Anticancer therapy induced cardiotoxicity: review of the literature

Measuring healthy life expectancy and determinants of poor perceived health: A population-based study among a subset of rare and common cancer survivors

BACKGROUND

As the survival proportions for rare cancers are on average worse than for common cancers, assessing the expected remaining life years in good health becomes highly relevant. This study aimed to estimate the healthy life expectancy (HLE) of a subset of rare and common cancer survivors, and to assess the determinants of poor perceived health in rare cancer survivors.

METHODS

To calculate HLE, survival data from the population-based Netherlands Cancer Registry of survivors of a rare cancer (i.e., ovarian cancer, thyroid cancer, Hodgkin lymphoma, non-Hodgkin lymphoma) (n=21,376) and a common cancer (i.e., colorectal cancer (CRC)) (n=76,949) were combined with quality of life (QoL) data from the PROFILES registry on a random sample of the rare (n=1025) and common cancer (n=2400) survivors. A flexible parametric relative survival model was used to estimate life expectancy (LE) and years of life lost, and multivariate logistic regression was applied to determine factors related to reported poor perceived health.

RESULTS

Patients previously diagnosed with a rare cancer had an average LE of 8-36 years and were expected to spend ≥67 % of their remaining life in good health. CRC survivors had an average LE of 10 years with approximately 65 % of their remaining life expected to spend in good health. For all cancer types, those aged ≥65 years or with stage IV had the lowest HLE. Low socioeconomic status, advanced stage, and having received radiotherapy only were important predictors of poor perceived health among rare cancer survivors.

CONCLUSION

HLE can provide meaningful perspective for patients and practitioners for all cancer types, including rare cancers. Yet, data on QoL for rare cancers should be routinely collected, as such will serve as an indicator for monitoring and improving cancer care, and for enabling HLE measurements in cancer survivors.

Prognosis and cardiotoxicity associated to adjuvant trastuzumab for breast cancer: real world study in a public health system

Objective

To analyze the prognosis of patients with breast cancer who developed trastuzumab-induced cardiotoxicity and to analyze factors associated with and resulting from cardiotoxicity.

Methods

This was a retrospective cohort study that included 255 HER2-positive breast cancer patients who received adjuvant trastuzumab therapy. The inclusion criteria were a diagnosis of HER2-positive breast cancer and adjuvant trastuzumab therapy; disease stage I-III; <70 years; and a baseline echocardiogram showing a left ventricular ejection fraction (LVEF) ≥ 55%. The Kaplan-Meier method, the log-rank test, and the Cox proportional hazards model were used.

Results

In all, 15.3% (39/255) of patients presented with cardiotoxicity. Treatment was suspended in 92.3% (36/39) of patients who presented with cardiotoxicity during trastuzumab treatment. The treatment was suspended in 46 of 255 patients and it was permanently interrupted in 84.8% (33/46) of these patients, with 84.8% (28/33) due to cardiotoxicity. Cardiotoxicity was not associated with disease-free survival (DFS) (hazard ratio (HR) = 1.48; 95% confidence interval (CI = 0.79-2.78) or overall survival (OS) (HR = 1.68; 95%CI= 0.83-3.41). Patients with clinical stage III and whom trastuzumab therapy was suspended (all causes) had worse DFS; (HR = 3.19; 95% CI=1.77-5.74) and (HR = 1.83; 95% CI=1.01-3.32) respectively. Those with clinical stage III and whom trastuzumab therapy was permanently interrupted had worse OS; (HR = 3.80; 95% CI =1.82-7.94), and (HR = 2,26; 95% CI =1.09-4.68 respectively.

Conclusion

Cardiotoxicity was not associated with DFS or OS. Clinical stage III, Suspension and permanent interruption of treatment regardless of the cause were associated with worse DFS and OS in breast cancer patients.

Acacetin is a Promising Drug Candidate for Cardiovascular Diseases

Phytochemical flavonoids have been proven to be effective in treating various disorders, including cardiovascular diseases. Acacetin is a natural flavone with diverse pharmacological effects, uniquely including atrial-selective anti-atrial fibrillation (AF) via the inhibition of the atrial specific potassium channel currents [Formula: see text] (ultra-rapidly delayed rectifier potassium current), [Formula: see text] (acetylcholine-activated potassium current), [Formula: see text] (calcium-activated small conductance potassium current), and [Formula: see text] (transient outward potassium current). [Formula: see text] inhibition by acacetin, notably, suppresses experimental J-wave syndromes. In addition, acacetin provides extensive cardiovascular protection against ischemia/reperfusion injury, cardiomyopathies/heart failure, autoimmune myocarditis, pulmonary artery hypertension, vascular remodeling, and atherosclerosis by restoring the downregulated intracellular signaling pathway of Sirt1/AMPK/PGC-1α followed by increasing Nrf2/HO-1/SOD thereby inhibiting oxidation, inflammation, and apoptosis. This review provides an integrated insight into the capabilities of acacetin as a drug candidate for treating cardiovascular diseases, especially atrial fibrillation and cardiomyopathies/heart failure.

Novel PLGA-based nanoformulation decreases doxorubicin-induced cardiotoxicity

Nanotechnology has the potential to provide formulations of antitumor agents with increased selectivity towards cancer tissue thereby decreasing systemic toxicity. This in vivo study evaluated the potential of novel nanoformulation based on poly(lactic-co-glycolic acid) (PLGA) to reduce the cardiotoxic potential of doxorubicin (DOX). In vivo toxicity of PLGADOX was compared with clinically approved non-PEGylated, liposomal nanoformulation of DOX (LipoDOX) and conventional DOX form (ConvDOX). The study was performed using Wistar Han rats of both sexes that were treated intravenously for 28 days with 5 doses of tested substances at intervals of 5 days. Histopathological analyses of heart tissues showed the presence of myofiber necrosis, degeneration processes, myocytolysis, and hemorrhage after treatment with ConvDOX, whereas only myofiber degeneration and hemorrhage were present after the treatment with nanoformulations. All DOX formulations caused an increase in the troponin T with the greatest increase caused by convDOX. qPCR analyses revealed an increase in the expression of inflammatory markers IL-6 and IL-8 after ConvDOX and an increase in IL-8 expression after lipoDOX treatments. The mass spectra imaging (MSI) of heart tissue indicates numerous metabolic and lipidomic changes caused by ConvDOX, while less severe cardiac damages were found after treatment with nanoformulations. In the case of LipoDOX, autophagy and apoptosis were still detectable, whereas PLGADOX induced only detectable mitochondrial toxicity. Cardiotoxic effects were frequently sex-related with the greater risk of cardiotoxicity observed mostly in male rats.

A prospective study to evaluate the efficacy and safety of vitamin E and levocarnitine prophylaxis against doxorubicin-induced cardiotoxicity in adult breast cancer patients

BACKGROUND

Doxorubicin induces acute and chronic cardiotoxicity. This study is aimed to evaluate the efficacy and safety of vitamin E and levocarnitine (EL) as cardioprotective agents against acute doxorubicin cardiotoxicity in female adult breast cancer patients.

METHODS

A prospective, randomized controlled study was conducted in patients treated with doxorubicin and cyclophosphamide (AC). Patients were randomly assigned to EL plus AC or AC alone for the duration of 4 cycles. Cardiac enzymes (B-type natriuretic peptide, creatine kinase, troponin I (Trop)) and cardiac events were monitored during treatment to evaluate the cardioprotective efficacy of EL.

RESULTS

Seventy-four patients were recruited and received four cycles of chemotherapy. The intervention group (n = 35) showed a significant reduction in both the B-type natriuretic peptide and creatine kinase cardiac enzymes compared to the control group (n = 39). The median (IQR) change for BNP was 0.80 (0.00-4.00) for IG versus 1.80 (0.40-3.60) for CG groups (p < 0.001); creatine kinase was -0.08 (-0.25-0.05) for IG versus 0.20 (0.05-0.50) for CG (p < 0.001). The addition of EL decreased the cardiac events by 24.2% (p = 0.02). All adverse events were tolerable and manageable.

CONCLUSION

This study supports the addition of EL as prophylaxis against acute doxorubicin cardiotoxicity and it was also very well tolerated by a majority of the patients. The co-administration of EL at higher doxorubicin (240 mg/m2) dose should be further investigated.

