Genetics of Anthracycline-Associated Cardiotoxicity

Drugs Metabolism-Related Genes Variants Impact on Anthracycline-Based Chemotherapy Induced Subclinical Cardiotoxicity in Breast Cancer Patients

Breast cancer is the most common cancer in women worldwide. Anthracyclines (doxorubicin, epirubicin, daunorubicin, idarubicin) are among the most used drugs for the treatment of breast cancer. Unfortunately, anthracyclines cause cardiotoxicity, which is a limiting factor for its use, and the lifetime cumulative dose of anthracyclines is the major risk factor for cardiotoxicity. In our study, we focused on acute and subacute heart damage. One of the main factors is a genetic predisposition, which determines individual susceptibility to anthracycline cardiotoxicity. The main idea of this study was, for the first time, to evaluate drug metabolism-related genes as a risk factor for developing cardiovascular toxicity in breast cancer patients. The main objective of our study was to identify the impact of drug metabolism-related gene SNPs on the development of subclinical heart damage during and/or after doxorubicin-based chemotherapy in breast cancer patients. The data of 81 women with breast cancer treated with doxorubicin-based chemotherapy in an outpatient clinic were analyzed, and SNP RT-PCR tests were performed. The drug metabolism-related gene variants SULT2B1 rs10426377, UGT1A6 rs17863783, CBR1 rs9024, CBR3 rs1056892, NCF4 rs1883112, and CYBA rs1049255 did not reach a statistically important impact on ABCC in multivariate logistic regression analysis. However, we identified that NCF4 rs1883112 had a risk reduction tendency for ABCC (OR = 0.49, 95% CI 0.27-0.87, p = 0.015). Our findings suggest that some SNPs, such as NCF4 rs1883112, may be associated with a reduced risk of cardiotoxicity, while no variants in this study showed a statistically significant increased risk. Even though, NCF4 rs1883112 showed a risk reduction tendency, suggesting the potential for personalized risk stratification. We can conclude that multiple genes are involved in ABCC, with different impacts, and it is unlikely that there is a single driver gene in ABCC pathogenesis.

SNP's use as a potential chemotoxicity stratification tool in breast cancer: from bench to clinic

Breast cancer (BC) remains one of the most prevalent malignancies affecting women worldwide, necessitating ongoing research to improve treatment outcomes and minimize adverse effects associated with chemotherapy. This article explores the role of genetic variations, particularly single nucleotide polymorphisms (SNPs), in influencing the efficacy and toxicity of chemotherapeutic agents used in BC treatment. It highlights the impact of polymorphisms in drug metabolism and transport genes, such as UDP-glucuronosyltransferase 1A1 (UGT1A1), carbonyl reductase 1 (CBR1), and ATP-binding cassette multidrug transporter (ABCB1) on the risk of adverse effects, including cardiotoxicity and hematological toxicities. By identifying specific SNPs associated with drug response and toxicity, this research underscores the potential for personalized medicine approaches to optimize treatment regimens, enhance therapeutic efficacy, and minimize side effects in BC patients. The findings advocate for the integration of genetic screening in clinical practice to improve patient outcomes and tailor chemotherapy based on individual genetic profiles.

Artificial Intelligence to Enhance Precision Medicine in Cardio-Oncology: A Scientific Statement From the American Heart Association

Artificial intelligence is poised to transform cardio-oncology by enabling personalized care for patients with cancer, who are at a heightened risk of cardiovascular disease due to both the disease and its treatments. The rising prevalence of cancer and the availability of multiple new therapeutic options has resulted in improved survival among patients with cancer and has expanded the scope of cardio-oncology to not only short-term but also long-term cardiovascular risks resulting from both cancer and its treatments. However, there is considerable heterogeneity in cardiovascular risk, driven by the nature of the malignancy as well as each individual's unique characteristics. The use of novel therapies, such as targeted therapies and immune checkpoint inhibitors, across multiple cancer groups has also broadened the populations among which cardiotoxicity has become an important consideration of therapy. Therefore, the ability to understand and personalize cardiovascular risk management in patients with cancer is a key target for artificial intelligence, which can deduce and respond to complex patterns within the data. These advances necessitate an overview of established biomarkers of risk, spanning advanced imaging, diagnostic testing, and multi-omics, the evidence supporting their use, and the proven and proposed role of artificial intelligence in refining this risk to attain greater precision in risk prediction and management in cardio-oncologic care.

