1
|
Waterhouse JV, Welch CA, Battisti NML, Sweeting MJ, Paley L, Lambert PC, Deanfield J, de Belder M, Peake MD, Adlam D, Ring A. Geographical Variation in Underlying Social Deprivation, Cardiovascular and Other Comorbidities in Patients with Potentially Curable Cancers in England: Results from a National Registry Dataset Analysis. Clin Oncol (R Coll Radiol) 2023; 35:e708-e719. [PMID: 37741712 DOI: 10.1016/j.clon.2023.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 08/23/2023] [Indexed: 09/25/2023]
Abstract
AIMS To describe the prevalence of cardiovascular disease (CVD), multiple comorbidities and social deprivation in patients with a potentially curable cancer in 20 English Cancer Alliances. MATERIALS AND METHODS This National Registry Dataset Analysis used national cancer registry data and CVD databases to describe rates of CVD, comorbidities and social deprivation in patients diagnosed with a potentially curable malignancy (stage I-III breast cancer, stage I-III colon cancer, stage I-III rectal cancer, stage I-III prostate cancer, stage I-IIIA non-small cell lung cancer, stage I-IV diffuse large B-cell lymphoma, stage I-IV Hodgkin lymphoma) between 2013 and 2018. Outcome measures included observation of CVD prevalence, other comorbidities (evaluated by the Charlson Comorbidity Index) and deprivation (using the Index of Multiple Deprivation) according to tumour site and allocation to Cancer Alliance. Patients were allocated to CVD prevalence tertiles (minimum: <33.3rd percentile; middle: 33.3rd to 66.6th percentile; maximum: >66.6th percentile). RESULTS In total, 634 240 patients with a potentially curable malignancy were eligible. The total CVD prevalence for all cancer sites varied between 13.4% (CVD n = 2058; 95% confidence interval 12.8, 13.9) and 19.6% (CVD n = 7818; 95% confidence interval 19.2, 20.0) between Cancer Alliances. CVD prevalence showed regional variation both for male (16-26%) and female patients (8-16%) towards higher CVD prevalence in northern Cancer Alliances. Similar variation was observed for social deprivation, with the proportion of cancer patients being identified as most deprived varying between 3.3% and 32.2%, depending on Cancer Alliance. The variation between Cancer Alliance for total comorbidities was much smaller. CONCLUSION Social deprivation, CVD and other comorbidities in patients with a potentially curable malignancy in England show significant regional variations, which may partly contribute to differences observed in treatments and outcomes.
Collapse
Affiliation(s)
- J V Waterhouse
- Breast Unit, Department of Medicine, The Royal Marsden NHS Foundation Trust, SM2 5PT, London, United Kingdom; Breast Cancer Research Division, The Institute of Cancer Research, London, United Kingdom
| | - C A Welch
- Biostatistics Research Group, Department of Health Sciences, University of Leicester, University Road, LE1 7RH, Leicester, United Kingdom; National Disease Registration Service, NHS England, 10 South Colonnade, Canary Wharf, E14 4PU, London, United Kingdom
| | - N M L Battisti
- Breast Unit, Department of Medicine, The Royal Marsden NHS Foundation Trust, SM2 5PT, London, United Kingdom; Breast Cancer Research Division, The Institute of Cancer Research, London, United Kingdom
| | - M J Sweeting
- Biostatistics Research Group, Department of Health Sciences, University of Leicester, University Road, LE1 7RH, Leicester, United Kingdom; Statistical Innovation, Oncology Biometrics, Oncology R&D, AstraZeneca, Cambridge, United Kingdom
| | - L Paley
- National Disease Registration Service, NHS England, 10 South Colonnade, Canary Wharf, E14 4PU, London, United Kingdom
| | - P C Lambert
- Biostatistics Research Group, Department of Health Sciences, University of Leicester, University Road, LE1 7RH, Leicester, United Kingdom; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - J Deanfield
- Institute of Cardiovascular Sciences, University College London, 62 Huntley St London, WC1E 6DD, United Kingdom
| | - M de Belder
- National Institute for Cardiovascular Outcomes Research, NHS Arden & Greater East Midlands Commissioning Support Unit, 2nd floor 1 St Martin's le Grand London, EC1A 4AS, United Kingdom
| | - M D Peake
- Department of Health Sciences, University of Leicester, University Rd, Leicester, LE1 7RH, United Kingdom; University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - D Adlam
- University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Glenfield Hospital, Groby Road, Leicester, LE3 9QP, United Kingdom.
| | - A Ring
- Breast Unit, Department of Medicine, The Royal Marsden NHS Foundation Trust, SM2 5PT, London, United Kingdom; Breast Cancer Research Division, The Institute of Cancer Research, London, United Kingdom
| |
Collapse
|
2
|
Pinho J, Carvalho M, Paiva M, Teixeira-Tavares N, Costa-Santos C, Sousa C. Is dyslipidemia a risk factor for trastuzumab-induced cardiotoxicity in breast cancer patients? A systematic review and meta-analysis. Rev Port Cardiol 2023; 42:961-984. [PMID: 37399885 DOI: 10.1016/j.repc.2022.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 10/11/2022] [Indexed: 07/05/2023] Open
Abstract
INTRODUCTION Breast cancer patients undergoing trastuzumab therapy have greater risk of cardiovascular disease. Risk factors for this effect have been proposed. However, the role of dyslipidemia is not completely understood. This systematic review aimed to explore the role of dyslipidemia in trastuzumab-induced cardiotoxicity. METHODS The investigators searched MEDLINE, Scopus, and Web of Science up to October 25, 2020. A random-effects model was used to determine pooled estimates of the results. The primary endpoint was trastuzumab-induced cardiotoxicity in patients with and without dyslipidemia. RESULTS A total of 39 studies were selected for inclusion in our systematic review assessing 21079 patients. One study demonstrated a statistically significant association between dyslipidemia and cardiotoxicity (OR=2.28, 95% CI 1.22-4.26, p=0.01). In all other studies, no such association was observed. Twenty-one studies including 6135 patients were eligible for meta-analysis. In this meta-analysis of unadjusted data, dyslipidemia was significantly associated with cardiotoxicity (OR=1.25, 95% CI 1.01-1.53, p=0.04, I2=0%), however, a subgroup analysis of studies reporting adjusted measures did not demonstrate a significant association (OR=0.89, 95% CI 0.73-1.10, p=0.28, I2=0%). CONCLUSION This systematic review and meta-analysis did not demonstrate a significant association between dyslipidemia alone and the development of cardiotoxicity. In the absence of other relevant cardiovascular risk factors, review of lipid profile may not be obligatory, and management of patients could be performed without referral for cardio-oncology assessment. Further investigation of risk factors for trastuzumab-induced cardiotoxicity is required to confirm these results.
