strasbourg, France
| | - Allan F Pagano
- EA 3072: Mitochondria, Oxidative Stress and Muscular Protection Laboratory, Faculty of Medicine, Faculty of Sports Sciences, University of Strasbourg, Strasbourg, France
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Oikonomou EK, Kokkinidis DG, Kampaktsis PN, Amir EA, Marwick TH, Gupta D, Thavendiranathan P. Assessment of Prognostic Value of Left Ventricular Global Longitudinal Strain for Early Prediction of Chemotherapy-Induced Cardiotoxicity: A Systematic Review and Meta-analysis. JAMA Cardiol 2020; 4:1007-1018. [PMID: 31433450 DOI: 10.1001/jamacardio.2019.2952] [Citation(s) in RCA: 196] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Importance Echocardiographic left ventricular global longitudinal strain (GLS) detects early subclinical ventricular dysfunction and can be used in patients receiving potentially cardiotoxic chemotherapy. A meta-analysis of the prognostic value of GLS for cancer therapy-related cardiac dysfunction (CTRCD) has not been performed, to our knowledge. Objective To explore the prognostic value of GLS for the prediction of CTRCD. Data Sources Systematic search of the MEDLINE, Embase, Scopus, and the Cochrane Library databases from database inception to June 1, 2018. Study Selection Cohort studies assessing the prognostic or discriminatory performance of GLS before or during chemotherapy for subsequent CTRCD. Data Extraction and Synthesis Random-effects meta-analysis and hierarchical summary receiver operating characteristic curves (HSROCs) were used to summarize the prognostic and discriminatory performance of different GLS indices. Publication bias was assessed using the Egger test, and meta-regression was performed to assess sources of heterogeneity. Main Outcomes and Measures The primary outcome was CTRCD, defined as a clinically significant change in left ventricular ejection fraction with or without new-onset heart failure symptoms. Results Analysis included 21 studies comprising 1782 patients with cancer, including breast cancer, hematologic malignancies, or sarcomas, treated with anthracyclines with or without trastuzumab. The incidence of CTRCD ranged from 9.3% to 43.8% over a mean follow-up of 4.2 to 23.0 months (pooled incidence, 21.0%). For active treatment absolute GLS (9 studies), the high-risk cutoff values ranged from -21.0% to -13.8%, with worse GLS associated with a higher CTRCD risk (odds ratio, 12.27; 95% CI, 7.73-19.47; area under the HSROC, 0.86; 95% CI, 0.83-0.89). For relative changes vs a baseline value (9 studies), cutoff values ranged from 2.3% to 15.9%, with a greater decrease linked to a 16-fold higher risk of CTRCD (odds ratio, 15.82; 95% CI, 5.84-42.85; area under the HSROC, 0.86; 95% CI, 0.83-0.89). Both indices showed significant publication bias. Meta-regression identified differences in sample size and CTRCD definition but not GLS cutoff value as significant sources of interstudy heterogeneity. Conclusions and Relevance In this meta-analysis, measurement of GLS after initiation of potentially cardiotoxic chemotherapy with anthracyclines with or without trastuzumab had good prognostic performance for subsequent CTRCD. However, risk of bias in the original studies, publication bias, and limited data on the incremental value of GLS and its optimal cutoff values highlight the need for larger prospective multicenter studies.
