Metastatic malignancies and the effect on arterial stiffness and blood pressure levels: the possible role of chemotherapy

Intercellular pathways of cancer treatment-related cardiotoxicity and their therapeutic implications: the paradigm of radiotherapy

Advances in cancer therapeutics have improved patient survival rates. However, cancer survivors may suffer from adverse events either at the time of therapy or later in life. Cardiovascular diseases (CVD) represent a clinically important, but mechanistically understudied complication, which interfere with the continuation of best-possible care, induce life-threatening risks, and/or lead to long-term morbidity. These concerns are exacerbated by the fact that targeted therapies and immunotherapies are frequently combined with radiotherapy, which induces durable inflammatory and immunogenic responses, thereby providing a fertile ground for the development of CVDs. Stressed and dying irradiated cells produce 'danger' signals including, but not limited to, major histocompatibility complexes, cell-adhesion molecules, proinflammatory cytokines, and damage-associated molecular patterns. These factors activate intercellular signaling pathways which have potentially detrimental effects on the heart tissue homeostasis. Herein, we present the clinical crosstalk between cancer and heart diseases, describe how it is potentiated by cancer therapies, and highlight the multifactorial nature of the underlying mechanisms. We particularly focus on radiotherapy, as a case known to often induce cardiovascular complications even decades after treatment. We provide evidence that the secretome of irradiated tumors entails factors that exert systemic, remote effects on the cardiac tissue, potentially predisposing it to CVDs. We suggest how diverse disciplines can utilize pertinent state-of-the-art methods in feasible experimental workflows, to shed light on the molecular mechanisms of radiotherapy-related cardiotoxicity at the organismal level and untangle the desirable immunogenic properties of cancer therapies from their detrimental effects on heart tissue. Results of such highly collaborative efforts hold promise to be translated to next-generation regimens that maximize tumor control, minimize cardiovascular complications, and support quality of life in cancer survivors.

Cancer Therapy and Exercise Intolerance: The Heart Is But a Part: JACC: CardioOncology State-of-the-Art Review

The landscape of cancer therapeutics is continually evolving, with successes in improved survivorship and reduced disease progression for many patients with cancer. Improved cancer outcomes expose competing comorbidities, some of which may be exacerbated by cancer therapies. The leading cause of disability and death for many early-stage cancers is cardiovascular disease (CVD), which is often attributed to direct or indirect cardiac injury from cancer therapy. In this review, the authors propose that toxicities related to conventional and novel cancer therapeutics should be considered beyond the heart. The authors provide a framework using the oxygen pathway to understand the impact of cancer treatment on peak oxygen uptake, a marker of integrative cardiopulmonary function and CVD risk. Peripheral toxicities and the impact on oxygen transport are discussed. Consideration for the broad effects of cancer therapies will improve the prediction and identification of cancer survivors at risk for CVD, functional disability, and premature mortality and those who would benefit from therapeutic intervention, ultimately improving patient outcomes.

Arterial Stiffness Changes in Adult Cancer Patients Receiving Anticancer Chemotherapy: A Real-World Bicentric Experience

Background Chemotherapy correlates to acute and long-term cardiotoxicity, is reflected clinically by myocardial and vascular endothelial dysfunction, and can cause cardiovascular complications. Thus, early diagnosis of cardiovascular disease in cancer patients undergoing anti-cancer treatment is necessary to enhance long-term survival. Our principal objective in this study was to discern the impact of specific anti-cancer chemotherapeutics and biologics on arterial stiffness alterations before and after the administration. Methods Conducted at Mustafa Bacha University Hospital, Algeria, the study focused on arterial stiffness in anti-cancer chemotherapy patients. Assessments included blood pressure, diabetes, and dyslipidemia, with precise measurements using validated systems, particularly pulse wave velocity (PWV). Various chemotherapy protocols were applied, and statistical analysis with R software (R Foundation for Statistical Computing, Vienna, Austria) maintained a significance level of p=0.05. Key outcomes centered on carotid-femoral PWV and secondary endpoints such as central and peripheral pressures and pulse pressure (PP). Univariate and bivariate analyses were conducted using appropriate statistical tests.  Results A comparative prospective observational study was completed on 58 patients (34 women and 24 men; mean age: 52.64 +/- 12.12 years) treated with anti-cancer chemotherapy agents. Our evaluation included a complete clinical exam, electrocardiogram, Doppler echocardiography, and applanation tonometry with arterial stiffness measurement using PWV. Patients presented significantly higher levels of carotid-femoral PWV, regardless of the chosen chemotherapy protocol, with no return to the initial level after one year of stopping treatment (p-value < 0.01). Moreover, this increase was more significant in patients with diabetes and hypertension and patients treated with monoclonal antibodies or intercalants.  Conclusion This prospective study shows that chemotherapy patients have elevated arterial stiffness, emphasizing the need to assess PWV and monitor cardiovascular risk factors. PP measurement with PWV could improve risk management.