Collapse
Affiliation(s)
- Jaime Pinho
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal.
| | - Miguel Carvalho
- Centro Hospitalar e Universitário de São João, Porto, Portugal
| | - Mariana Paiva
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal; Centro Hospitalar e Universitário de São João, Porto, Portugal
| | | | | | - Carla Sousa
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal; Centro Hospitalar e Universitário de São João, Porto, Portugal
| |
Collapse
|
3
|
Jung YH, Yun IL, Park EC, Jang SI. New-onset dyslipidemia in adult cancer survivors from medically underserved areas: a 10-year retrospective cohort study. BMC Cancer 2023; 23:904. [PMID: 37752422 PMCID: PMC10521396 DOI: 10.1186/s12885-023-11384-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 09/07/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND Cancer survival rates are increasing; however, studies on dyslipidemia as a comorbidity of cancer are limited. For efficient management of the disease burden, this study aimed to understand new-onset dyslipidemia in medically underserved areas (MUA) among cancer survivors > 19 years. METHODS This study used 11-year (2009-2019) data from the Korean National Health Insurance Service sample cohort. Cancer survivors for five years or more (diagnosed with ICD-10 codes 'C00-C97') > 19 years were matched for sex, age, cancer type, and survival years using a 1:1 ratio with propensity scores. New-onset dyslipidemia outpatients based on MUA were analyzed using the Cox proportional hazards model. RESULTS Of the 5,736 cancer survivors included in the study, the number of new-onset dyslipidemia patients was 855 in MUA and 781 in non-MUA. Cancer survivors for five years or more from MUA had a 1.22-fold higher risk of onset of dyslipidemia (95% CI = 1.10-1.34) than patients from non-MUA. The prominent factors for the risk of dyslipidemia in MUA include women, age ≥ 80 years, high income, disability, complications, and fifth-year cancer survivors. CONCLUSIONS Cancer survivors for five years or more from MUA had a higher risk of new-onset dyslipidemia than those from non-MUA. Thus, cancer survivors for five years or more living in MUA require healthcare to prevent and alleviate dyslipidemia.
Collapse
Affiliation(s)
- Yun Hwa Jung
- Department of Public Health, Graduate School, Yonsei University, Seoul, Republic of Korea
- Institute of Health Services Research, Yonsei University, Seoul, Republic of Korea
| | - I L Yun
- Department of Public Health, Graduate School, Yonsei University, Seoul, Republic of Korea
- Institute of Health Services Research, Yonsei University, Seoul, Republic of Korea
| | - Eun-Cheol Park
- Institute of Health Services Research, Yonsei University, Seoul, Republic of Korea
- Department of Preventive Medicine &, Institute of Health Services Research, Yonsei University College of Medicine, 50 Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea
| | - Sung-In Jang
- Institute of Health Services Research, Yonsei University, Seoul, Republic of Korea.
- Department of Preventive Medicine &, Institute of Health Services Research, Yonsei University College of Medicine, 50 Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea.
| |
Collapse
|
4
|
Li Y, Shang C, Liang H, Zhang K, Wu Y, Guo H. Associations of novel serum lipid index with epithelial ovarian cancer chemoresistance and prognosis. Front Oncol 2023; 13:1052760. [PMID: 36860321 PMCID: PMC9968862 DOI: 10.3389/fonc.2023.1052760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 01/24/2023] [Indexed: 02/16/2023] Open
Abstract
Purpose To evaluate the relationship between novel serum lipid index and chemoresistance as well as prognosis of epithelial ovarian cancer (EOC). Patients and methods Patients' serum lipid profiles of 249 cases diagnosed with epithelial ovarian cancer, including total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C) as well as their ratios, the novel indicators HDL-C/TC and HDL-C/LDL-C, and clinicopathologic characteristics were retrospectively collected and calculated from January 2016 to January 2020 and correlation between serum lipid index and clinicopathological features such as chemoresistance as well as prognosis were evaluated. Results 249 patients pathologically diagnosed EOC who underwent cytoreductive surgery were included in our cohort. The mean age of these patients was 55.20 ± 11.07 years. Binary logistic regression analyses indicated Federation International of Gynecology and Obstetrics (FIGO(stage and HDL-C/TC ratio had significant association with chemoresistance. Univariate analyses demonstrated pathological type, chemoresistance, FIGO stage, neoadjuvant chemotherapy, maintenance treatment, HDL-C/LDL-C ratio, HDL-C/TC ratio were related to Progression-Free Survival (PFS) and Overall Survival (OS) (P<0. 05). Particularly, multivariate analyses indicated that HDL-C/LDL-C ratio was independent protective factors for both PFS and OS. Conclusion The complex serum lipid index HDL-C/TC ratio has a significant correlation with chemoresistance. HDL-C/LDL-C ratio is closely related to the clinicopathological characteristics and prognosis of patients with EOC and is an independent protective factor indicating better outcome.