The Role of Cancer in the Risk of Cardiovascular and All-Cause Mortality: A Nationwide Prospective Cohort Study

Objectives: Evidence on cardiovascular-related and all-cause mortality risks in a wide range of cancer survivors is scarce but needed to inform prevention and management. Methods: We performed a nationwide prospective cohort study using information from the Continuous National Health and Nutrition Examination Survey (NHANES) in the United States and the linked mortality follow-up files, available for public access. A propensity score-matched analysis with a 1:1 ratio was conducted to reduce the baseline differences between participants with and without cancer. The relationship between cancer status and the cardiovascular-related and all-cause mortality risk was examined using weighted Cox proportional hazards regression. Independent stratification analysis and cancer-specific analyses were also performed. Results: The study sample included 44,342 participants, aged 20-85, interviewed between 1999 and 2018. Of these, 4,149 participants had cancer. All-cause death occurred in 6,655 participants, of whom 2,053 died from cardiovascular causes. Propensity-score matching identified 4,149 matched pairs of patients. A fully adjusted Cox proportional hazards regression showed that cancer was linked to an elevated risk of cardiovascular-related and all-cause mortality both before and after propensity score matching. Stratification analysis and cancer-specific analyses confirmed robustness of results. Conclusion: Our study confirmed that cancer was strongly linked to cardiovascular-related and all-cause mortality, even after adjusting for other factors that could impact a risk, including the American Heart Association (AHA)'s Life's Simple 7 cardiovascular health score, age, sex, ethnicity, marital status, income, and education level.

Gel/hydrogel-based in situ biomaterial platforms for cancer postoperative treatment and recovery

Tumor surgical resection is the major strategy for cancer treatment. Meanwhile, perioperative treatment especially the postoperative adjuvant anticancer strategies play essential roles in satisfying therapeutic results and rapid recovery. Postoperative tumor recurrence, metastasis, bleeding, inter-tissue adhesion, infection, and delayed wound healing are vital risks that could lead to poor prognosis or even treatment failure. Therefore, methods targeting these postoperative complications are in desperate need. In situ biomaterial-based drug delivery platforms are promising candidates for postoperative treatment and recovery, resulting from their excellent properties including good biocompatibility, adaptive shape, limited systemic effect, designable function, and easy drug loading. In this review, we focus on introducing the gel/hydrogel-based in situ biomaterial platforms involving their properties, advantages, and synthesis procedures. Based on the loaded contents in the gel/hydrogel such as anticancer drugs, immunologic agents, cell components, and multifunctional nanoparticles, we further discuss the applications of the in situ platforms for postoperative tumor recurrence and metastasis inhibition. Finally, other functions aiming at fast postoperative recovery were introduced, including hemostasis, antibacterial infection, adhesion prevention, tissue repair, and wound healing. In conclusion, gel/hydrogel is a developing and promising platform for postoperative treatment, exhibiting gratifying therapeutic effects and inconspicuous toxicity to normal tissues, which deserves further research and exploration.

The current role of nuclear medicine in breast cancer

Breast cancer is the most common cancer in females worldwide. Nuclear medicine plays an important role in patient management, not only in initial staging, but also during follow-up. Radiopharmaceuticals to study breast cancer have been used for over 50 years, and several of these are still used in clinical practice, according to the most recent guideline recommendations.In this critical review, an overview of nuclear medicine procedures used during the last decades is presented. Current clinical indications of each of the conventional nuclear medicine and PET/CT examinations are the focus of this review, and are objectively provided. Radionuclide therapies are also referred, mainly summarising the methods to palliate metastatic bone pain. Finally, recent developments and future perspectives in the field of nuclear medicine are discussed. In this context, the promising potential of new radiopharmaceuticals not only for diagnosis, but also for therapy, and the use of quantitative imaging features as potential biomarkers, are addressed.Despite the long way nuclear medicine has gone through, it looks like it will continue to benefit clinical practice, paving the way to improve healthcare provided to patients with breast cancer.

Angiotensin-(1-7) reduces doxorubicin-induced aortic arch dysfunction in male and female juvenile Sprague Dawley rats through pleiotropic mechanisms

Doxorubicin (Dox), an effective chemotherapeutic, can cause cumulative dose-dependent cardiovascular toxicity, which may manifest as vascular dysfunction leading to long-term end-organ damage. Currently, there are no effective treatments to mitigate Dox-induced vascular damage in cancer patients, particularly pediatric patients. We showed that angiotensin-(1-7) [Ang-(1-7)], an endogenous peptide hormone, mitigated cardiac damage in Dox-treated juvenile rats. In this study assessing aortic stiffness, juvenile male and female rats were administered a clinically equivalent dose of Dox (21-24 mg/kg) over 6 weeks, in the presence and absence of Ang-(1-7) [24 µg/kg/h]. Aortic function was measured using echocardiography. Ang-(1-7) reduced the Dox-mediated increase in pulse wave velocity, a measure of arterial stiffness (males: p < 0.05; females: p < 0.001) as compared in control animals. Dox decreased aortic lumen diameter (p < 0.0001) and increased wall thickness (p < 0.01) in males, which was attenuated by Ang-(1-7). In male but not female aortic arches, Dox increased media hypertrophy (p < 0.05) and reduced elastin content (p < 0.001), which were prevented by Ang-(1-7). Conversely, Dox increased fibrosis (p < 0.0001) in juvenile female rats, which was reduced by Ang-(1-7). Adjunct Ang-(1-7) prevented the Dox-induced increase in total cell and nuclear pERK1/2 in the aortic intima and media of male rats and nuclear pSMAD2 in the intimal and medial regions of the aortic arches of both sexes. These results demonstrate that Ang-(1-7) attenuated Dox-induced aortic dysfunction in both sexes of juvenile rats, albeit through different mechanisms, suggesting that Ang-(1-7) may serve as an effective adjuvant to ameliorate cardiovascular and long-term end-organ damage in pediatric patients produced by anthracyclines.

Anti-Inflammatory, Anti-Apoptotic, and Antioxidant Roles of Honey, Royal Jelly, and Propolis in Suppressing Nephrotoxicity Induced by Doxorubicin in Male Albino Rats

Nephrotoxicity is one of the limiting factors for using doxorubicin (DOX). Honey, propolis, and royal jelly were evaluated for their ability to protect against nephrotoxicity caused by DOX. Forty-two adult albino rats were divided into control groups. The DOX group was injected i.p. with a weekly dose of 3 mg/kg of DOX for six weeks. The DOX plus honey treated group was injected with DOX and on the next day, received 500 mg/kg/day of honey orally for 21 days. The DOX plus royal jelly treated group was injected with DOX and on the following day, received 100 mg/kg/day of royal jelly orally for 21 days. The DOX plus propolis treated group received DOX and on the following day, was treated orally with 50 mg/kg/day of propolis for 21 days. The DOX plus combined treatment group received DOX and on the following day, was treated with a mix of honey, royal jelly, and propolis orally for 21 days. Results confirmed that DOX raised creatinine, urea, MDA, and TNF-α while decreasing GPX and SOD. Damages and elevated caspase-3 expression were discovered during renal tissue's histopathological and immunohistochemical studies. Combined treatment with honey, royal jelly, and propolis improved biochemical, histological, and immunohistochemical studies in the renal tissue. qRT-PCR revealed increased expression of poly (ADP-Ribose) polymerase-1 (PARP-1) and a decline of Bcl-2 in the DOX group. However, combined treatment induced a significant decrease in the PARP-1 gene and increased Bcl-2 expression levels. In addition, the combined treatment led to significant improvement in the expression of both PARP-1 and Bcl-2 genes. In conclusion, the combined treatment effectively inhibited nephrotoxicity induced by DOX.

Cardiotoxicity of Anticancer Drugs: Molecular Mechanisms and Strategies for Cardioprotection

Chemotherapy and targeted therapies have significantly improved the prognosis of oncology patients. However, these antineoplastic treatments may also induce adverse cardiovascular effects, which may lead to acute or delayed onset of cardiac dysfunction. These common cardiovascular complications, commonly referred to as cardiotoxicity, not only may require the modification, suspension, or withdrawal of life-saving antineoplastic therapies, with the risk of reducing their efficacy, but can also strongly impact the quality of life and overall survival, regardless of the oncological prognosis. The onset of cardiotoxicity may depend on the class, dose, route, and duration of administration of anticancer drugs, as well as on individual risk factors. Importantly, the cardiotoxic side effects may be reversible, if cardiac function is restored upon discontinuation of the therapy, or irreversible, characterized by injury and loss of cardiac muscle cells. Subclinical myocardial dysfunction induced by anticancer therapies may also subsequently evolve in symptomatic congestive heart failure. Hence, there is an urgent need for cardioprotective therapies to reduce the clinical and subclinical cardiotoxicity onset and progression and to limit the acute or chronic manifestation of cardiac damages. In this review, we summarize the knowledge regarding the cellular and molecular mechanisms contributing to the onset of cardiotoxicity associated with common classes of chemotherapy and targeted therapy drugs. Furthermore, we describe and discuss current and potential strategies to cope with the cardiotoxic side effects as well as cardioprotective preventive approaches that may be useful to flank anticancer therapies.