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Affiliation(s)
- Evangelos K Oikonomou
- Department of Internal Medicine, Yale New Haven Hospital, Yale School of Medicine, New Haven, Connecticut
| | - Damianos G Kokkinidis
- Department of Internal Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, New York, New York
| | - Polydoros N Kampaktsis
- Department of Cardiology, New York Presbyterian Hospital, Weill Cornell Medical College, New York
| | - Eitan A Amir
- Division of Medical Oncology, Princess Margaret Cancer Center, University of Toronto, Toronto, Ontario, Canada
| | - Thomas H Marwick
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Dipti Gupta
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Paaladinesh Thavendiranathan
- Peter Munk Cardiac Centre, Ted Rogers Program in Cardiotoxicity Prevention, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
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Calvillo-Argüelles O, Abdel-Qadir H, Ky B, Liu JE, Lopez-Mattei JC, Amir E, Thavendiranathan P. Modified Routine Cardiac Imaging Surveillance of Adult Cancer Patients and Survivors During the COVID-19 Pandemic. JACC CardioOncol 2020; 2:345-349. [PMID: 32309816 PMCID: PMC7162635 DOI: 10.1016/j.jaccao.2020.04.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Affiliation(s)
- Oscar Calvillo-Argüelles
- Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Husam Abdel-Qadir
- Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Women’s College Hospital, Toronto, Ontario, Canada
| | - Bonnie Ky
- Penn Cardiovascular Institute, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
- Center for Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jennifer E. Liu
- Memorial Sloan-Kettering Cancer Center, Department of Medicine/Cardiology Service, New York, New York, USA
| | - Juan C. Lopez-Mattei
- The University of Texas MD Anderson Cancer Center, Department of Cardiology, Houston, Texas, USA
| | - Eitan Amir
- Princess Margaret Cancer Center, Division of Medical Oncology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Paaladinesh Thavendiranathan
- Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Evolution in the risk of adverse events of adjuvant endocrine therapy in postmenopausal women with early-stage breast cancer. Breast Cancer Res Treat 2020; 182:259-266. [PMID: 32488391 DOI: 10.1007/s10549-020-05715-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 05/26/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Adjuvant endocrine therapy is a gold standard in early-stage, hormone receptor positive breast cancer. In postmenopausal women, aromatase inhibitors (AIs) are associated with improved outcome compared to tamoxifen monotherapy. Differences in the toxicity profiles of these drugs are described; however, little is known about whether the risk of adverse events changes over time. METHODS Sequential reports of large, randomized, adjuvant endocrine therapy trials comparing AIs to tamoxifen were reviewed. Data on pre-specified adverse events were extracted including cardiovascular events, bone fractures, cerebrovascular disease, endometrial cancer, secondary malignancies excluding breast cancer, venous thrombosis and death without recurrence. Odds ratios (ORs) were calculated for each adverse event at each time over the course of follow-up. The change in the ORs for adverse events over time was evaluated using weighted linear regression. RESULTS Analysis included 21 reports of 7 trials comprising 30,039 patients and reporting outcomes between 28 and 128 months of follow-up. Compared to tamoxifen, AIs use was associated with a significant reduction in the magnitude of increased odds of bone fracture over time (β = - 0.63, p = 0.013). There was a non-significant decrease in the magnitude of reduced odds of secondary malignancies over time (β = 0.448, p = 0.094). The differences in other toxicity profiles between AIs and tamoxifen did not change significantly over time. CONCLUSIONS The increased risk of bone fractures associated with adjuvant AIs falls over time and after discontinuation of treatment. Differences in other toxicities between AIs and tamoxifen do not change significantly over time including a persistently elevated risk of cardiovascular events.
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Abstract
Purpose of review Participation in cardiac rehabilitation is associated with improved quality of life and physical functioning and may be an effective strategy to assist in the recovery from cancer. We conducted a scoping review to identify studies that enrolled cancer survivors into cardiac rehabilitation programs. Recent findings We identified nine studies that included 662 cancer survivors. Five studies integrated cancer survivors and cardiac patients into the same sessions, three studies developed cancer-only rehabilitation sessions, and one study did not report details on the rehabilitation sessions. On average, more than 60% of enrolled cancer survivors completed the rehabilitation programs and many health and psychosocial outcomes improved after rehabilitation. Summary Cardiac rehabilitation appears to be acceptable and favorably impacts many health and psychosocial outcomes among cancer survivors. Future research should consider randomized controlled trial study designs, enrolling diverse survivor populations, and using a set of core physical function and psychosocial outcomes.