Collapse
Affiliation(s)
- Yuan Li
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Chunliang Shang
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Huamao Liang
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Kun Zhang
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Yu Wu
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | | |
Collapse
|
5
|
Tranchita E, Murri A, Grazioli E, Cerulli C, Emerenziani GP, Ceci R, Caporossi D, Dimauro I, Parisi A. The Beneficial Role of Physical Exercise on Anthracyclines Induced Cardiotoxicity in Breast Cancer Patients. Cancers (Basel) 2022; 14:cancers14092288. [PMID: 35565417 PMCID: PMC9104319 DOI: 10.3390/cancers14092288] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/15/2022] [Accepted: 04/29/2022] [Indexed: 12/24/2022] Open
Abstract
The increase in breast cancer (BC) survival has determined a growing survivor population that seems to develop several comorbidities and, specifically, treatment-induced cardiovascular disease (CVD), especially those patients treated with anthracyclines. Indeed, it is known that these compounds act through the induction of supraphysiological production of reactive oxygen species (ROS), which appear to be central mediators of numerous direct and indirect cardiac adverse consequences. Evidence suggests that physical exercise (PE) practised before, during or after BC treatments could represent a viable non-pharmacological strategy as it increases heart tolerance against many cardiotoxic agents, and therefore improves several functional, subclinical, and clinical parameters. At molecular level, the cardioprotective effects are mainly associated with an exercise-induced increase of stress response proteins (HSP60 and HSP70) and antioxidant (SOD activity, GSH), as well as a decrease in lipid peroxidation, and pro-apoptotic proteins such as Bax, Bax-to-Bcl-2 ratio. Moreover, this protection can potentially be explained by a preservation of myosin heavy chain (MHC) isoform distribution. Despite this knowledge, it is not clear which type of exercise should be suggested in BC patient undergoing anthracycline treatment. This highlights the lack of special guidelines on how affected patients should be managed more efficiently. This review offers a general framework for the role of anthracyclines in the physio-pathological mechanisms of cardiotoxicity and the potential protective role of PE. Finally, potential exercise-based strategies are discussed on the basis of scientific findings.
Collapse
Affiliation(s)
- Eliana Tranchita
- Laboratory of Physical Exercise and Sport Science, Department of Exercise, Human and Health Sciences, University of Rome Foro Italico, Piazza Lauro de Bosis 15, 00135 Rome, Italy; (E.T.); (A.M.); (C.C.); (A.P.)
| | - Arianna Murri
- Laboratory of Physical Exercise and Sport Science, Department of Exercise, Human and Health Sciences, University of Rome Foro Italico, Piazza Lauro de Bosis 15, 00135 Rome, Italy; (E.T.); (A.M.); (C.C.); (A.P.)
| | - Elisa Grazioli
- Laboratory of Physical Exercise and Sport Science, Department of Exercise, Human and Health Sciences, University of Rome Foro Italico, Piazza Lauro de Bosis 15, 00135 Rome, Italy; (E.T.); (A.M.); (C.C.); (A.P.)
- Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy;
- Correspondence: ; Tel.: +39-06-3673-3532
| | - Claudia Cerulli
- Laboratory of Physical Exercise and Sport Science, Department of Exercise, Human and Health Sciences, University of Rome Foro Italico, Piazza Lauro de Bosis 15, 00135 Rome, Italy; (E.T.); (A.M.); (C.C.); (A.P.)
| | - Gian Pietro Emerenziani
- Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy;
| | - Roberta Ceci
- Laboratory of Biochemistry and Molecular Biology, Department of Exercise, Human and Health Sciences, University of Rome Foro Italico, 00135 Rome, Italy;
| | - Daniela Caporossi
- Unit of Biology and Genetics of Movement, Department of Movement, Human and Health Sciences, University of Rome Foro Italico, Piazza Lauro de Bosis 15, 00135 Rome, Italy; (D.C.); (I.D.)
| | - Ivan Dimauro
- Unit of Biology and Genetics of Movement, Department of Movement, Human and Health Sciences, University of Rome Foro Italico, Piazza Lauro de Bosis 15, 00135 Rome, Italy; (D.C.); (I.D.)
| | - Attilio Parisi
- Laboratory of Physical Exercise and Sport Science, Department of Exercise, Human and Health Sciences, University of Rome Foro Italico, Piazza Lauro de Bosis 15, 00135 Rome, Italy; (E.T.); (A.M.); (C.C.); (A.P.)
| |
Collapse
|
6
|
Ramirez MU, Clear KYJ, Cornelius Z, Bawaneh A, Feliz‐Mosquea YR, Wilson AS, Ruggiero AD, Cruz‐Diaz N, Shi L, Kerr BA, Soto‐Pantoja DR, Cook KL. Diet impacts triple-negative breast cancer growth, metastatic potential, chemotherapy responsiveness, and doxorubicin-mediated cardiac dysfunction. Physiol Rep 2022; 10:e15192. [PMID: 35439354 PMCID: PMC9017973 DOI: 10.14814/phy2.15192] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 01/05/2022] [Indexed: 05/21/2023] Open
Abstract
Anthracyclines are standard-of-care chemotherapy for the treatment of triple-negative breast cancer (TNBC). However, high anthracyclines cumulative doses increase heart failure risk. Designing therapeutic strategies that ameliorate cardiac toxicities without compromising oncologic efficacy are important to improve TNBC outcomes and survivorship. The purpose of this study was to determine the impact of diet on TNBC chemotherapeutic responsiveness and development of chemotherapy-induced cardiac damage. Female BALB/c mice fed a control, Western, Mediterranean, or Western + fish oil diet were injected with 1 × 106 4T1-luciferase TNBC into the mammary fat pad. Tumors grew for 21 days before surgical tumor resection, then mice were treated with 3.3 mg/kg i.v. doxorubicin for 3 weeks. Vevo (R) cardiac ultrasound was performed. Female nu/nu mice were placed on diets before 1 × 105 MDA-MB-231-luciferase TNBC were injected via the tail vein to induce the development of lung metastases. Mice were treated with saline or 3.3 mg/kg i.v. doxorubicin for 3 weeks, and the development of metastases visualized by IVIS (R). Consumption of a high-fat diet increased TNBC growth regardless of dietary pattern. Western diet-fed mice developed lung metastases sooner and displayed increased lung metastatic lesion formation, which was not observed in Mediterranean diet-fed mice. Western diet-fed animals displayed worse cardiac function when compared with Mediterranean diet-fed animals. Hearts from Western diet-fed animals displayed increased fibrosis. Diet represents a modifiable component directly impacting tumor growth, antitumor chemotherapy efficacy, and cardiac toxicities. Our data suggest that the Mediterranean diet may reduce lung metastatic lesions formation and prevent the development of cardiac toxicities.