Early Change in Area Strain Detected by 3D Speckle Tracking Is Associated With Subsequent Cardiotoxicity in Patients Treated With Low Doses of Anthracyclines

Objective

To evaluate the prognostic impact of the parameters of myocardial deformation using three-dimensional speckle tracking echocardiography (3DSTE) in patients with breast cancer who underwent chemotherapy with low doses of anthracyclines.

Background

Chemotherapy-related cardiotoxicity has an important prognostic impact on cancer survivors. Three-dimensional STE has revealed more consistent data than two-dimensional techniques and may represent a more accurate tool in the evaluation of myocardial function in patients who underwent chemotherapy.

Methods

We evaluated patients with breast cancer who were treated with anthracyclines (associated or not with trastuzumab) in five stages: baseline, after cumulative doses of 120 and 240 mg/m² of doxorubicin, and then, after 6 months and at least 1 year after anthracyclines. Ultrasensitive troponin I (US-TnI) and a standard echocardiography study were performed at each stage. We analyzed left ventricular ejection fraction (LVEF) by Simpson's method, two-dimensional speckle tracking (2DSTE) with longitudinal and radial strain values, and 3DSTE with longitudinal, radial, and circumferential strain as well as twist, torsion, rotation, and three-dimensional global area strain (3DGAS). Cardiotoxicity was defined as a decrease in LVEF by more than 10 percentage points to a value lower than 53%.

Results

We evaluated 51 female patients who were aged 50.6 ± 11 years. After the cumulative dose of 240 mg/m² of doxorubicin, US-TnI was increased (>34 pg/ml) in 21 patients (45%, p > 0.001), LVEF remained unchanged (p = 0.178), while 2DSTE longitudinal strain was decreased (from −17.8% to −17.1%, p < 0.001) and 3DSTE detected changes in longitudinal, radial, circumferential, and area strain. After a lower cumulative dose of doxorubicin (120 mg/m²), 3DGAS (p < 0.001) was the only parameter that was changed. In the follow-up, 7 (13%) patients presented a decrease in LVEF. Three-dimensional GAS early changed to abnormal values was the only variable associated with a subsequent decrease in LVEF (definitive cardiotoxicity).

Conclusion

In patients with breast cancer, 3DSTE detected early changes in area strain after very low doses of doxorubicin. The 3DGAS early changed to abnormal values was associated with a subsequent decrease in LVEF, representing a promising technique to predict chemotherapy-induced cardiomyopathy.

Transcriptional co-activators YAP1-TAZ of Hippo signalling in doxorubicin-induced cardiomyopathy

AIMS

Hippo signalling is an evolutionarily conserved pathway that controls organ size by regulating apoptosis, cell proliferation, and stem cell self-renewal. Recently, the pathway has been shown to exert powerful growth regulatory activity in cardiomyocytes. However, the functional role of this stress-related and cell death-related pathway in the human heart and cardiomyocytes is not known. In this study, we investigated the role of the transcriptional co-activators of Hippo signalling, YAP and TAZ, in human-induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs) in response to cardiotoxic agents and investigated the effects of modulating the pathway on cardiomyocyte function and survival.

METHODS AND RESULTS

RNA-sequencing analysis of human heart samples with doxorubicin-induced end-stage heart failure and healthy controls showed that YAP and ERBB2 (HER2) as upstream regulators of differentially expressed genes correlated with doxorubicin treatment. Thus, we tested the effects of doxorubicin on hiPSC-CMs in vitro. Using an automated high-content screen of 96 clinically relevant antineoplastic and cardiotherapeutic drugs, we showed that doxorubicin induced the highest activation of YAP/TAZ nuclear translocation in both hiPSC-CMs and control MCF7 breast cancer cells. The overexpression of YAP rescued doxorubicin-induced cell loss in hiPSC-CMs by inhibiting apoptosis and inducing proliferation. In contrast, silencing of YAP and TAZ by siRNAs resulted in elevated mitochondrial membrane potential loss in response to doxorubicin. hiPSC-CM calcium transients did not change in response to YAP/TAZ silencing.

CONCLUSIONS

Our results suggest that Hippo signalling is involved in clinical anthracycline-induced cardiomyopathy. Modelling with hiPSC-CMs in vitro showed similar responses to doxorubicin as adult cardiomyocytes and revealed a potential cardioprotective effect of YAP in doxorubicin-induced cardiotoxicity.

The Role of Healthy Lifestyle in Cancer Incidence and Temporal Transitions to Cardiometabolic Disease

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.

Consideration of Sex as a Biological Variable in the Development of Doxorubicin Myotoxicity and the Efficacy of Exercise as a Therapeutic Intervention

Doxorubicin (DOX) is an anthracycline antibiotic used to treat a wide variety of hematological and solid tumor cancers. While DOX is highly effective at reducing tumor burden, its clinical use is limited by the development of adverse effects to both cardiac and skeletal muscle. The detrimental effects of DOX to muscle tissue are associated with the increased incidence of heart failure, dyspnea, exercise intolerance, and reduced quality of life, which have been reported in both patients actively receiving chemotherapy and cancer survivors. A variety of factors elevate the probability of DOX-related morbidity in patients; however, the role of sex as a biological variable to calculate patient risk remains unclear. Uncertainty regarding sexual dimorphism in the presentation of DOX myotoxicity stems from inadequate study design to address this issue. Currently, the majority of clinical data on DOX myotoxicity come from studies where the ratio of males to females is unbalanced, one sex is omitted, and/or the patient cohort include a broad age range. Furthermore, lack of consensus on standard outcome measures, difficulties in long-term evaluation of patient outcomes, and other confounding factors (i.e., cancer type, drug combinations, adjuvant therapies, etc.) preclude a definitive answer as to whether differences exist in the incidence of DOX myotoxicity between sexes. This review summarizes the current clinical and preclinical literature relevant to sex differences in the incidence and severity of DOX myotoxicity, the proposed mechanisms for DOX sexual dimorphism, and the potential for exercise training to serve as an effective therapeutic countermeasure to preserve muscle strength and function in males and females.

Genetic Variability of Antioxidative Mechanisms and Cardiotoxicity after Adjuvant Radiotherapy in HER2-Positive Breast Cancer Patients

Background

Breast cancer treatment is associated with the occurrence of various cardiac adverse events. One of the mechanisms associated with cardiotoxicity is oxidative stress, against which cells are protected by antioxidative enzymes. Genetic variability of antioxidative enzymes can affect enzyme activity or expression, which modifies the ability of cells to defend themselves against oxidative stress and could consequently contribute to the occurrence of treatment-related cardiotoxicity. Our aim was to evaluate the association of common polymorphisms in antioxidative genes with cardiotoxicity after adjuvant radiotherapy (RT) in HER2-positive breast cancer patients.

Methods

Our retrospective study included 101 HER2-positive early breast cancer patients who received trastuzumab and adjuvant RT. We isolated DNA from buccal swabs and used competitive allele-specific PCR for genotyping of PON1 rs854560 and rs662, GSTP1 rs1138272 and rs1695, SOD2 rs4880, CAT rs1001179, and HIF1 rs1154965 polymorphisms. N-terminal pro B-type natriuretic peptide (NT-proBNP), left ventricular ejection fraction, and NYHA class were used as markers of cardiotoxicity. We used logistic regression to evaluate the association of genetic factors with markers of cardiotoxicity.

Results

Carriers of at least one polymorphic PON1 rs854560 allele were less likely to have increased NT-proBNP (OR = 0.34; 95% CI = 0.15-0.79; P = 0.012), even after adjustment for age (OR = 0.35; 95% CI = 0.15-0.83; P = 0.017). Carriers of at least one polymorphic PON1 rs662 allele were more likely to have increased NT-proBNP (OR = 4.44; 95% CI = 1.85-10.66; P = 0.001), even after adjustment for age (OR = 5.41; 95% CI = 2.12-13.78; P < 0.001). GSTP1 rs1695 was also associated with decreased NT-proBNP in the multivariable analysis (P = 0.026), while CAT rs1001179 was associated with NYHA class in the univariable (P = 0.012) and multivariable analysis (P = 0.023).

Conclusion

In our study, polymorphisms PON1 rs662 and rs854560, CAT rs1001179, and GSTP1 rs1695 were significantly associated with the occurrence of cardiac adverse events after adjuvant RT and could serve as biomarkers contributing to treatment personalization.

Association between history of cancer and major adverse cardiovascular events in patients with chest pain presenting to the emergency department: a secondary analysis of a prospective cohort study

OBJECTIVES

Cancer survivorship status among patients evaluated for chest pain at the emergency department (ED) warrants high degree of suspicion. However, it remains unclear whether cancer survivorship is associated with different risk of major adverse cardiac events (MACE) compared to those with no history of cancer. Furthermore, while HEART score is widely used in ED evaluation, it is unclear whether it can adequately triage chest pain events in cancer survivors. We sought to compare the rate of MACE in patients with a recent history of cancer in remission evaluated for acute chest pain at the ED to those with no history of cancer, and compare the performance of a common chest pain risk stratification score (HEART) between the two groups.