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Hedayati E, Papakonstantinou A, Gernaat SAM, Altena R, Brand JS, Alfredsson J, Bhoo-Pathy N, Herrmann J, Linde C, Dahlstrom U, Bergh J, Hubbert L. Outcome and presentation of heart failure in breast cancer patients: findings from a Swedish register-based study. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2020; 6:147-155. [PMID: 31328233 DOI: 10.1093/ehjqcco/qcz039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 07/09/2019] [Accepted: 07/12/2019] [Indexed: 02/07/2023]
Abstract
AIMS Heart failure (HF) patients diagnosed with breast cancer (BC) may have a higher risk of death, and different HF presentation and treatment than patients without BC. METHODS AND RESULTS A total of 14 998 women with incident HF (iHF) or prevalent HF (pHF) enrolled in the Swedish HF Registry within and after 1 month since HF diagnosis, respectively, between 2008 and 2013. Patients were linked with the National Patient-, Cancer-, and Cause-of-Death Registry. Two hundred and ninety-four iHF and 338 pHF patients with BC were age-matched to 1470 iHF and 1690 pHF patients without BC. Comorbidity and treatment characteristics were compared using the χ2 tests for categories. Cox proportional hazard models assessed the hazard ratio (HR) and 95% confidence intervals (95% CIs) of all-cause and cardiovascular mortality among HF patients with and without BC. In the pHF group, BC patients had less often myocardial infarction (21.6% vs. 28.6%, P < 0.01) and received less often aspirin (47.6% vs. 55.1%, P = 0.01), coronary revascularization (11.8% vs. 16.2%, P < 0.01), or device therapy (0.9% vs. 3.0%, P = 0.03). After median follow-up of 2 years, risk of all-cause mortality (iHF: HR = 1.04, 95% CI = 0.83-1.29 and pHF: HR = 0.94, 95% CI = 0.79-1.12), cardiovascular mortality (iHF: HR = 0.94, 95% CI = 0.71-1.24 and pHF: HR = 0.89, 95% CI = 0.71-1.10), and HF mortality (iHF: HR = 0.80, 95% CI = 0.34-1.90 and pHF: HR = 0.75, 95% CI = 0.43-1.29) were similar for patients with and without BC in the iHF and pHF groups. CONCLUSION Risk of all-cause and cardiovascular mortality in HF patients did not differ by BC status. Differences in pre-existing myocardial infarction and HF treatment among pHF patients with and without BC may suggest differences in pathogenesis of HF.
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Affiliation(s)
- Elham Hedayati
- Department of Oncology-Pathology, Karolinska Institute and University Hospital, SE-17176 Stockholm, Sweden.,Breast Cancer Flow, Patient Area of Breast Cancer Sarcoma and Endocrine Tumours, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Antroula Papakonstantinou
- Department of Oncology-Pathology, Karolinska Institute and University Hospital, SE-17176 Stockholm, Sweden.,Breast Cancer Flow, Patient Area of Breast Cancer Sarcoma and Endocrine Tumours, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Sofie A M Gernaat
- Department of Oncology-Pathology, Karolinska Institute and University Hospital, SE-17176 Stockholm, Sweden
| | - Renske Altena
- Department of Oncology-Pathology, Karolinska Institute and University Hospital, SE-17176 Stockholm, Sweden.,Breast Cancer Flow, Patient Area of Breast Cancer Sarcoma and Endocrine Tumours, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Judit S Brand
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Joakim Alfredsson
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linkoping University, Linkoping, Sweden.,Department of Medical and Health Sciences, Linkoping University, Linkoping, Sweden
| | - Nirmala Bhoo-Pathy
- Julius Centre University of Malaya, Faculty of Medicine, University of Malaya, 50603 Lembah Pantai, Kuala Lumpur, Malaysia
| | - Jeorg Herrmann
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Cecilia Linde
- Heart and Vascular Theme, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Ulf Dahlstrom
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linkoping University, Linkoping, Sweden.,Department of Medical and Health Sciences, Linkoping University, Linkoping, Sweden
| | - Jonas Bergh
- Department of Oncology-Pathology, Karolinska Institute and University Hospital, SE-17176 Stockholm, Sweden.,Breast Cancer Flow, Patient Area of Breast Cancer Sarcoma and Endocrine Tumours, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Laila Hubbert
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Norrkoping, Sweden.,Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
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Chou YH, Huang JY, Kornelius E, Chiou JY, Huang CN. Major Adverse Cardiovascular Events after Treatment in Early-stage Breast Cancer Patients Receiving Hormone Therapy. Sci Rep 2020; 10:1408. [PMID: 31996695 PMCID: PMC6989448 DOI: 10.1038/s41598-020-57726-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 12/30/2019] [Indexed: 11/08/2022] Open
Abstract
This nationwide population-based study investigated the differences in the risks of major adverse cardiovascular events (MACEs) among patients with hormone receptor-positive early-stage breast cancer undergoing different combinations of adjuvant treatments in Taiwan. Data from the National Health Insurance Research Database (NHIRD) and Taiwan Cancer Registry (TCR) along with the national mortality data were used. Patients who underwent surgery as the first mode of treatment were divided into four groups based on the subsequent adjuvant therapy received: hormone therapy (H), hormone therapy + chemotherapy (CH), hormone therapy + radiotherapy (RH), and hormone therapy + radiotherapy + chemotherapy (CRH) groups. The risks of fatal and nonfatal MACE among the groups were examined using the inverse probability of treatment weighted hazard ratio (IPTW-HR). Adjuvant treatment, age, tumour size, and comorbidities significantly affected the risks of MACEs among the 19,007 patients analysed. For nonfatal MACEs, the IPTW-HR was significantly lower in the CH group compare to the H group (0.704, 95% confidence interval [CI]: 0.516-0.961). No significant differences in the risks for fatal MACE were observed among the four groups. The IPTW-HRs for haemorrhagic stroke in the CH group was 0.424 (95% CI: 0.188-0.957), for congestive heart failure (CHF) in the RH group was 0.260 (95% CI: 0.088-0.762), and for ischaemic heart disease in the CRH group was 0.544 (95% CI: 0.317-0.934). Increase in the adjuvant modality does not necessarily increase the nonfatal or fatal MACE risks. Cardiac health should be monitored even in patients receiving hormone therapy alone.