Collapse
Affiliation(s)
- Manuel U. Ramirez
- Department of Physiology and PharmacologyWake Forest University Health SciencesWinston‐SalemNorth CarolinaUSA
- Department of Surgery‐HypertensionWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Kenysha Y. J. Clear
- Department of Physiology and PharmacologyWake Forest University Health SciencesWinston‐SalemNorth CarolinaUSA
- Department of Surgery‐HypertensionWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Zipporah Cornelius
- Department of Surgery‐HypertensionWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Alaa Bawaneh
- Department of Physiology and PharmacologyWake Forest University Health SciencesWinston‐SalemNorth CarolinaUSA
- Department of Surgery‐HypertensionWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Yismeilin R. Feliz‐Mosquea
- Department of Physiology and PharmacologyWake Forest University Health SciencesWinston‐SalemNorth CarolinaUSA
- Department of Surgery‐HypertensionWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Adam S. Wilson
- Department of Surgery‐HypertensionWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | | | - Nildris Cruz‐Diaz
- Department of Surgery‐HypertensionWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
- Cardiovascular SciencesWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Lihong Shi
- Department of Cancer BiologyWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Bethany A. Kerr
- Department of Cancer BiologyWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
- Comprehensive Cancer CenterWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - David R. Soto‐Pantoja
- Department of Surgery‐HypertensionWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
- Cardiovascular SciencesWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
- Department of Cancer BiologyWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
- Comprehensive Cancer CenterWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Katherine L. Cook
- Department of Surgery‐HypertensionWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
- Cardiovascular SciencesWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
- Department of Cancer BiologyWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
- Comprehensive Cancer CenterWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| |
Collapse
|
7
|
Albert K, Pollard D, Klemp J, Kondapalli L, Tuffield D. Assessment of Oncology Provider Knowledge and Cardiovascular Screening Practices: A Call for Heightened Screening. J Adv Pract Oncol 2022; 12:795-807. [PMID: 35295544 PMCID: PMC8631344 DOI: 10.6004/jadpro.2021.12.8.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Cardiac risk factors are known to compound the development of cardiotoxicities (CTx) in patients exposed to anthracycline (ANT) chemotherapy agents. National oncology and cardiology organizations have published recommendations for cardiovascular risk stratification and screening cancer patients following exposure to ANTs. The frequency with which oncology providers are integrating these principles into practice is unknown. This knowledge-based quality improvement (QI) project was designed to heighten oncology provider competencies such that screening frequency of cancer patients for CTx in the post-ANT setting aligns more closely with national guidelines for care. A web-based educational intervention, cardiac screening tool, and evidence-based literature were shared with 20 oncology providers over the course of 5 months. Retrospective chart reviews and pre- and post-project surveys were performed to assess competencies and practice trends. Qualitative and quantitative data were analyzed to illustrate whether the interventions improved knowledge and changed practice. Findings revealed an increase in the number of provider-perceived percentage of high cardiac risk patients and the number of patients screened, knowledge did not improve, and the frequency by which oncology providers ordered echocardiograms increased minimally. Factors such as organizational system changes, time constraints, and change fatigue limited effective and consistent implementation of the project interventions. The trajectory of cancer survivorship is affected by cardiovascular disease. Cardiac screening of cancer patients is a critical component of cancer care that has the potential to positively impact economic and health outcomes of this susceptible population.
Collapse
Affiliation(s)
- Katherine Albert
- Helen and Arthur E. Johnson Beth-El College of Nursing and Health Sciences, University of Colorado at Colorado Springs, Denver, Colorado
| | - Deborah Pollard
- Helen and Arthur E. Johnson Beth-El College of Nursing and Health Sciences, University of Colorado at Colorado Springs, Denver, Colorado
| | - Jennifer Klemp
- KU Medical Center, The University of Kansas, Kansas City, Kansas
| | - Lavanya Kondapalli
- University of Colorado Health Heart and Vascular Center, Denver, Colorado
| | - Deborah Tuffield
- Helen and Arthur E. Johnson Beth-El College of Nursing and Health Sciences, University of Colorado at Colorado Springs, Denver, Colorado
| |
Collapse
|
8
|
Al‑Saleh K, Abdel‑Warith A, Alghamdi M, Aldiab A, Ali A, Alsaeed E, Abozeed W, Abdel‑aziz N. Incidence of trastuzumab‑induced cardiotoxicity and impact of body mass index in patients with breast cancer: Results from a Saudi tertiary cancer center. Mol Clin Oncol 2022; 16:78. [DOI: 10.3892/mco.2022.2511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 05/05/2021] [Indexed: 11/06/2022] Open
Affiliation(s)
- Khalid Al‑Saleh
- Department of Medicine, College of Medicine, King Saud University, Riyadh 12372, Saudi Arabia
| | - Ahmed Abdel‑Warith
- Division of Hematology/Oncology, Department of Medicine, King Khalid University Hospital, College of Medicine, King Saud University Medical City, Riyadh 12372, Saudi Arabia
| | - Mohammed Alghamdi
- Division of Hematology/Oncology, Department of Medicine, King Khalid University Hospital, College of Medicine, King Saud University Medical City, Riyadh 12372, Saudi Arabia
| | - Abdurrahman Aldiab
- Division of Hematology/Oncology, Department of Medicine, King Khalid University Hospital, College of Medicine, King Saud University Medical City, Riyadh 12372, Saudi Arabia
| | - Arwa Ali