Racial and Ethnic Disparities in Cardiotoxicity in Patients With Cancer Treated With Anthracyclines

BACKGROUND

Cardiotoxicity in patients with cancer treated with anthracyclines is associated with increased morbidity and mortality. We aimed to examine the incidence of and risk factors for cardiotoxicity in a racially and ethnically diverse cohort with cancer treated with anthracyclines.

METHODS

We included consecutive adult patients who underwent anthracycline-based chemotherapy from 2016 to 2019 for any type of cancer. The end point was the development of cardiotoxicity (defined as clinical heart failure or drop in left ventricular ejection fraction ≥10% to ≤50%).

RESULTS

A total of 743 individuals were included (28.0% Non-Hispanic [NH] White, 30.5% NH Black, 38.5% Hispanic, 3.0% Asian). Hypertension, diabetes, hyperlipidemia, obesity, and low socioeconomic status were more common in NH Black and Hispanic individuals. During a median follow-up of 21 months, 98 individuals (13.2%) developed cardiotoxicity. The incidence of cardiotoxicity was significantly higher in NH Black (16.3%), Hispanic (14.7%) and Asian (18.2%) individuals than in NH White (7.2%) individuals (P=0.024). After adjusting for cardiovascular risk factors, socioeconomic status score, anthracycline dose, baseline left ventricular ejection fraction, and cancer type, being NH Black (hazard ratio [HR], 2.62 [95% CI, 1.23-5.56]) or Hispanic (HR, 2.37 [95% CI, 1.11-5.07]) was independently associated with a higher risk of cardiotoxicity. NH Black and Hispanic individuals had a greater decline in left ventricular ejection fraction compared with NH White and Asian counterparts. The associations between baseline characteristics and incident cardiotoxicity were similar across different racial and ethnic groups.

CONCLUSIONS

In a large retrospective multiracial and ethnic cohort treated with anthracyclines, NH Black, Hispanic, and Asian individuals had an increased risk of cardiotoxicity compared with their NH White counterparts.

Anthracycline Cardiotoxicity in Adult Cancer Patients: JACC: CardioOncology State-of-the-Art Review

Since their introduction in the 1960s, anthracyclines have been a significant breakthrough in oncology, introducing dramatic changes in the treatment of solid and hematologic malignancies. Although new-generation targeted drugs and cellular therapies are revolutionizing contemporary oncology, anthracyclines remain the cornerstone of treatment for lymphomas, acute leukemias, and soft tissue sarcomas. However, their clinical application is limited by a dose-dependent cardiotoxicity that can reduce cardiac performance and eventually lead to overt heart failure. The field of cardio-oncology has emerged to safeguard the cardiovascular health of cancer patients receiving these therapies. It focuses on controlling risk factors, implementing preventive strategies, ensuring appropriate surveillance, and managing complications. This state-of-the-art review summarizes the current indications for anthracyclines in modern oncology, explores recent evidence on pathophysiology and epidemiology, and discusses advances in cardioprotection measures in the anthracycline-treated patient. Additionally, it highlights key clinical challenges and research gaps in this area.

Meta-analysis of genome-wide association studies for cancer therapy-related cardiovascular dysfunction and functional mapping highlight an intergenic region close to TP63

Cancer therapy-related cardiac dysfunction (CTRCD), which commonly includes left ventricular dysfunction and heart failure, is the main adverse effect of anticancer therapy. In recent years several candidate genes studies and genome-wide association studies have identified common genetic variants associated with CTRCD, but evidence remains limited and few genetic variants are robust. A genome-wide meta-analysis of CTRCD was performed with 852 oncology patients receiving cancer therapy. DNA samples were genotyped and imputed to perform a GWAS meta-analysis for case-control (N = 852 (380 cases and 472 controls) and extreme phenotypes (N = 618 (78 cases and 472 controls) looking for genetic variants that predispose to CTRCD. The results were validated in a replicate cohort of 1,191 oncology patients (245 cases and 946 controls). Functional mapping of the replicated loci was then performed. The meta-analysis showed 9 and 17 loci suggestively associated (P-value < 1 × 10-5) with CTRCD in case-control and extreme phenotypes analyses, respectively. The 3q28 locus (rs rs7652759, P = 5.64 × 10-6) in the case-control analysis was the strongest signal, with up to 64 SNPs above the suggestive significance threshold. The rs7652759, an intergenic variant between TPRG1 and TP63 genes, was the only variant validated in the replication cohort (P-value = 0.01). Functional mapping of this significant locus revealed up to 5 new genes potentially involved in the CTRCD. We identified the intergenic region near TP63 as a novel CTRCD susceptibility locus. In the future, the genotyping of these markers could be considered in new CTRCD risk scores to improve preventive strategies in cardio-oncology.