METHODS

We performed a secondary analysis of a prospective observational cohort study of chest pain patients presenting to the EDs of three tertiary care hospitals in the USA. Cancer survivorship status, HEART scores, and the presence of MACE within 30 days of admission were retrospectively adjudicated from the charts. We defined patients with recent history of cancer in remission as those with a past history of cancer of less than 10 years, and currently cured or in remission.

RESULTS

The sample included 750 patients (age: 59 ± 17; 42% females, 40% Black), while 69 patients (9.1%) had recent history of cancer in remission. A cancer in remission status was associated with a higher comorbidity burden, older age, and female sex. There was no difference in risk of MACE between those with a cancer in remission and their counterparts in both univariate [17.4 vs. 19.5%, odds ratio (OR) = 0.87 (95% confidence interval (CI), 0.45-1.66], P = 0.67] and multivariable analysis adjusting for demographics and comorbidities [OR = 0.62 (95% CI, 0.31-1.25), P = 0.18]. Patients with cancer in remission had higher HEART score (4.6 ± 1.8 vs. 3.9 ± 2.0, P = 0.006), and a higher proportion triaged as intermediate risk [68 vs. 56%, OR = 1.67 (95% CI, 1.00-2.84), P = 0.05]; however, no difference in the performance of HEART score existed between the groups (area under the curve = 0.86 vs. 0.84, P = 0.76).

CONCLUSIONS

There was no difference in rate of MACE between those with recent history of cancer in remission compared to their counterparts. A higher proportion of patients with cancer in remission was triaged as intermediate risk by the HEART score, but we found no difference in the performance of the HEART score between the groups.

Global Longitudinal Strain: Is It Time to Change the Preoperative Cardiac Assessment of Oncology Patients?

The introduction of new anticancer treatment modalities has improved survival rates, transforming cancer into a chronic disease in many instances. One of the most devastating complications of cancer treatment is cancer therapy-related cardiac dysfunction. Adequate preoperative assessment of any significant cancer therapy-related cardiac impairment is critical, and may be missed with conventional measures. The assessment of global longitudinal strain by speckle-tracking echocardiography is more sensitive for the early detection of cardiac contractility before a decline in ejection fraction can be discovered. Global longitudinal strain can also predict postoperative cardiac dysfunction, which makes it a good alternative for preoperative cardiac assessment in the oncology population when cancer therapies have been administered that can alter normal performance.

Factors Associated with Adverse Cardiovascular Events in Cancer Patients Treated with Bevacizumab

Background: Bevacizumab, a vascular endothelial growth factor (VEGF) monoclonal antibody commonly used for the treatment of various cancers, is often associated with adverse cardiovascular effects such as hypertension, cardiac and cerebral ischemia, thrombosis, and bleeding events. Factors associated with increased risks of adverse cardiovascular effects with bevacizumab have not been intensively studied. In this study, we determined factors associated with hospital admissions due to cardiovascular complications in patients who received bevacizumab for cancer treatment. Methods and Results: We retrospectively collected data for all patients treated with bevacizumab between the 1st January 2016 and the 31st December 2017 at the Hunter New England Local Health District. Patients' characteristics and their medical history were obtained from hospital electronic medical records. Outcome data were sourced from the Institutional Cardiac and Stroke Outcomes Unit database. A total of n = 230 patients (mean age 65, males n = 124 (53.9%)) were treated with bevacizumab during the study period. N = 28 patients were admitted to hospital for a major cardiovascular-related event. Higher total treatment dose (p < 0.05), concomitant hypertension (p = 0.005), diabetes (p = 0.04), atrial fibrillation (p = 0.03), and lack of use of statin therapy (p = 0.03) were key contributors to hospital admission. Conclusions: Results of our study highlight the fact that patients with concomitant baseline cardiovascular disease/risk factors are at an increased risk of cardiovascular hospitalization related to bevacizumab treatment. Careful baseline cardiovascular assessment may be an essential step to minimize cardiovascular complications.

Inhibitory effects of brusatol delivered using glycosaminoglycan‑placental chondroitin sulfate A‑modified nanoparticles on the proliferation, migration and invasion of cancer cells

Breakthroughs in cancer management result from the development of drugs that can be used for early diagnosis and effective treatment. Surgery, chemotherapy, radiotherapy and hormone therapy are the main anticancer therapies. However, traditional cancer chemotherapy is associated with serious systemic side effects. Nanoparticles (NPs) provide an effective solution for cancer treatment via the targeted delivery of drugs to cancer cells, while minimizing injury to normal cells. Glycosaminoglycan-placental chondroitin sulfate A (plCSA) is expressed in a number of tumor cells and trophoblasts. A plCSA-binding peptide (plCSA-BP) was isolated from malaria protein VAR2CSA, which can effectively promote the binding of lipid polymer NPs to tumor cells, thereby significantly enhancing the anticancer effect of encapsulated drugs. Brusatol is an important compound derived from Brucea javanica that exerts a multitude of biological effects, including inhibiting tumor cell growth, reducing the reproduction of malaria parasites, reducing inflammation and resisting virus invasion. In the present study, brusatol-loaded NPs (BNPs) or coumarin 6 NPs (CNPs), plCSA-BP and scrambled control peptide-bound BNPs or CNPs were prepared. Ovarian cancer cells (SKOV3), endometrial cancer cells (HEC-1-A) and lung cancer cells (A549) were treated with the NPs. The uptake of plCSA-CNPs by tumor cells was found to be markedly higher compared with that of other types of NPs. Further studies demonstrated that the plCSA-BNPs promoted the apoptosis of cancer cells more effectively and inhibited their proliferation, invasion and migration, accompanied by downregulation of matrix metalloproteinase (MMP)-2, MMP-9 and B-cell CLL/lymphoma 2 (BCL2) levels, but upregulation of BCL2-associated X protein BAX and cleaved caspase-3 levels. The results demonstrated the potential of brusatol delivered by plCSA-modified NPs as a chemotherapeutic agent for the targeted therapy of tumors by regulating the BCL2, BAX, cleaved caspase-3, MMP-2 and MMP-9 pathways, and indicated that it may be an effective and safe strategy for the treatment of various tumors.

Angiotensin-(1–7) reduces doxorubicin-induced cardiac dysfunction in male and female Sprague-Dawley rats through antioxidant mechanisms

Doxorubicin (Dox) is an effective chemotherapeutic for a variety of pediatric malignancies. Unfortunately, Dox administration often results in a cumulative dose-dependent cardiotoxicity that manifests with marked oxidative stress, leading to heart failure. Adjunct therapies are needed to mitigate Dox cardiotoxicity and enhance quality of life in pediatric patients with cancer. Angiotensin-(1–7) [Ang-(1–7)] is an endogenous hormone with cardioprotective properties. This study investigated whether adjunct Ang-(1–7) attenuates cardiotoxicity resulting from exposure to Dox in male and female juvenile rats. Dox significantly reduced body mass, and the addition of Ang-(1–7) had no effect. However, adjunct Ang-(1–7) prevented Dox-mediated diastolic dysfunction, including markers of decreased passive filling as measured by reduced early diastole mitral valve flow velocity peak ( E) ( P < 0.05) and early diastole mitral valve annulus peak velocity ( e′; P < 0.001) and increased E/e′ ( P < 0.001), an echocardiographic measure of diastolic dysfunction. Since Dox treatment increases reactive oxygen species (ROS), the effect of Ang-(1–7) on oxidative by-products and enzymes that generate or reduce ROS was investigated. In hearts of male and female juvenile rats, Dox increased NADPH oxidase 4 ( P < 0.05), a major cardiovascular NADPH oxidase isozyme that generates ROS, as well as 4-hydroxynonenal ( P < 0.001) and malondialdehyde ( P < 0.001), markers of lipid peroxidation; Ang-(1–7) prevented these effects of Dox. Cotreatment with Dox and Ang-(1–7) increased the antioxidant enzymes SOD1 (male: P < 0.05; female: P < 0.01) and catalase ( P < 0.05), which likely contributed to reduced ROS. These results demonstrate that Ang-(1–7) prevents diastolic dysfunction in association with a reduction in ROS, suggesting that the heptapeptide hormone may serve as an effective adjuvant to improve Dox-induced cardiotoxicity.

NEW & NOTEWORTHY Ang-(1–7) is a clinically safe peptide hormone with cardioprotective and antineoplastic properties that could be used as an adjuvant therapy to improve cancer treatment and mitigate the long-term cardiotoxicity associated with doxorubicin in pediatric patients with cancer.