- Department of Medical Oncology, South Egypt Cancer Institute, Assiut University, Assiut 71516, Egypt
| | - Eyad Alsaeed
- Department of Oncology, Division of Radiation Oncology, King Khalid University Hospital, College of Medicine, King Saud University Medical City, Riyadh 12372, Saudi Arabia
| | - Waleed Abozeed
- Clinical Oncology Department, Faculty of Medicine, Mansoura University, Mansoura 35516, Egypt
| | - Nashwa Abdel‑aziz
- Division of Hematology/Oncology, Department of Medicine, King Khalid University Hospital, College of Medicine, King Saud University Medical City, Riyadh 12372, Saudi Arabia
| |
Collapse
|
9
|
Kwan ML, Cheng RK, Iribarren C, Neugebauer R, Rana JS, Nguyen-Huynh M, Shi Z, Laurent CA, Lee VS, Roh JM, Shen H, Rillamas-Sun E, Santiago-Torres M, Hershman DL, Kushi LH, Greenlee H. Risk of Cardiometabolic Risk Factors in Women With and Without a History of Breast Cancer: The Pathways Heart Study. J Clin Oncol 2022; 40:1635-1646. [PMID: 35025627 PMCID: PMC9113213 DOI: 10.1200/jco.21.01738] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
PURPOSE The incidence of cardiometabolic risk factors in breast cancer (BC) survivors has not been well described. Thus, we compared risk of hypertension, diabetes, and dyslipidemia in women with and without BC. METHODS Women with invasive BC diagnosed from 2005 to 2013 at Kaiser Permanente Northern California (KPNC) were identified and matched 1:5 to noncancer controls on birth year, race, and ethnicity. Cumulative incidence rates of hypertension, diabetes, and dyslipidemia were estimated with competing risk of overall death. Subdistribution hazard ratios (sHRs) were estimated by Fine and Gray regression, adjusted for cardiovascular disease-related risk factors, and stratified by treatment and body mass index (BMI). RESULTS A total of 14,942 BC cases and 74,702 matched controls were identified with mean age 61.2 years and 65% non-Hispanic White. Compared with controls, BC cases had higher cumulative incidence rates of hypertension (10.9% v 8.9%) and diabetes (2.1% v 1.7%) after 2 years, with higher diabetes incidence persisting after 10 years (9.3% v 8.8%). In multivariable models, cases had higher risk of diabetes (sHR, 1.16; 95% CI, 1.07 to 1.26) versus controls. Cases treated with chemotherapy (sHR, 1.23; 95% CI, 1.11 to 1.38), left-sided radiation (sHR, 1.29; 95% CI, 1.13 to 1.48), or endocrine therapy (sHR, 1.23; 95% CI, 1.12 to 1.34) continued to have higher diabetes risk. Hypertension risk was higher for cases receiving left-sided radiation (sHR, 1.11; 95% CI, 1.02 to 1.21) or endocrine therapy (sHR, 1.10; 95% CI, 1.03 to 1.16). Normal-weight (BMI < 24.9 kg/m2) cases had higher risks overall and within treatment subgroups versus controls. CONCLUSION BC survivors at KPNC experienced elevated risks of diabetes and hypertension compared with women without BC depending on treatments received and BMI. Future studies should examine strategies for cardiometabolic risk factor prevention in BC survivors.
Collapse
Affiliation(s)
- Marilyn L Kwan
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Richard K Cheng
- University of Washington School of Medicine, Seattle, WA.,Seattle Cancer Care Alliance, Seattle, WA, US
| | - Carlos Iribarren
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Romain Neugebauer
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Jamal S Rana
- Division of Research, Kaiser Permanente Northern California, Oakland, CA.,Oakland Medical Center, Kaiser Permanente Northern California, Oakland, CA
| | - Mai Nguyen-Huynh
- Division of Research, Kaiser Permanente Northern California, Oakland, CA.,Walnut Creek Medical Center, Kaiser Permanente Northern California, Walnut Creek, CA
| | - Zaixing Shi
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics and Key Laboratory of Health Technology Assessment of Fujian Province, School of Public Health, Xiamen University, Xiamen, China.,Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Cecile A Laurent
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Valerie S Lee
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Janise M Roh
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Hanjie Shen
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Eileen Rillamas-Sun
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | - Dawn L Hershman
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY
| | - Lawrence H Kushi
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Heather Greenlee
- University of Washington School of Medicine, Seattle, WA.,Seattle Cancer Care Alliance, Seattle, WA, US.,Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA
| |
Collapse
|
10
|
Gallo M, Adinolfi V, Barucca V, Prinzi N, Renzelli V, Barrea L, Di Giacinto P, Ruggeri RM, Sesti F, Arvat E, Baldelli R, Arvat E, Colao A, Isidori A, Lenzi A, Baldell R, Albertelli M, Attala D, Bianchi A, Di Sarno A, Feola T, Mazziotti G, Nervo A, Pozza C, Puliani G, Razzore P, Ramponi S, Ricciardi S, Rizza L, Rota F, Sbardella E, Zatelli MC. Expected and paradoxical effects of obesity on cancer treatment response. Rev Endocr Metab Disord 2021; 22:681-702. [PMID: 33025385 DOI: 10.1007/s11154-020-09597-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/25/2020] [Indexed: 12/12/2022]
Abstract
Obesity, whose prevalence is pandemic and continuing to increase, is a major preventable and modifiable risk factor for diabetes and cardiovascular diseases, as well as for cancer. Furthermore, epidemiological studies have shown that obesity is a negative independent prognostic factor for several oncological outcomes, including overall and cancer-specific survival, for several site-specific cancers as well as for all cancers combined. Yet, a recently growing body of evidence suggests that sometimes overweight and obesity may associate with better outcomes, and that immunotherapy may show improved response among obese patients compared with patients with a normal weight. The so-called 'obesity paradox' has been reported in several advanced cancer as well as in other diseases, albeit the mechanisms behind this unexpected relationship are still not clear. Aim of this review is to explore the expected as well as the paradoxical relationship between obesity and cancer prognosis, with a particular emphasis on the effects of cancer therapies in obese people.