Pediatric Cardio-Oncology: Screening, Risk Stratification, and Prevention of Cardiotoxicity Associated with Anthracyclines

Anthracyclines have significantly improved the survival of children with malignant tumors, but the associated cardiotoxicity, an effect now under the purview of pediatric cardio-oncology, due to its cumulative and irreversible effects on the heart, limits their clinical application. A systematic screening and risk stratification approach provides the opportunity for early identification and intervention to mitigate, reverse, or prevent myocardial injury, remodeling, and dysfunction associated with anthracyclines. This review summarizes the risk factors, surveillance indexes, and preventive strategies of anthracycline-related cardiotoxicity to improve the safety and efficacy of anthracyclines.

Anthracycline-induced hypertension in pediatric cancer survivors: unveiling the long-term cardiovascular risks

BACKGROUND

Long-term cardiovascular complications are common among pediatric cancer survivors, and anthracycline-induced hypertension has become an essential reason for concern. Compared to non-cancer controls, survivors have a higher prevalence of hypertension, and as they age, their incidence rises, offering significant dangers to cardiovascular health.

MAIN BODY

Research demonstrates that exposure to anthracyclines is a major factor in the development of hypertension in children who have survived cancer. Research emphasizes the frequency and risk factors of anthracycline-induced hypertension, highlighting the significance of routine measurement and management of blood pressure. Furthermore, cardiovascular toxicities, such as hypertension, after anthracycline-based therapy are a crucial be concerned, especially for young adults and adolescents. Childhood cancer survivors deal with a variety of cardiovascular diseases, such as coronary artery disease and cardiomyopathy, which are made worse by high blood pressure. In order to prevent long-term complications, it is essential to screen for and monitor for anthracycline-induced hypertension. Echocardiography and cardiac biomarkers serve as essential tools for early detection and treatment. In order to lower cardiovascular risks in pediatric cancer survivors, comprehensive management strategies must include lifestyle and medication interventions in addition to survivor-centered care programs.

SHORT CONCLUSION

Proactive screening, monitoring, and management measures are necessary for juvenile cancer survivors due to the substantial issue of anthracycline-induced hypertension in their long-term care. To properly include these strategies into survivor-ship programs, oncologists, cardiologists, and primary care physicians need to collaborate together. The quality of life for pediatric cancer survivors can be enhanced by reducing the cardiovascular risks linked to anthracycline therapy and promoting survivor-centered care and research.

Breast Cancer and Therapy-Related Cardiovascular Toxicity

The global incidence of breast cancer is on the rise, a trend also observed in South Korea. However, thanks to the rapid advancements in anticancer therapies, survival rates are improving. Consequently, post-treatment health and quality of life for breast cancer survivors are emerging as significant concerns, particularly regarding treatment-related cardiotoxicity. In this review, we delve into the cardiovascular complications associated with breast cancer treatment, explore surveillance protocols for early detection and diagnosis of late complications, and discuss protective strategies against cardiotoxicity in breast cancer patients undergoing anticancer therapy, drawing from multiple guidelines.