Having co-morbid cardiovascular disease at time of cancer diagnosis: already one step behind when it comes to HRQoL?

Background: The relation between cardiovascular disease (CVD) present at the time of cancer diagnosis and Health-Related Quality of Life (HRQoL) assessed years after cancer diagnosis has - to our knowledge - not been studied. The objective is, therefore, to examine the relation between co-morbid CVD at cancer diagnosis and HRQoL among cancer survivors diagnosed with colorectal, thyroid, prostate, endometrium, ovarian cancer, melanoma, (non-)Hodgkin lymphoma, chronic lymphocytic leukemia (CLL), or multiple myeloma (MM) in an exploratory population-based cross-sectional study.Material and methods: Analyses were performed on combined data sets from the PROFILES and Netherlands Cancer Registry (NCR). Data on co-morbid CVD at cancer diagnosis was extracted from the NCR. HRQoL was measured via PROFILES at a median of 4.6 years after cancer diagnosis. General Linear Model Analyses were run for the total group of cancer survivors and for each malignancy.Results: In total, 5930 cancer survivors (2281 colorectal, 280 thyroid, 1054 prostate, 177 endometrium, 389 ovarian cancer, 212 melanoma, 874 non-Hodgkin and 194 Hodgkin lymphoma, 242 CLL, and 227 MM survivors) were included. For the total group, survivors who had a CVD at cancer diagnosis (n = 1441, 23.4%) reported statistically significant and clinically important lower scores on global QoL and physical functioning and higher scores for dyspnea (p < .05) compared to those without CVD. Co-morbid CVD at cancer diagnosis was negatively related to global QoL, the five functional scales and the symptoms fatigue and dyspnea across most malignancies (i.e., colorectal, and prostate cancer, non-Hodgkin lymphoma, ovarium cancer, melanoma, and CLL). No significant relations were found among thyroid and endometrium cancer, Hodgkin lymphoma and MM survivors, likely due to small numbers.Conclusion: In conclusion, co-morbid CVD at cancer diagnosis was negatively related to HRQoL, especially to global QoL, physical and role functioning, and the symptoms fatigue and dyspnea.

Visualization of Cancer and Cardiovascular Disease Co-Occurrence With Network Methods

PURPOSE

Cancer and cardiovascular disease (CVD) are common causes of morbidity and mortality, and measurement and interpretation of their co-occurrence rate have important implications for public health and patient care. Here, we present the raw and adjusted co-occurrence rates of cancer and CVD in the overall population by using a visually intuitive network approach.

METHODS

By using baseline survey and linked health outcome data from 490,842 individuals age 40 to 69 years from the UK Biobank, we recorded diagnoses between 1997 and 2014 of specific cancers and specific CVDs ascertained through hospital claims. We measured raw and adjusted rates of CVD for the following groups: individuals with Hodgkin or non-Hodgkin lymphoma, lung and trachea cancer, uterus cancer, colorectal cancer, prostate cancer, breast cancer, or no recorded diagnosed cancer during this time period. Analysis accounted for age, sex, and behavioral risk factors, without regard to the order of occurrence of cancer and CVD.

RESULTS

A significantly increased rate of CVD was found in patients with multiple types of cancers, including Hodgkin and non-Hodgkin lymphoma and lung and trachea, uterus, colorectal, and breast cancer, compared with patients without cancer by using age and sex-adjusted models. Increased co-occurrence for many CVD categories remained after correction for behavioral risk factors. Construction of co-occurrence networks highlighted heart failure as a shared CVD diagnosis across multiple cancer types, including breast cancer, lung cancer, non-Hodgkin lymphoma, and colorectal cancer. Smoking, physical activity, and other lifestyle factors accounted for some but not all of the increased co-occurrence for many of the CVD diagnoses.

CONCLUSION

Increased co-occurrence of several common CVD conditions is seen widely across multiple malignancies, and shared diagnoses, such as heart failure, were highlighted by using network methods.

Detection of anthracycline-induced cardiotoxicity using perfusion-corrected 99mTc sestamibi SPECT

By the time cardiotoxicity-associated cardiac dysfunction is detectable by echocardiography it is often beyond meaningful intervention. ^99mTc-sestamibi is used clinically to image cardiac perfusion by single photon emission computed tomography (SPECT) imaging, but as a lipophilic cation its distribution is also governed by mitochondrial membrane potential (ΔΨ_m). Correcting scans for variations in perfusion (using a ΔΨ_m-independent perfusion tracer such as (bis(N-ethoxy-N-ethyldithiocarbamato)nitrido ^99mTc(V)) (^99mTc-NOET) could allow ^99mTc-sestamibi to be repurposed to specifically report on ΔΨ_m as a readout of evolving cardiotoxicity. Isolated rat hearts were perfused within a γ-detection apparatus to characterize the pharmacokinetics of ^99mTc-sestamibi and ^99mTc-NOET in response to mitochondrial perturbation by hypoxia, ionophore (CCCP) or doxorubicin. All interventions induced ^99mTc-sestamibi washout; hypoxia from 24.9 ± 2.6% ID to 0.4 ± 6.2%, CCCP from 22.8 ± 2.5% ID to −3.5 ± 3.1%, and doxorubicin from 23.0 ± 2.2% ID to 17.8 ± 0.7, p < 0.05. Cardiac ^99mTc-NOET retention (34.0 ± 8.0% ID) was unaffected in all cases. Translating to an in vivo rat model, 2 weeks after bolus doxorubicin injection, there was a dose-dependent loss of cardiac ^99mTc-sestamibi retention (from 2.3 ± 0.3 to 0.9 ± 0.2 ID/g with 10 mg/kg (p < 0.05)), while ^99mTc-NOET retention (0.93 ± 0.16 ID/g) was unaffected. ^99mTc-NOET therefore traps in myocardium independently of the mitochondrial perturbations that induce ^99mTc-sestamibi washout, demonstrating proof-of-concept for an imaging approach to detect evolving cardiotoxicity.

Incidence of cardiovascular disease up to 13 year after cancer diagnosis: A matched cohort study among 32 757 cancer survivors

We examined the incidence of cardiovascular disease (CVD) among 32 757 cancer survivors and age-, gender-, and geographically matched cancer-free controls during a follow-up period of 1-13 years, and explored whetherCVD incidence differed by received cancer treatment, traditional cardiovascular risk factors, age, or gender. Adult 1-year cancer survivors without a history ofCVD diagnosed with breast (n = 6762), prostate (n = 4504), non-Hodgkin (n = 1553), Hodgkin (n = 173), lung and trachea (n = 2661), basal cell carcinoma (BCC; n = 12 476), and colorectal (n = 4628) cancer during 1999-2011 were selected from the Netherlands Cancer Registry and matched to cancer-free controls without a history ofCVD. Drug dispenses and hospitalizations from thePHARMO Database Network were used as proxy forCVD. Data were analyzed using Cox regression analyses. Prostate (HR: 1.17; 95%CI: 1.01-1.35) and lung and trachea (HR: 1.48; 95%CI: 1.10-1.97) cancer survivors had an increased risk for developingCVD compared to cancer-free controls. This increased risk among lung and trachea cancer survivors remained statistically significant after including traditional cardiovascular risk factors and cancer treatment information (HR: 1.41; 95%CI: 1.06-1.89). Among prostate cancer survivors, the increased risk of incidentCVD was limited to those who received hormones and those without traditional cardiovascular risk factors. Breast, non-Hodgkin,BCC, and colorectal cancer survivors showed no increasedCVD risk compared to cancer-free controls. There was an increased risk of incidentCVD among prostate, and lung and trachea cancer survivors compared to age-, gender- and geographically matched cancer-free controls. Studies including longer follow-up periods are warranted to examine whether cancer survivors are at increased risk of long-term incidentCVD.

Embryonic stem cell-derived cardiomyocytes for the treatment of doxorubicin-induced cardiomyopathy

BACKGROUND

Doxorubicin (Dox) is a chemotherapy drug with limited application due to cardiotoxicity that may progress to heart failure. This study aims to evaluate the role of cardiomyocytes derived from mouse embryonic stem cells (CM-mESCs) in the treatment of Dox-induced cardiomyopathy (DIC) in mice.

METHODS

The mouse embryonic stem cell (mESC) line E14TG2A was characterized by karyotype analysis, gene expression using RT-PCR and immunofluorescence. Cells were transduced with luciferase 2 and submitted to cardiac differentiation. Total conditioned medium (TCM) from the CM-mESCs was collected for proteomic analysis. To establish DIC in CD1 mice, Dox (7.5 mg/kg) was administered once a week for 3 weeks, resulting in a cumulative Dox dose of 22.5 mg/kg. At the fourth week, a group of animals was injected intramyocardially with CM-mESCs (8 × 105 cells). Cells were tracked by a bioluminescence assay, and the body weight, echocardiogram, electrocardiogram and number of apoptotic cardiomyocytes were evaluated.