Collapse
Affiliation(s)
- Marco Gallo
- Oncological Endocrinology Unit, Department of Medical Sciences, University of Turin, AOU Città della Salute e della Scienza di Torino, Via Genova, 3, 10126, Turin, Italy.
| | - Valerio Adinolfi
- Endocrinology and Diabetology Unit, ASL Verbano Cusio Ossola, Domodossola, Italy
| | - Viola Barucca
- Oncology Unit, Department of Oncology and Medical Specialities, AO San Camillo-Forlanini, Rome, Italy
| | - Natalie Prinzi
- ENETS Center of Excellence, Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale Tumori Milano, Milan, Italy
| | - Valerio Renzelli
- Department of Experimental Medicine, AO S. Andrea, Sapienza University of Rome, Rome, Italy
| | - Luigi Barrea
- Endocrinology Unit, Department of Clinical Medicine and Surgery, Federico II University Medical School of Naples, Naples, Italy
| | - Paola Di Giacinto
- Endocrinology Unit, Department of Oncology and Medical Specialities, AO San Camillo-Forlanini, Rome, Italy
| | - Rosaria Maddalena Ruggeri
- Endocrine Unit, Department of Clinical and Experimental Medicine, University of Messina, AOU Policlinico G. Martino, Messina, Italy
| | - Franz Sesti
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Emanuela Arvat
- Oncological Endocrinology Unit, Department of Medical Sciences, University of Turin, AOU Città della Salute e della Scienza di Torino, Via Genova, 3, 10126, Turin, Italy
| | - Roberto Baldelli
- Endocrinology Unit, Department of Oncology and Medical Specialities, AO San Camillo-Forlanini, Rome, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Abstract
Mitochondria are the most abundant organelles in cardiac cells, and are essential to maintain the normal cardiac function, which requires mitochondrial dynamics and mitophagy to ensure the stability of mitochondrial quantity and quality. When mitochondria are affected by continuous injury factors, the balance between mitochondrial dynamics and mitophagy is broken. Aging and damaged mitochondria cannot be completely removed in cardiac cells, resulting in energy supply disorder and accumulation of toxic substances in cardiac cells, resulting in cardiac damage and cardiotoxicity. This paper summarizes the specific underlying mechanisms by which various adverse factors interfere with mitochondrial dynamics and mitophagy to produce cardiotoxicity and emphasizes the crucial role of oxidative stress in mitophagy. This review aims to provide fresh ideas for the prevention and treatment of cardiotoxicity induced by altered mitochondrial dynamics and mitophagy.
Collapse
Affiliation(s)
- Yiyuan Yin
- Department of Emergency Medicine, ShengJing Hospital of China Medical University, Shenyang, China
| | - Haitao Shen
- Department of Emergency Medicine, ShengJing Hospital of China Medical University, Shenyang, China
| |
Collapse
|
12
|
Zhao C, Hu W, Xu Y, Wang D, Wang Y, Lv W, Xiong M, Yi Y, Wang H, Zhang Q, Wu Y. Current Landscape: The Mechanism and Therapeutic Impact of Obesity for Breast Cancer. Front Oncol 2021; 11:704893. [PMID: 34350120 PMCID: PMC8326839 DOI: 10.3389/fonc.2021.704893] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 07/05/2021] [Indexed: 12/22/2022] Open
Abstract
Obesity is defined as a chronic disease induced by an imbalance of energy homeostasis. Obesity is a widespread health problem with increasing prevalence worldwide. Breast cancer (BC) has already been the most common cancer and one of the leading causes of cancer death in women worldwide. Nowadays, the impact of the rising prevalence of obesity has been recognized as a nonnegligible issue for BC development, outcome, and management. Adipokines, insulin and insulin-like growth factor, sex hormone and the chronic inflammation state play critical roles in the vicious crosstalk between obesity and BC. Furthermore, obesity can affect the efficacy and side effects of multiple therapies such as surgery, radiotherapy, chemotherapy, endocrine therapy, immunotherapy and weight management of BC. In this review, we focus on the current landscape of the mechanisms of obesity in fueling BC and the impact of obesity on diverse therapeutic interventions. An in-depth exploration of the underlying mechanisms linking obesity and BC will improve the efficiency of the existing treatments and even provide novel treatment strategies for BC treatment.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | - Haiping Wang
- Department of Plastic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qi Zhang
- Department of Plastic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yiping Wu
- Department of Plastic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
13
|
Abstract
AbstractThe world is in the grip of an obesity pandemic, with tripling of obesity rates since 1975; it is predicted that one-third of people on Earth will be obese by 2025. The health consequences of obesity are primarily thought to be related to cardiometabolic disorders such as diabetes and cardiovascular diseases. It is less well appreciated that obesity has been related to at least 13 different cancers and in future, (with increasing control over tobacco misuse and infections), obesity will be the main cause of cancers. While this is an area of active research, there are large gaps in the definition of what is an obesity related cancer (JRC) and more importantly, what are the underlying mechanisms. To an extent, this is due to the controversy on what constitutes “unhealthy obesity” which is further related to the causes of obesity. This narrative review examines the causes and measurement of obesity, the types of obesity-related cancers and possible mechanisms. The information has wide implications ranging from prevention, screening, prognosis and therapeutic strategies. Obesity related cancers should be an area of high-priority research. Oncologists can contribute by spreading awareness and instituting management measures for individual patients in their care.