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Affiliation(s)
- Ying-Hsiang Chou
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan, ROC
- Department of Medical Imaging and Radiological Sciences, Chung Shan Medical University, Taichung, Taiwan, ROC
- Department of Radiation Oncology, Chung Shan Medical University Hospital, Taichung, Taiwan, ROC
| | - Jing-Yang Huang
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung, Taiwan, ROC
| | - Edy Kornelius
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan, ROC
- Division of Endocrinology and Metabolism, Department of Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan, ROC
| | - Jeng-Yuan Chiou
- School of Health Policy and Management, Chung Shan Medical University, Taichung, Taiwan, ROC
| | - Chien-Ning Huang
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan, ROC.
- Division of Endocrinology and Metabolism, Department of Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan, ROC.
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Bobrowski D, Suntheralingam S, Calvillo-Argüelles O, Michalowska M, Amir E, Sacha Bhatia R, Thavendiranathan P, Abdel-Qadir H. The Yield of Routine Cardiac Imaging in Breast Cancer Patients Receiving Trastuzumab-Based Treatment: A Retrospective Cohort Study. Can J Cardiol 2019; 36:1658-1666. [PMID: 32621888 DOI: 10.1016/j.cjca.2019.12.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 12/09/2019] [Accepted: 12/21/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND There are limited data on the yield of routine cardiac imaging for trastuzumab-treated patients with breast cancer. METHODS We conducted a retrospective cohort study of patients with breast cancer treated with adjuvant trastuzumab between 2007 and 2012 at Princess Margaret Cancer Centre (Toronto, Canada). We classified imaging tests as clinically prompted or routinely ordered and determined whether each test led to changes in patient care. A generalized estimating equation model was used to determine if patient characteristics predicted routine studies more likely to change care. We analysed routine tests that were exclusively preceded by consecutive tests that did not change care to determine if their yield differed by time since trastuzumab start and the number of prior tests that did not change care. RESULTS We identified 448 patients who received 1735 cardiac imaging studies after trastuzumab initiation. Of 1555 routine tests, 44 led to changes in care (2.8%) for 43 patients, whereas 50 of 180 clinically prompted tests (27.8%) altered care in 29 patients (P-value < 0.001). Earlier stage cancer, diabetes, prior anthracyclines, and prior cardiovascular disease were associated with a higher likelihood of changes in care following routine tests (P-value < 0.05). Among routine tests that were exclusively preceded by consecutive tests that did not change care, tests ordered outside months 3-9 and those that followed ≥ 3 tests were even less likely to change care. CONCLUSIONS Routine cardiac imaging tests rarely changed care for trastuzumab-treated patients with breast cancer, particularly among lower risk anthracycline-naïve women who had multiple prior tests that did not change care.