RESULTS

mESCs exhibited a normal karyotype and expressed pluripotent markers. Proteomic analysis of TCM showed proteins related to the negative regulation of cell death. CM-mESCs presented ventricular action potential characteristics. Mice that received Dox developed heart failure and showed significant differences in body weight, ejection fraction (EF), end-systolic volume (ESV), stroke volume (SV), heart rate and QT and corrected QT (QTc) intervals when compared to the control group. After cell or placebo injection, the Dox + CM-mESC group showed significant increases in EF and SV when compared to the Dox + placebo group. Reduction in ESV and QT and QTc intervals in Dox + CM-mESC-treated mice was observed at 5 or 30 days after cell treatment. Cells were detected up to 11 days after injection. The Dox + CM-mESC group showed a significant reduction in the percentage of apoptotic cardiomyocytes in the hearts of mice when compared to the Dox + placebo group.

CONCLUSIONS

CM-mESC transplantation improves cardiac function in mice with DIC.

Pharmaceutically treated anxiety but not depression prior to cancer diagnosis predicts the onset of cardiovascular disease among breast cancer survivors

PURPOSE

To examine the associations between pharmaceutically treated anxiety and depression present in the year prior to breast cancer diagnosis and the risk of incident cardiovascular disease (CVD), while controlling for traditional cardiovascular risk factors and clinical characteristics in a population-based observational study.

METHODS

Adult 1-year breast cancer survivors (n = 7227), diagnosed between 01-01-1999 and 12-31-2010, with no history of CVD, were selected from the Netherlands Cancer Registry. Drug dispensing data were derived from the PHARMO Database Network and used as proxy for CVD, anxiety, and depression. By multivariable Cox regression analysis, we examined the risk associated with pharmaceutically treated anxiety and depression for developing CVD after cancer diagnosis, adjusting for age, pharmaceutically treated hypertension, hypercholesterolemia, and diabetes mellitus in the year prior to cancer diagnosis, tumor stage, and cancer treatment.

RESULTS

During the 13-year follow-up period, 193 (3%) breast cancer survivors developed CVD. Women pharmaceutically treated for anxiety in the year prior to their cancer diagnosis had a 48% increased hazard for CVD [HR = 1.48; 95% CI 1.05-1.08] after full adjustment. This association was restricted to breast cancer survivors who were 65 years or younger. Depression was not associated with CVD risk [HR = 0.89; 95% CI 0.52-1.53]. Older age [HR = 1.06; 95% CI 1.05-1.08], hypertension [HR = 1.80; 95% CI 1.32-2.46], and hypercholesterolemia [HR = 1.63; 95% CI 1.15-2.33] were associated with an increased hazard for incident CVD, whereas hormone therapy [HR = 0.59; 95% CI 0.42-0.83] was protective.

CONCLUSIONS

Anxiety present in the year prior to breast cancer diagnosis increases the risk of incident CVD in 1-year breast cancer survivors, after adjustment for depression, traditional cardiovascular risk factors, and clinical characteristics.

Cardio-Oncology: Cancer Therapy-related Cardiovascular Complications in a Molecular Targeted Era: New Concepts and Perspectives

Cardio-oncology is a medical discipline that identifies, prevents, and treats the cardiovascular complications related to cancer therapy. Due to the remarkable proliferation of new cancer therapies causing cardiovascular complications, such as hypertension, heart failure, vascular complications, and cardiac arrhythmia, we provide an extensive, comprehensive revision of the most up-to-date scientific information available on the cardiovascular complications associated with the use of newer, novel chemotherapeutic agents, including their reported incidence, suggested pathophysiology, clinical manifestations, potential treatment, and prevention. The authors consider this topic to be relevant for the clinicians since cardiovascular complications associated with the administration of recently approved drugs are relatively underappreciated. The purpose of this article is to provide a state-of-the-art review of cardiovascular complications associated with the use of newer, novel chemotherapeutic agents and targeted therapies, including their reported incidence, suggested pathophysiology, clinical manifestations, potential treatment, and prevention.  Ongoing efforts are needed to provide a better understanding of the frequency, mechanisms of disease, prevention, and treatment of cardiovascular complications induced by the newer, novel chemotherapeutic agents. Development of a cardio-oncology discipline is warranted in order to promote task forces aimed at the creation of oncology patient-centered guidelines for the detection, prevention, and treatment of potential cardiovascular side effects associated with newer cancer therapies.

CuIIcomplex of emodin with improved anticancer activity as demonstrated by its performance on HeLa and Hep G2 cells

Structure of Cu^IIcomplex of emodin was solved from PXRD data. [Cu^II(emod)₂]²⁻binds DNA better than emodin. Thermodynamic parameters for binding were found. Complex performs better than emodin on HeLa & Hep G2 cells; not affecting WI 38 normal cells.

Novel transferrin modified and doxorubicin loaded Pluronic 85/lipid-polymeric nanoparticles for the treatment of leukemia: In vitro and in vivo therapeutic effect evaluation

PURPOSE

Childhood leukemia is a common malignant disease in children. Doxorubicin (DOX) was widely used for the treatment of leukemia. However, severe toxic side effects and drug resistance are the major limitations of DOX. Nanocarriers offer the opportunity to overcome these drawbacks, there are many attempts to enhance the activity of DOX against drug resistance. This study aimed to develop a novel transferrin (Tf) modified and doxorubicin (DOX) loaded Pluronic 85/lipid-polymeric nanoparticles for the treatment of leukemia.

METHODS

In this study, a novel targeted ligand: transferrin-polyethylene glycol-oleic acid (Tf-PEG-OA) was synthesized. Tf modified and DOX loaded Pluronic 85/lipid-polymeric nanoparticles (Tf-DOX P85/LPNs) were prepared via the self-assembly of PLGA, P85, stearic acid and Tf-PEG-OA using the nanoprecipitation method. The physicochemical properties of LPNs were characterized. In vitro and in vivo anti-tumor efficacy of LPNs was evaluated in human promyelocytic leukemia cell line (HL-60 cells) and DOX resistance HL-60 cell line (HL-60/DOX cells) including the relevant animal models.

RESULTS

Tf-DOX P85/LPNs displayed strong anti-tumor ability on both HL-60 cells and HL-60/DOX cells than other formulations used as contrast. Also, in HL-60/DOX bearing animal models, Tf-DOX P85/LPNs exhibited the highest efficiency as well as the lowest systemic toxicity.

CONCLUSION

The results indicated that Tf P85/LPNs is a promising platform to enhance efficacy, reduce toxicity and overcome drug resistance of DOX for the treatment of leukemia.

Cardiovascular co-morbidity in cancer patients: the role of psychological distress

Due to aging of the population and cardiotoxic cancer treatment, there is an increasing group of patients with cancer and co-morbid cardiovascular disease (CVD). In order to find a balance between the risk of undertreating the malignancy on the one hand and inducing CVD on the other hand, CVD risk stratification at the time of cancer diagnosis and knowledge on the pathway for developing incident CVD in cancer patients is vital. In this paper, we propose an adapted multiple-hit hypothesis for developing CVD in cancer patients describing that patients with cancer are exposed to a series of sequential or concurrent events that together make them more vulnerable to reduced cardiovascular reserves, development of incident CVD and ultimately death. We highlight the possible impact of psychological distress secondary to a cancer diagnosis and/or treatment, which in turn may increase the risk of incident CVD in patients diagnosed with cancer. Furthermore, we discuss potential behavioral and pathophysiological mechanisms underlying the link between psychological distress and the pathophysiology of incident CVD. In addition, key unanswered questions for future research are posed. In the future, researching the adapted multiple-hit hypothesis for developing CVD among cancer patients will hopefully advance the care of cancer patients by finding some of the missing pieces of the puzzle. To do so, we need to focus on minimizing cardiovascular risk and promoting cardiovascular health in cancer patients by addressing the knowledge gaps formulated in this paper.

Drugs That May Cause or Exacerbate Heart Failure: A Scientific Statement From the American Heart Association

Heart failure is a common, costly, and debilitating syndrome that is associated with a highly complex drug regimen, a large number of comorbidities, and a large and often disparate number of healthcare providers. All of these factors conspire to increase the risk of heart failure exacerbation by direct myocardial toxicity, drug-drug interactions, or both. This scientific statement is designed to serve as a comprehensive and accessible source of drugs that may cause or exacerbate heart failure to assist healthcare providers in improving the quality of care for these patients.