Collapse
Affiliation(s)
- Ajit Venniyoor
- National Oncology Centre, The Royal Hospital, Muscat, Sultanate of Oman
| |
Collapse
|
14
|
Anwar SL, Cahyono R, Prabowo D, Avanti WS, Choridah L, Dwianingsih EK, Harahap WA, Aryandono T. Metabolic comorbidities and the association with risks of recurrent metastatic disease in breast cancer survivors. BMC Cancer 2021; 21:590. [PMID: 34022845 PMCID: PMC8141199 DOI: 10.1186/s12885-021-08343-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 05/11/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Obesity and other metabolic comorbidities affect over 10% of patients with breast cancer and are closely related with adverse outcomes. Although metabolic comorbidities among breast cancer patients in low- and middle-income countries are suggested to be lower, only a few studies are currently available. Effective management of metabolic comorbidities in cancer patients has been associated with better outcomes. METHODS Non-metastatic breast cancer patients (N = 1081) treated in our department (2014-2018) were monitored for the presence of high Body Mass Index (BMI), diabetes or glucose intolerance, dyslipidemia, and hypertension and the development of recurrent metastatic diseases during a median follow-up of 3.9 years. RESULTS Glucose intolerance, hypertension, dyslipidemia, and BMI ≥ 27.7 kg/m2 considered at risk for metabolic comorbidities were found in 26.5, 42.6, 27.7, and 23.3% of breast cancer patients, respectively. Diabetes or glucose intolerance and having both glucose intolerance and dyslipidemia were associated with the risk of recurrent metastatic disease (OR = 1.442, 95%CI = 1.071-1.943, p = 0.016 and OR = 1.495, 95%CI = 1.090-2.049, p = 0.010; respectively). Having three or more metabolic comorbidities was significantly associated with the risk of recurrent metastatic disease (OR = 1.647, 95%CI = 1.139-2.382, p = 0.008) compared to patients without any comorbidity. The metabolic comorbidities were distributed unevenly among breast cancer subtypes. A significant association with recurrent metastatic disease was found in the Luminal B-like subtype. In post-menopausal patients, having more than three comorbidities was associated with a higher risk of recurrent metastatic disease compared to those without any comorbidity (OR = 2.000, 95%CI = 1.035-3.067, p = 0.001). The risks of having three or more metabolic comorbidities were significantly higher in breast cancer survivors who were obese, lived in an urban area, and received hormonal therapy of aromatase inhibitors. CONCLUSION Metabolic comorbidities were frequently found in breast cancer patients and were associated with higher risks to develop recurrent metastatic disease, particularly in post-menopausal women. Subsequent larger studies are needed to better understand the association of metabolic comorbidities with patients' quality of life and prognosis, and to explore the potential combination of clinical intervention and lifestyle modification in breast cancer survivors to treat as well as reduce their impact.
Collapse
Affiliation(s)
- Sumadi Lukman Anwar
- Division of Surgical Oncology - Department of Surgery, Dr. Sardjito Hospital / Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Jl. Kesehatan No. 1, Yogyakarta, 55281, Indonesia.
| | - Roby Cahyono
- Division of Surgical Oncology - Department of Surgery, Dr. Sardjito Hospital / Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Jl. Kesehatan No. 1, Yogyakarta, 55281, Indonesia
| | - Dayat Prabowo
- Division of Surgical Oncology - Department of Surgery, Dr. Sardjito Hospital / Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Jl. Kesehatan No. 1, Yogyakarta, 55281, Indonesia
| | - Widya Surya Avanti
- Department of Radiology, Dr. Sardjito Hospital/Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, 55281, Indonesia
| | - Lina Choridah
- Department of Radiology, Dr. Sardjito Hospital/Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, 55281, Indonesia
| | - Ery Kus Dwianingsih
- Department of Anatomical Pathology, Dr. Sardjito Hospital / Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, 55281, Indonesia
| | - Wirsma Arif Harahap
- Division of Surgical Oncology, Dr. M Jamil Hospital / Faculty of Medicine, Universitas Andalas, Padang, 25127, Indonesia
| | - Teguh Aryandono
- Division of Surgical Oncology - Department of Surgery, Dr. Sardjito Hospital / Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Jl. Kesehatan No. 1, Yogyakarta, 55281, Indonesia
| |
Collapse
|
15
|
Abstract
BACKGROUND Overall survival has improved significantly in patients with human epidermal growth receptor 2 (HER2)-positive breast cancer due to the use of the monoclonal antibody trastuzumab blocking HER2. However, patients may develop trastuzumab-induced cardiotoxicity (TIC) leading to congestive heart failure. Here we assessed whether analysing NT-proBNP and assessment of electrocardiography (ECG) could detect TIC during trastuzumab therapy. METHODS One hundred thirty-six patients undergoing adjuvant, neoadjuvant or palliative chemotherapy and HER2 blockade for HER2-positive breast cancer were prospectively assessed with echocardiography, ECG and N-terminal - pro hormone B-type natriuretic peptide (NT-proBNP) testing at baseline and at 6 and 12 months of trastuzumab therapy. TIC was defined as a left ventricular ejection fraction (LVEF) of less than 50% and a decline from baseline of ≥10 units. RESULTS Six patients developed TIC under 12 months of trastuzumab therapy (incidence 4.4%). NT-proBNP increased from 198.8 ± 64.0 pg/ml to 678.7 ± 132.4 pg/ml (p < .05) in TIC patients. With a cut-off point of 276.5 pg/ml for NTproBNP and increase in NT-proBNP by 75.8 pg/ml from baseline the sensitivity was 100% and the specificity 95% to detect TIC. Compared with controls, TIC patients were older (68.3 ± 1.1 years and 56.2 ± 1.4 years, respectively; p < .01), had more often diabetes mellitus (OR = 63.5, 95% CI: 5.63-915, p < .01) and atrial fibrillation (OR = 12.3; 95% CI: 1.89-74.62; p < .05) and had lower baseline LVEF (57.1 ± 1.4% and 61.4 ± 0.3%, respectively; p < .001). Abnormal ECGs were common in patients developing TIC. CONCLUSIONS Measuring changes in NTproBNP may be used to monitor patients for TIC under trastuzumab therapy. Patients with a cardiovascular risk profile are more at risk of developing TIC.