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Affiliation(s)
| | - Sivisan Suntheralingam
- Ted Rogers Program in Cardiotoxicity Prevention, Division of Cardiology, Peter Munk Cardiac Center, University Health Network, Toronto, Ontario, Canada
| | - Oscar Calvillo-Argüelles
- Ted Rogers Program in Cardiotoxicity Prevention, Division of Cardiology, Peter Munk Cardiac Center, University Health Network, Toronto, Ontario, Canada
| | - Maria Michalowska
- Ted Rogers Program in Cardiotoxicity Prevention, Division of Cardiology, Peter Munk Cardiac Center, University Health Network, Toronto, Ontario, Canada
| | - Eitan Amir
- Department of Medicine, Division of Medical Oncology and Hematology, Princess Margaret Cancer Center, Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - R Sacha Bhatia
- Women's College Hospital (WCH), Toronto, Ontario, Canada; WCH Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada
| | - Paaladinesh Thavendiranathan
- Ted Rogers Program in Cardiotoxicity Prevention, Division of Cardiology, Peter Munk Cardiac Center, University Health Network, Toronto, Ontario, Canada; Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
| | - Husam Abdel-Qadir
- Women's College Hospital (WCH), Toronto, Ontario, Canada; Ted Rogers Program in Cardiotoxicity Prevention, Division of Cardiology, Peter Munk Cardiac Center, University Health Network, Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; WCH Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada.
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Medium and long-term risks of specific cardiovascular diseases in survivors of 20 adult cancers: a population-based cohort study using multiple linked UK electronic health records databases. Lancet 2019. [PMID: 31443926 DOI: 10.1016/s01406736(19)31674-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
BACKGROUND The past few decades have seen substantial improvements in cancer survival, but concerns exist about long-term cardiovascular disease risk in survivors. Evidence is scarce on the risks of specific cardiovascular diseases in survivors of a wide range of cancers to inform prevention and management. In this study, we used large-scale electronic health records data from multiple linked UK databases to address these evidence gaps. METHODS For this population-based cohort study, we used linked primary care, hospital, and cancer registry data from the UK Clinical Practice Research Datalink to identify cohorts of survivors of the 20 most common cancers who were 18 years or older and alive 12 months after diagnosis and controls without history of cancer, matched for age, sex, and general practice. We compared risks for a range of cardiovascular disease outcomes using crude and adjusted Cox models. We fitted interactions to investigate effect modification, and flexible parametric survival models to estimate absolute excess risks over time. FINDINGS Between Jan 1, 1990, and Dec 31, 2015, 126 120 individuals with a diagnosis of a cancer of interest still being followed up at least 1 year later were identified and matched to 630 144 controls. After exclusions, 108 215 cancer survivors and 523 541 controls were included in the main analyses. Venous thromboembolism risk was elevated in survivors of 18 of 20 site-specific cancers compared with that of controls; adjusted hazard ratios (HRs) ranged from 1·72 (95% CI 1·57-1·89) in patients after prostate cancer to 9·72 (5·50-17·18) after pancreatic cancer. HRs decreased over time, but remained elevated more than 5 years after diagnosis. We observed increased risks of heart failure or cardiomyopathy in patients after ten of 20 cancers, including haematological (adjusted HR 1·94, 1·66-2·25, with non-Hodgkin lymphoma; 1·77, 1·50-2·09, with leukaemia; and 3·29, 2·59-4·18, with multiple myeloma), oesophageal (1·96, 1·46-2·64), lung (1·82, 1·52-2·17) kidney (1·73, 1·38-2·17) and ovarian (1·59, 1·19-2·12). Elevated risks of arrhythmia, pericarditis, coronary artery disease, stroke, and valvular heart disease were also observed for multiple cancers, including haematological malignancies. HRs for heart failure or cardiomyopathy and venous thromboembolism were greater in patients without previous cardiovascular disease and in younger patients. However, absolute excess risks were generally greater with increasing age. Increased risks of these outcomes seemed most pronounced in patients who had received chemotherapy. INTERPRETATION Survivors of most site-specific cancers had increased medium-term to long-term risk for one or more cardiovascular diseases compared with that for the general population, with substantial variations between cancer sites. FUNDING Wellcome Trust and Royal Society.