Folic acid linked amino‐cellulose for in vitro evaluation of doxorubicin delivery: Synthesis and characterization

In this study, cellulose, a biodegradable polymer, was successfully aminated. For this purpose the cellulose was converted to a bromoacetylated derivative by reaction with bromoacetyl bromide. The resulting bromide derivative was then substituted with azido groups by reaction with sodium azide. Then the azido group was reduced to amines via the formation of the triphenylphosphinimine intermediate followed by hydrolysis using aqueous hydrazine. This sequence produced amino‐cellulose. To gain a tumor‐targeting doxorubicin (DOX) delivery system, we conjugated an active tumor‐targeting ligand, folic acid, to the end of the resulting copolymer (FA‐Amino‐Cell). The structure of this copolymer was confirmed by FT‐IR, UV–Vis, TGA, SEM, and 1H NMR spectroscopy. The SEM images showed that the hydrodynamic dimension of the resulted product is about 40 nm. Moreover, the Release profiles of DOX from the FA‐Amino‐Cell and its loading capacity were determined by UV–Vis absorption measurement at λmax 483 nm. The results showed that the DOX loaded copolymer had good control on the release period of DOX. So, it seems that the FA‐Amino‐Cell is a potential candidate for the targeted delivery of DOX for cancer treatment.

Risk factors of atherosclerosis during systemic therapy targeting vascular endothelial growth factor

The aim of the present study was to examine the changes in intima-media thickness (IMT) and myocardial perfusion in association with other laboratory risk factors for atherosclerosis in patients treated with therapy that targeted vascular endothelial growth factor (VEGF). IMT, myocardial perfusion and laboratory risk factors of atherosclerosis were studied in 58 patients with metastatic colorectal carcinoma or metastatic renal cell carcinoma prior to and at 3-monthly intervals during anti-VEGF treatment. Compared with the pretreatment IMT, the results indicated that the IMT was consistently increased during therapy in the two patient groups. Patient blood pressure and concentration of troponin T increased transiently. An increase in the concentration of high-density lipoprotein cholesterol and decrease in the concentrations of C-reactive protein and homocysteine were also observed. Novel myocardial ischemia was evident in individual patients. In conclusion, anti-VEGF therapy affects the laboratory risk factors of atherosclerosis and results in an acceleration of atherosclerosis, as demonstrated by increased IMT.

An update on the risk prediction and prevention of anticancer therapy-induced cardiotoxicity

PURPOSE OF REVIEW

Cardiotoxicity is a well established complication of anticancer therapy. As cancer survivorship and life expectancy for cancer patients improves, the morbidity and mortality of anticancer therapy-related cardiotoxicity has become more problematic. It is of utmost importance to identify patients at the highest risk for the development of cardiotoxicity and to determine strategies for prevention, early detection and treatment.

RECENT FINDINGS

Clinical risk factors, biomarkers, advanced cardiac imaging and pharmacogenomics may be used to classify patients at risk for therapy-induced cardiotoxicity. A much broader armamentarium of imaging modalities for risk prediction, in addition to simple two-dimensional echocardiogram and radionucleotide angiography, has also shown clinical utility in identifying early-onset cardiotoxicity and areas of reversible myocardial injury. Exciting new research aimed at predicting cardiotoxicity and developing cardioprotective strategies may lead to changes in the administration of cardiotoxic chemotherapies.

SUMMARY

Personalized assessments of the risks and benefits of therapy should be used as opposed to standardized dosing and schedules. Patients at higher risk for cardiotoxicity should receive closer monitoring, cardioprotective agents, dose adjustment or alternative regimens in an effort to reduce cardiovascular morbidity and mortality. Future research will hopefully define specific risk prediction tools and clinical protocols to prevent irreversible cardiotoxicity.

Identifying cancer patients at risk for cardiotoxicity

Improvements in therapies have significantly changed survival of cancer patients. However, the clinical history and oncologic treatment put cancer patients at higher risk for developing cardiovascular problems. Anthracyclines, but also the targeted therapy and angiogenesis inhibitors, are all treatments associated with cardiotoxicity. The most common adverse event is a reduction in left ventricular ejection fraction that may progress to overt heart failure. Recognition of a cardiac impairment during or after a potential cardiotoxic treatment requires a stringent assessment of clinical symptoms and signs of heart failure associated with an evaluation of the left ventricular ejection fraction, which, however, detects the damage already installed. Circulating cardiac biomarkers are promising in detecting cardiotoxicity and will likely change the approach for identifying patients at risk.

Mesenchymal stem cell therapy for doxorubicin cardiomyopathy: hopes and fears

Chemotherapy has made an essential contribution to cancer treatment in recent decades despite its adverse effects. As cancer survivors have increased, concern about ex-patient lifespan has become more important too. Doxorubicin is an effective anti-neoplastic drug that produces a cardiotoxic effect. Cancer survivors who received doxorubicin became more vulnerable to cardiac disease than the normal population did. Many efforts have been made to prevent cardiac toxicity in patients with cancer. However, current therapies cannot guarantee permanent cardiac protection. One of their main limitations is that they do not promote myocardium regeneration. In this review, we summarize and discuss the promising use of mesenchymal stem cells for cardio-protection or cardio-regeneration therapies and consider their regenerative potential without leaving aside their controversial effects on tumor progression.

A retrospective study of the impact of 21-gene recurrence score assay on treatment choice in node positive micrometastatic breast cancer

To assess clinical utility of the 21-gene assay (Oncotype DX^® Recurrence Score^®), we determined whether women with HER2(−)/ER+ pN1mi breast cancer with low (<18) Recurrence Scores results are given adjuvant chemotherapy in a lower proportion than those with high scores (≥31). This was a multicenter chart review of ≥18 year old women with pN1mi breast cancer, HER2(−)/ER+ tumors, ductal/lobular/mixed histology, with the assay ordered on or after 1 January 2007. One hundred and eighty one patients had a mean age of 60.7 years; 82.9% had ECOG performance status 0; 33.7% had hypertension, 22.7% had osteoporosis, 18.8% had osteoarthritis, and 8.8% had type-2 diabetes. Mean Recurrence Score was 17.8 (range: 0–50). 48.6% had a mastectomy; 55.8% had a lumpectomy. 19.8% of low-risk group patients were recommended chemotherapy vs. 57.9% in the intermediate-risk group and 100% in the high-risk group (p < 0.001). A total of 80.2% of the low-risk group were recommended endocrine therapy alone, while 77.8% of the high-risk group were recommended both endocrine and chemotherapy (p < 0.001). The Oncotype DX Recurrence Score result provides actionable information that can be incorporated into treatment planning for women with HER2(−)/ER+ pN1mi breast cancer. The Recurrence Score result has clinical utility in treatment planning for HER2(−)/ER+ pN1mi breast cancer patients.

The role of general nuclear medicine in breast cancer

The rising incidence of breast cancer worldwide has prompted many improvements to current care. Routine nuclear medicine is a major contributor to a full gamut of clinical studies such as early lesion detection and stratification; guiding, monitoring, and predicting response to therapy; and monitoring progression, recurrence or metastases. Developments in instrumentation such as the high-resolution dedicated breast device coupled with the diagnostic versatility of conventional cameras have reinserted nuclear medicine as a valuable tool in the broader clinical setting. This review outlines the role of general nuclear medicine, concluding that targeted radiopharmaceuticals and versatile instrumentation position nuclear medicine as a powerful modality for patients with breast cancer.

Influence of ionic strength on the interaction of THA and its Cu(ii) complex with DNA helps to explain studies on various breast cancer cells

Purpurin, a structural analogue of anthracycline anticancer drugs, was used to understand how environmental changes affect its biophysical interactions with DNA and along with its Cu(ii) complex, the activity it shows on breast cancer cells.

Recombinant neuregulin 1 does not activate cardiomyocyte DNA synthesis in normal or infarcted adult mice

Objectives

Neuregulin 1 signaling plays an important role in cardiac trabecular development, and in sustaining functional integrity in adult hearts. Treatment with neuregulin 1 enhances adult cardiomyocyte differentiation, survival and/or function in vitro and in vivo. It has also been suggested that recombinant neuregulin 1β1 (NRG1β1) induces cardiomyocyte proliferation in normal and injured adult hearts. Here we further explore the impact of neuregulin 1 signaling on adult cardiomyocyte cell cycle activity.