Association between genetic variants of transmembrane transporters and susceptibility to anthracycline-induced cardiotoxicity: Current understanding and existing evidence

Anthracyclines remain the cornerstone of numerous chemotherapeutic protocols, with beneficial effects against haematological malignancies and solid tumours. Unfortunately, the clinical usefulness of anthracyclines is compromised by the development of cardiotoxic side effects, leading to dose limitations or treatment discontinuation. There is no absolute linear correlation between the incidence of cardiotoxicity and the threshold dose, suggesting that genetic factors may modify the association between anthracyclines and cardiotoxicity risk. And the majority of single nucleotide polymorphisms (SNPs) associated with anthracycline pharmacogenomics were identified in the ATP-binding cassette (ABC) and solute carrier (SLC) transporters, generating increasing interest in the pharmacogenetic implications of their genetic variations for anthracycline-induced cardiotoxicity (AIC). This review focuses on the influence of SLC and ABC polymorphisms on AIC and highlights the prospects and clinical significance of pharmacogenetics for individualised preventive approaches.

Anthracycline-related cardiotoxicity in patients with breast cancer harboring mutational signature of homologous recombination deficiency (HRD)

BACKGROUND

The BRCA proteins play a key role in the homologous recombination (HR) pathway. Beyond BRCA1/2, other genes are involved in the HR repair (HRR). Due to the prominent role in the cellular repair process, pathogenic or likely pathogenic variants (PV/LPVs) in HRR genes may cause inadequate DNA damage repair in cardiomyocytes.

PATIENTS AND METHODS

This was a multicenter, hospital-based, retrospective cohort study to investigate the heart toxicity from anthracycline-containing regimens (ACRs) in the adjuvant setting of breast cancer (BC) patients carrying germline BRCA PV/LPVs and no-BRCA HRR pathway genes. The left ventricular ejection fraction (LVEF) was assessed using cardiac ultrasound before starting ACR therapy and at subsequent time points according to clinical indications.

RESULTS

Five hundred and three BC patients were included in the study. We predefined three groups: (i) BRCA cohort; (ii) no-BRCA cohort; (iii) variant of uncertain significance (VUS)/wild-type (WT) cohort. When baseline (T0) and post-ACR (T1) LVEFs between the three cohorts were compared, pre-treatment LVEF values were not different (BRCA1/2 versus HRR-no-BRCA versus VUS/WT cohort). Notably, during monitoring (T1, median 3.4 months), patients carrying BRCA or HRR no-BRCA germline pathogenic or likely pathogenic variants showed a statistically significant reduction of LVEF compared to baseline (T0). To assess the relevance of HRR on the results, we included the analysis of the subgroup of 20 BC patients carrying PV/LPVs in other genes not involved in HRR, such as mismatch repair genes (MUTYH, PMS2, MSH6). Unlike HRR genes, no significant differences in T0-T1 were found in this subgroup of patients.

CONCLUSION

Our data suggest that deleterious variants in HRR genes, leading to impaired HR, could increase the sensitivity of cardiomyocytes to ACR in early BC patients. In this subgroup of patients, other measurements, such as the global longitudinal strain, and a more in-depth assessment of risk factors may be proposed in the future to optimize cardiovascular risk management and improve long-term survival.

Altered Peripheral Blood Gene Expression in Childhood Cancer Survivors With Anthracycline-Induced Cardiomyopathy - A COG-ALTE03N1 Report

Background Anthracycline-induced cardiomyopathy is a leading cause of premature death in childhood cancer survivors, presenting a need to understand the underlying pathogenesis. We sought to examine differential blood-based mRNA expression profiles in anthracycline-exposed childhood cancer survivors with and without cardiomyopathy. Methods and Results We designed a matched case-control study (Children's Oncology Group-ALTE03N1) with mRNA sequencing on total RNA from peripheral blood in 40 anthracycline-exposed survivors with cardiomyopathy (cases) and 64 matched survivors without (controls). DESeq2 identified differentially expressed genes. Ingenuity Pathway Analyses (IPA) and Gene Set Enrichment Analyses determined the potential roles of altered genes in biological pathways. Functional validation was performed by gene knockout in human-induced pluripotent stem cell-derived cardiomyocytes using CRISPR/Cas9 (clustered regularly interspaced short palindromic repeats/CRISPR-associated protein 9) technology. Median age at primary cancer diagnosis for cases and controls was 8.2 and 9.7 years, respectively. Thirty-six differentially expressed genes with fold change ≥±2 were identified; 35 were upregulated. IPA identified "hepatic fibrosis" and "iron homeostasis" pathways to be significantly modulated by differentially expressed genes, including toxicology functions of myocardial infarction, cardiac damage, and cardiac dilation. Leading edge analysis from Gene Set Enrichment Analyses identified lactate dehydrogenase A (LDHA) and cluster of differentiation 36 (CD36) genes to be significantly upregulated in cases. Interleukin 1 receptor type 1, 2 (IL1R1, IL1R2), and matrix metalloproteinase 8, 9 (MMP8, MMP9) appeared in multiple canonical pathways. LDHA-knockout human-induced pluripotent stem cell-derived cardiomyocytes showed increased sensitivity to doxorubicin. Conclusions We identified differential mRNA expression profiles in peripheral blood of anthracycline-exposed childhood cancer survivors with and without cardiomyopathy. Upregulation of LDHA and CD36 genes suggests metabolic perturbations in a failing heart. Dysregulation of proinflammatory cytokine receptors IL1R1 and IL1R2 and matrix metalloproteinases, MMP8 and MMP9 indicates structural remodeling that accompanies the clinical manifestation of symptomatic cardiotoxicity.