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Strongman H, Gadd S, Matthews A, Mansfield KE, Stanway S, Lyon AR, Dos-Santos-Silva I, Smeeth L, Bhaskaran K. Medium and long-term risks of specific cardiovascular diseases in survivors of 20 adult cancers: a population-based cohort study using multiple linked UK electronic health records databases. Lancet 2019; 394:1041-1054. [PMID: 31443926 PMCID: PMC6857444 DOI: 10.1016/s0140-6736(19)31674-5] [Citation(s) in RCA: 488] [Impact Index Per Article: 97.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 06/14/2019] [Accepted: 06/19/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND The past few decades have seen substantial improvements in cancer survival, but concerns exist about long-term cardiovascular disease risk in survivors. Evidence is scarce on the risks of specific cardiovascular diseases in survivors of a wide range of cancers to inform prevention and management. In this study, we used large-scale electronic health records data from multiple linked UK databases to address these evidence gaps. METHODS For this population-based cohort study, we used linked primary care, hospital, and cancer registry data from the UK Clinical Practice Research Datalink to identify cohorts of survivors of the 20 most common cancers who were 18 years or older and alive 12 months after diagnosis and controls without history of cancer, matched for age, sex, and general practice. We compared risks for a range of cardiovascular disease outcomes using crude and adjusted Cox models. We fitted interactions to investigate effect modification, and flexible parametric survival models to estimate absolute excess risks over time. FINDINGS Between Jan 1, 1990, and Dec 31, 2015, 126 120 individuals with a diagnosis of a cancer of interest still being followed up at least 1 year later were identified and matched to 630 144 controls. After exclusions, 108 215 cancer survivors and 523 541 controls were included in the main analyses. Venous thromboembolism risk was elevated in survivors of 18 of 20 site-specific cancers compared with that of controls; adjusted hazard ratios (HRs) ranged from 1·72 (95% CI 1·57-1·89) in patients after prostate cancer to 9·72 (5·50-17·18) after pancreatic cancer. HRs decreased over time, but remained elevated more than 5 years after diagnosis. We observed increased risks of heart failure or cardiomyopathy in patients after ten of 20 cancers, including haematological (adjusted HR 1·94, 1·66-2·25, with non-Hodgkin lymphoma; 1·77, 1·50-2·09, with leukaemia; and 3·29, 2·59-4·18, with multiple myeloma), oesophageal (1·96, 1·46-2·64), lung (1·82, 1·52-2·17) kidney (1·73, 1·38-2·17) and ovarian (1·59, 1·19-2·12). Elevated risks of arrhythmia, pericarditis, coronary artery disease, stroke, and valvular heart disease were also observed for multiple cancers, including haematological malignancies. HRs for heart failure or cardiomyopathy and venous thromboembolism were greater in patients without previous cardiovascular disease and in younger patients. However, absolute excess risks were generally greater with increasing age. Increased risks of these outcomes seemed most pronounced in patients who had received chemotherapy. INTERPRETATION Survivors of most site-specific cancers had increased medium-term to long-term risk for one or more cardiovascular diseases compared with that for the general population, with substantial variations between cancer sites. FUNDING Wellcome Trust and Royal Society.
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Affiliation(s)
- Helen Strongman
- Department of Non-Communicable Diseases Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Sarah Gadd
- Department of Non-Communicable Diseases Epidemiology, London School of Hygiene & Tropical Medicine, London, UK; School of Geography, University of Leeds, Leeds, UK
| | - Anthony Matthews
- Department of Non-Communicable Diseases Epidemiology, London School of Hygiene & Tropical Medicine, London, UK; Institute of Environmental Medicine, Karolinska Institute, Stockholm, Sweden
| | - Kathryn E Mansfield
- Department of Non-Communicable Diseases Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Alexander R Lyon
- Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, London, UK
| | - Isabel Dos-Santos-Silva
- Department of Non-Communicable Diseases Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Liam Smeeth
- Department of Non-Communicable Diseases Epidemiology, London School of Hygiene & Tropical Medicine, London, UK; Health Data Research UK, London, UK
| | - Krishnan Bhaskaran
- Department of Non-Communicable Diseases Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.
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Thavendiranathan P, Calvillo-Argüelles O. Breast Cancer Treatment and Diastolic Dysfunction: Should We Worry About Relaxing in Cardio-Oncology? JACC Cardiovasc Imaging 2019; 13:211-214. [PMID: 31542544 DOI: 10.1016/j.jcmg.2019.07.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 07/25/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Paaladinesh Thavendiranathan
- Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.
| | - Oscar Calvillo-Argüelles
- Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Lenihan DJ. Cardiac Disease After Breast Cancer Treatment: Make Sure to Check Our Blind Spot! J Natl Cancer Inst 2019; 111:762-763. [PMID: 30715396 DOI: 10.1093/jnci/djy219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 11/21/2018] [Indexed: 11/14/2022] Open
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