Monoclonal Antibodies in Oncology and their Effect on Arterial Stiffness — A Systematic Review

Introduction

Malignancies are the second leading cause of death worldwide. Treatment Monoclonal Antibody (MAbs)-based treatment of cancer has been established as one of the most successful therapeutic strategies in the last 20 years; however, there is a growing concern about the effects of these agents on patients’ cardiovascular profile.

Areas Covered

In this manuscript we summarize current evidence regarding MAb effects on arterial stiffness, which is an recognised biomarker of cardiovascular risk. For this purpose, we explored two bibliographic databases [PubMed, Scopus] and one full-text database (Google-Scholar) for all publications published on MAbs’ effects on arterial stiffness until December 2019. Only few of the monoclonal antibody agents used in oncology have been investigated as per their effects on arterial properties and this limited evidence suggests that cancer therapy with monoclonal antibodies demonstrates either a temporary or long-term increase in arterial stiffness.

Discussion

It seems that by targeting ‘checkpoints’ in cancer genesis, anticancer MAbs also affects vascular properties causing endothelial dysfunction and arterial stiffness. Furthermore, several MAbs cause hypertension and may as a result increase pulse wave velocity. On the other hand, MAbs that target inflammatory cytokines seem to improve cardiovascular survival however, their effect on arterial stiffness is yet to be investigated. Further research is warranted in order to elucidate the biochemical pathways, clinical implications and potential reversibility of monoclonal antibody chemotherapy-induced vascular dysfunction.

Anticancer Therapy-Related Increases in Arterial Stiffness: A Systematic Review and Meta-Analysis

Background

Cardio‐oncology is a clinical discipline focused primarily on the early detection of anticancer therapy–related cardiomyopathy. However, there is growing evidence that the direct adverse consequences extend beyond the myocardium to affect the vasculature, but this evidence remains limited. In addition, there remains a paucity of clinically based strategies for monitoring vascular toxicity in these patients. Importantly, arterial stiffness is increasingly recognized as a surrogate end point for cardiovascular disease and may be an important vascular outcome to consider. Therefore, the aim of this systematic review and meta‐analysis was to summarize evidence of increased arterial stiffening with anticancer therapy and evaluate the effect of treatment modifiers.

Methods and Results

A total of 19 longitudinal and cross‐sectional studies that evaluated arterial stiffness both during and following anticancer therapy were identified using multiple databases. Two separate analyses were performed: baseline to follow‐up (12 studies) and control versus patient groups (10 studies). Subgroup analysis evaluated whether stiffness differed as a function of treatment type and follow‐up time. Standard mean differences and mean differences were calculated using random effect models. Significant increases in arterial stiffness were identified from baseline to follow‐up (standard mean difference, 0.890; 95% CI, 0.448–1.332; P<0.0001; mean difference, 1.505; 95% CI, 0.789–2.221; P≤0.0001) and in patient versus control groups (standard mean difference, 0.860; 95% CI, 0.402–1.318; P=0.0002; mean difference, 1.437; 95% CI, 0.426–2.448; P=0.0052). Subgroup analysis indicated differences in arterial stiffness between anthracycline‐based and non‐anthracycline‐based therapies (standard mean difference, 0.20; 95% CI, 0.001–0.41; P=0.048), but not follow‐up time.

Conclusions

Significant arterial stiffening occurs following anticancer therapy. Our findings support the use of arterial stiffness as part of a targeted vascular imaging strategy for the identification of early cardiovascular injury during treatment and for the detection of long‐term cardiovascular injury into survivorship.