The dual role of ferroptosis in anthracycline-based chemotherapy includes reducing resistance and increasing toxicity

In conjunction with previous studies, we have noted that ferroptosis, as an emerging mode of regulated cell death (RCD), is intimately related to anthracycline pharmacotherapy. Not only does ferroptosis significantly modulate tumour resistance and drug toxicity, which are core links of the relevant chemotherapeutic process, but it also appears to play a conflicting role that has yet to be appreciated. By targeting the dual role of ferroptosis in anthracycline-based chemotherapy, this review aims to focus on the latest findings at this stage, identify the potential associations and provide novel perspectives for subsequent research directions and therapeutic strategies.

Cardio-oncology for Pediatric and Adolescent/Young Adult Patients

OPINION STATEMENT

As chemotherapy continues to improve the lives of patients with cancer, understanding the effects of these drugs on other organ systems, and the cardiovascular system in particular, has become increasingly important. The effects of chemotherapy on the cardiovascular system are a major determinant of morbidity and mortality in these survivors. Although echocardiography continues to be the most widely used modality for assessing cardiotoxicity, newer imaging modalities and biomarker concentrations may detect subclinical cardiotoxicity earlier. Dexrazoxane continues to be the most effective therapy for preventing anthracycline-induced cardiomyopathy. Neurohormonal modulating drugs have not prevented cardiotoxicity, so their widespread, long-term use for all patients is currently not recommended. Advanced cardiac therapies, including heart transplant, have been successful in cancer survivors with end-stage HF and should be considered for these patients. Research on new targets, especially genetic associations, may produce treatments that help reduce cardiovascular morbidity and mortality.

Preventive use of beta-blockers for anthracycline-induced cardiotoxicity: A network meta-analysis

Background

Anthracyclines are commonly used chemotherapeutic agents to treat malignant tumors. However, cardiotoxicity is a potentially serious adverse effect of anthracyclines. Beta-blockers may be effective in preventing anthracycline-induced cardiotoxicity (AIC). However, the lack of direct comparisons of various beta-blockers interferes with clinical decision-making. Network meta-analysis (NMA) was performed to assess the effectiveness of beta-blockers for AIC.

Methods

We searched PubMed, Embase, Web of Science, and the Cochrane Central Register of Clinical Trials. The last update was in May 2022. Randomized controlled trials (RCT) of beta-blockers for AIC were included. Four beta-blockers were selected for comparison based on the number of studies. NMA was conducted with STATA 14.0 software.

Results

A total of 10 RCTs (875 patients) met the selection criteria. NMA results showed that carvedilol was superior to bisoprolol [SMD = −0.50, 95% CI (−0.91, −0.10)] and nebivolol [SMD = −1.46, 95%CI (−2.82, −0.11)] in a delay of LVEF. The results of the cumulative probability ordering are as follows: carvedilol (83.8%) > metoprolol (71.8%) > bisoprolol (43.9%) > placebo (40.9%) > nebivolol (9.5%).

Conclusion

Based on the available evidence, carvedilol is the best beta-blocker for AIC, followed by metoprolol. However, additional studies with large samples should be conducted to confirm our findings.