Methods and Results

Adult mice were subjected to 9 consecutive daily injections of recombinant NRG1β1 or vehicle, and cardiomyocyte DNA synthesis was quantitated via bromodeoxyuridine (BrdU) incorporation, which was delivered using mini-osmotic pumps over the entire duration of NRG1β1 treatment. NRG1β1 treatment inhibited baseline rates of cardiomyocyte DNA synthesis in normal mice (cardiomyocyte labelling index: 0.019±0.005% vs. 0.003±0.001%, saline vs. NRG1β1, P<0.05). Acute NRG1β1 treatment did result in activation of Erk1/2 and cardiac myosin regulatory light chain (down-stream mediators of neuregulin signalling), as well as activation of DNA synthesis in non-cardiomyocytes, validating the biological activity of the recombinant protein. In other studies, mice were subjected to permanent coronary artery occlusion, and cardiomyocyte DNA synthesis was monitored via tritiated thymidine incorporation which was delivered as a single injection 7 days post-infarction. Daily NRG1β1 treatment had no impact on cardiomyocyte DNA synthesis in the infarcted myocardium (cardiomyocyte labelling index: 0.039±0.011% vs. 0.027±0.021%, saline vs. NRG1β1, P>0.05).

Summary

These data indicate that NRG1β1 treatment does not increase cardiomyocyte DNA synthesis (and consequently does not increase the rate of cardiomyocyte renewal) in normal or infarcted adult mouse hearts. Thus, any improvement in cardiac structure and function observed following neuregulin treatment of injured hearts likely occurs independently of overt myocardial regeneration.

Toxicology of chemically modified graphene-based materials for medical application

This review article aims to provide an overview of chemically modified graphene, and graphene oxide (GO), and their impact on toxicology when present in biological systems. Graphene is one of the most promising nanomaterials due to unique physicochemical properties including enhanced optical, thermal, and electrically conductive behavior in addition to mechanical strength and high surface-to-volume ratio. Graphene-based nanomaterials have received much attention over the last 5 years in the biomedical field ranging from their use as polymeric conduits for nerve regeneration, carriers for targeted drug delivery and in the treatment of cancer via photo-thermal therapy. Both in vitro and in vivo biological studies of graphene-based nanomaterials help understand their relative toxicity and biocompatibility when used for biomedical applications. Several studies investigating important material properties such as surface charge, concentration, shape, size, structural defects, and chemical functional groups relate to their safety profile and influence cyto- and geno-toxicology. In this review, we highlight the most recent studies of graphene-based nanomaterials and outline their unique properties, which determine their interactions under a range of environmental conditions. The advent of graphene technology has led to many promising new opportunities for future applications in the field of electronics, biotechnology, and nanomedicine to aid in the diagnosis and treatment of a variety of debilitating diseases.

Trastuzumab-induced cardiomyopathy: incidence and associated risk factors in an inner-city population

BACKGROUND

Although it is known that trastuzumab causes cardiotoxicity, its extent and reversibility are still in question. Earlier studies have not evaluated consecutive patients with reproducible nuclear ventriculography.

OBJECTIVE

We sought to evaluate the baseline characteristics which predispose patients to increased risk of trastuzumab cardiotoxicity and to determine the natural history of the cardiotoxicity.

METHODS AND RESULTS

Left ventricular ejection fraction (LVEF) was measured in 76 women aged 36-73 years who had been treated with trastuzumab at the University of Maryland Greenebaum Cancer Center. LVEF was determined at baseline and then 3, 6, 9, and 12 months after treatment initiation. Cardiotoxicity was defined as ≥ 16% decrease in LVEF or ≥ 10% decrease in LVEF to <50%. There were no differences in comorbidities, earlier treatment, or demographics between patients with and without trastuzumab-induced cardiomyopathy except that African Americans were more likely to develop decreased LVEF (P < .05). Twenty-one patients (28%) met criteria for cardiotoxicity. Four of those patients were continued on trastuzumab and 17 patients had therapy withheld at some point. Only 1 patient developed symptomatic heart failure requiring inpatient hospitalization. LVEF improved in most patients regardless of whether or not trastuzumab was continued.

CONCLUSIONS

Decreased LVEF while undergoing trastuzumab therapy occurs frequently and is usually reversible. African Americans had a higher risk of developing decreased LVEF. These findings raise clinically important questions as to whether it is necessary to discontinue trastuzumab for asymptomatic decrease in LVEF and whether African Americans are more predisposed to a decrease in LVEF while receiving trastuzumab. Further studies carefully assessing LVEF should address these hypotheses.

Cardiotoxicity of concomitant radiotherapy and trastuzumab for early breast cancer

BACKGROUND

Trastuzumab therapy given in combination with one of several chemotherapy regimens is currently considered the standard of care for the treatment of early-stage, human epidermal growth factor receptor-2 (HER2) -positive breast cancer. The treatment with trastuzumab is due to a significant impact on the survival part of the standard adjuvant treatment of patients with HER2-positive breast cancer. Patients treated with postoperative breast or chest wall irradiation receive trastuzumab concomitant with radiotherapy. In a small proportion of patients trastuzumab causes cardiotoxicity. Preclinical findings indicate a radiosensibilizing effect of trastuzumab in breast cancer cells, but it is not yet clear whether it radiosensibilizes cells of healthy tissues too.

CONCLUSIONS

Special attention is required when left breast or left thoracic wall is irradiated in patient receiving trastuzumab, because long-term effects of the concurrent treatment with trastuzumab and radiotherapy are not yet known. In an era where more patients are surviving a diagnosis of breast cancer, better understanding and earlier detection of therapy-induced cardiac toxicity will be of paramount importance.

Long-term follow-up for cardiovascular disease after chemotherapy and/or radiotherapy for breast cancer in an unselected population

PURPOSE

Whereas earlier research focused on specific patient groups, this study assessed the risk of cardiovascular disease (CVD) in an unselected population curatively treated for breast cancer (BC), compared with an age-matched random sample of controls.

METHODS

Risks were determined in BC survivors and controls. CVD was divided into three categories: congestive heart failure, vascular cardiac diseases, and "other" cardiac diseases. Hazard ratios (HRs) and 95% confidence intervals (95% CI) adjusted for age, CVD, and CVD risk factors at baseline were determined by Cox regression analyses.

RESULTS

All 561 survivors of BC experienced surgery of whom 229 received (neo)adjuvant radiotherapy, 145 received chemotherapy (with or without radiotherapy), and 187 received no adjuvant therapy. During follow-up (median 9; range 5-57 years), CVD occurred in 176/561 (31%) survivors and in 398/1,635 (24%) controls. After radiotherapy, no increased risks of congestive heart failure (HR 0.5; 95% CI 0.2-1.8), vascular cardiac diseases (HR 1.1; 95% CI 0.7-1.7), or other cardiac diseases (HR 1.3; 95% CI 0.8-2.3) were found compared with controls. Similar results were found after chemotherapy for congestive heart failure (HR 1.8; 95% CI 0.6-5.8), vascular cardiac diseases (HR 1.1; 95% CI 0.5-2.3), and other cardiac diseases (HR 1.2; 95% CI 0.3-5.5).

CONCLUSIONS

In an unselected population of BC survivors, no significant increased risk of CVD after radiotherapy and/or chemotherapy was found compared with controls. However, the HRs after chemotherapy were in-line with previous studies. Future studies should include more detailed information on treatment and more specific outcome measures.

Attenuation of doxorubicin-induced cardiotoxicity by mdivi-1: a mitochondrial division/mitophagy inhibitor

Doxorubicin is one of the most effective anti-cancer agents. However, its use is associated with adverse cardiac effects, including cardiomyopathy and progressive heart failure. Given the multiple beneficial effects of the mitochondrial division inhibitor (mdivi-1) in a variety of pathological conditions including heart failure and ischaemia and reperfusion injury, we investigated the effects of mdivi-1 on doxorubicin-induced cardiac dysfunction in naïve and stressed conditions using Langendorff perfused heart models and a model of oxidative stress was used to assess the effects of drug treatments on the mitochondrial depolarisation and hypercontracture of cardiac myocytes. Western blot analysis was used to measure the levels of p-Akt and p-Erk 1/2 and flow cytometry analysis was used to measure the levels p-Drp1 and p-p53 upon drug treatment. The HL60 leukaemia cell line was used to evaluate the effects of pharmacological inhibition of mitochondrial division on the cytotoxicity of doxorubicin in a cancer cell line. Doxorubicin caused a significant impairment of cardiac function and increased the infarct size to risk ratio in both naïve conditions and during ischaemia/reperfusion injury. Interestingly, co-treatment of doxorubicin with mdivi-1 attenuated these detrimental effects of doxorubicin. Doxorubicin also caused a reduction in the time taken to depolarisation and hypercontracture of cardiac myocytes, which were reversed with mdivi-1. Finally, doxorubicin caused a significant elevation in the levels of signalling proteins p-Akt, p-Erk 1/2, p-Drp1 and p-p53. Co-incubation of mdivi-1 with doxorubicin did not reduce the cytotoxicity of doxorubicin against HL-60 cells. These data suggest that the inhibition of mitochondrial fission protects the heart against doxorubicin-induced cardiac injury and identify mitochondrial fission as a new therapeutic target in ameliorating doxorubicin-induced cardiotoxicity without affecting its anti-cancer properties.