Gestational Trophoblastic Neoplasia With Urinary System Metastasis: A Single Center Experience

Background: Gestational trophoblastic neoplasia (GTN) with urinary system metastasis is rare. There is limited information about this situation. This study aimed to analyze clinical features, prognostic factors, and survival outcomes of patients with metastasis to the urinary system arising from GTN. Methods: Medical records of 53 consecutive GTN patients with urinary system metastases and treated at Peking Union Medical College Hospital (PUMCH) between 1990 and 2018 were reviewed. The Kaplan-Meier survival analysis was used to describe the overall survival. Prognostic factors were identified using univariate and multivariate analyses. Results: Fifty-three GTN patients with urinary tract metastasis were identified in our institution. The mean age of patients was 30.8 years (range, 23-53 years). Thirty-six (67.9%) patients achieved complete remission (CR), and the remaining 17 (32.1%) showed progressive disease. The 5-year overall survival rate of the entire cohort was 78.4%. Age ≥ 40 years was an independent risk factor for prognosis (HR 12.353, 95% CI 2.203-69.261, P = 0.004). Previous failed chemotherapy history (P = 0.040) and the presence of brain and/or liver metastases (P = 0.024) significantly influenced the survival of GTN patients with urinary tract system metastasis. Conclusion: GTN with urinary tract metastasis is a rare condition. Patients with different metastatic sites have different CR rates and prognosis. Therefore, individualized strategies should be considered for patients with different metastatic sites. Urinary system metastasis is probably not a prognostic factor in GTN patients. Patients aged ≥40, those who had previous failed multidrug chemotherapy, and presented brain and/or liver metastases showed a significant adverse outcome.

Cardiotoxic Profile and Arterial Stiffness of Adjuvant Chemotherapy for Colorectal Cancer

Background and Purpose

Even though new cancer therapies have improved the overall survival, in some cases they have been associated with adverse effects, including increased cardiotoxicity. The purpose of the present study was to assess the cardiovascular effects of adjuvant chemotherapy for colorectal cancer and mainly the impact on arterial stiffness indices.

Material and Methods

A total of 70 patients with non-metastatic colorectal cancer who were treated either with FOLFOX (n=16) or with XELOX (n=54) adjuvant chemotherapy were included in the study. All patients were subjected to full cardiovascular evaluation at the beginning and the end of chemotherapy. Arterial stiffness was assessed by means of pulse wave velocity (PWV) and augmentation index (Aix) and full laboratory examinations were conducted prior to, and soon after, the termination of chemotherapy.

Results

Patients exhibited significantly higher levels of carotid-radial PWV, carotid femoral RWV and Aix post-chemotherapy (p<0.001); these findings remained significant when examined separately in each treatment subgroup (FOLFOX, XELOX). The observed changes were independent of treatment regimen and baseline patient characteristics. Univariate regression analyses showed that baseline PWVc-r and PWVc-f were the only factors associated with PWVc-r and PWVc-f change, while Aix change was independent of its baseline value.

Conclusion

There is a clear burden in arterial stiffness indices post-adjuvant chemotherapy for colorectal cancer in both chemotherapy groups. This is a finding of important clinical significance, however more prospective studies are required in order to encode the possible mechanisms involved.

Aortic wall stiffness as a side-effect of anti-cancer medication

Introduction: Malignancies and cardiovascular disease are the two leading causes of mortality worldwide. There is a growing concern that anti-cancer drugs may lead to increased cardiovascular morbidity among cancer survivors. This may be the result of direct effects of the cancer treatment on heart function, or due to an indirect acceleration of atherosclerosis.Areas covered: We searched two bibliographic databases [PubMed, Scopus] and one full-text database (Google Scholar) for publications on chemotherapy and arterial stiffness since 1970. Anthracyclines, alkylating agents and tyrosine kinase inhibitors seem to affect arterial elastic properties. These effects can be non-reversible and may appear after treatment termination. Monoclonal antibodies may induce either a temporary increase or no change on arterial stiffness of patients with malignancies. Anti-microtubule agents and antimetabolites have not been extensively studied so far.Expert opinion: This literature review suggests that certain anticancer medications may impair arterial stiffness, and that assessment of arterial elastic properties before and after initiation of anti-neoplasmatic therapy may be clinically useful in order to develop protective strategies against chemotherapy-induced vascular effects. Further research is warranted to confirm the effects of anti-cancer agents on arterial stiffness, as well as their potential clinical implications. Future research lies in finding new targeted biomarkers identifying arterial stiffness such as micro RNAs while imaging techniques could also be implemented in assessment of vascular toxicity.