Collapse
Affiliation(s)
- Anton E. Andersson
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Barbro Linderholm
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Daniel Giglio
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Department of Oncology, Halland Hospital Varberg, Region Halland, Sweden
| |
Collapse
|
16
|
Mohammed T, Parekh T, Desai A. Cardiovascular risk management in cancer survivors: Are we doing it right? World J Clin Oncol 2021; 12:144-149. [PMID: 33767970 PMCID: PMC7968105 DOI: 10.5306/wjco.v12.i3.144] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/12/2021] [Accepted: 02/12/2021] [Indexed: 02/06/2023] Open
Abstract
Although under-recognized, cancer survivors continue to be at an increased risk of death from cardiovascular complications post-remission or cure. This increased burden of cardiovascular disease results from the interplay of various factors. Adequate cardiovascular risk assessment and timely intervention through a multi-disciplinary approach in these patients plays a pivotal role in the prevention of cardiovascular morbidity and mortality. We discuss the shortcomings of using current risk prediction scores in cancer survivors and provide some insights into cardiovascular risk management relevant for primary care physicians, oncologists, and cardiologists alike.
Collapse
Affiliation(s)
- Turab Mohammed
- Department of Medicine, University of Connecticut, Farmington, CT 06030, United States
| | - Tarang Parekh
- Department of Health Administration and Policy, George Mason University, Fairfax, VA 22030, United States
| | - Aakash Desai
- Department of Hematology and Oncology, Mayo Clinic, Rochester, MN 55902, United States
| |
Collapse
|
17
|
Lee A, Larck C, Moore DC. Impact of obesity on safety outcomes and treatment modifications with ado-trastuzumab emtansine in breast cancer patients. J Oncol Pharm Pract 2020; 28:49-54. [PMID: 33356991 DOI: 10.1177/1078155220982648] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Ado-trastuzumab emtansine (T-DM1) is an antibody-drug conjugate indicated for the treatment of HER2-positive breast cancer. The 2012 American Society of Clinical Oncology guidelines on chemotherapy dosing in obesity recommend using full weight-based cytotoxic chemotherapy doses to treat obese patients with cancer. These guidelines were published prior to the advent of anticancer antibody-drug conjugates. There is a need to investigate the safety of T-DM1 in obese patients. METHODS This retrospective chart review included adult patients with breast cancer receiving T-DM1. The primary endpoint was a composite of the incidence of T-DM1 treatment modifications secondary to an adverse event. Secondary outcomes included the incidence of dose reductions, dose delays, treatment discontinuations, and adverse events. RESULTS A total of 119 patients with HER2-positive breast cancer who received T-DM1 therapy were included in this study: 44 obese patients and 75 non-obese patients. The composite outcome of treatment modifications due to toxicity was significantly higher in obese patients compared to non-obese patients (45% vs 25%, p = 0.024). Treatment delays were significantly higher in obese patients (36% vs 16%, p = 0.011). All-grade adverse events with a higher incidence in obese patients included left ventricular ejection fraction decrease (11% vs 5%), bilirubin increase (32% vs 12%), thrombocytopenia (61% vs 55%), and peripheral neuropathy (34% vs 27%). CONCLUSIONS This study suggests obese patients receiving T-DM1 may require more treatment modifications secondary to adverse events compared to non-obese patients. Larger studies are needed to determine if obese patients are at higher risk for specific T-DM1-induced adverse events.
Collapse
Affiliation(s)
- Anna Lee
- Department of Pharmacy, Atrium Health, Levine Cancer Institute, Concord, NC, USA
| | - Chris Larck
- Department of Pharmacy, Atrium Health, Levine Cancer Institute, Concord, NC, USA
| | - Donald C Moore
- Department of Pharmacy, Atrium Health, Levine Cancer Institute, Concord, NC, USA
| |
Collapse
|
18
|
Olorundare O, Adeneye A, Akinsola A, Soyemi S, Mgbehoma A, Okoye I, Ntambi JM, Mukhtar H. African Vegetables ( Clerodendrum volibile Leaf and Irvingia gabonensis Seed Extracts) Effectively Mitigate Trastuzumab-Induced Cardiotoxicity in Wistar Rats. Oxid Med Cell Longev 2020; 2020:9535426. [PMID: 33178389 DOI: 10.1155/2020/9535426] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 09/14/2020] [Accepted: 09/22/2020] [Indexed: 02/07/2023]
Abstract
Trastuzumab (TZM) is a humanized monoclonal antibody that has been approved for the clinical management of HER2-positive metastatic breast and gastric cancers but its use is limited by its cumulative dose and off-target cardiotoxicity. Unfortunately, till date, there is no approved antidote to this off-target toxicity. Therefore, an acute study was designed at investigating the protective potential and mechanism(s) of CVE and IGE in TZM-induced cardiotoxicity utilizing cardiac enzyme and oxidative stress markers and histopathological endpoints. 400 mg/kg/day CVE and IGE dissolved in 5% DMSO in sterile water were investigated in Wistar rats injected with 2.25 mg/kg/day/i.p. route of TZM for 7 days, using serum cTnI and LDH, complete lipid profile, cardiac tissue oxidative stress markers assays, and histopathological examination of TZM-intoxicated heart tissue. Results showed that 400 mg/kg/day CVE and IGE profoundly attenuated increases in the serum cTnI and LDH levels but caused no significant alterations in the serum lipids and weight gain pattern in the treated rats. CVE and IGE profoundly attenuated alterations in the cardiac tissue oxidative stress markers' activities while improving TZM-associated cardiac histological lesions. These results suggest that CVE and IGE could be mediating its cardioprotection via antioxidant, free radical scavenging, and antithrombotic mechanisms, thus, highlighting the therapeutic potentials of CVE and IGE in the management of TZM-mediated cardiotoxicity.
Collapse
|
19
|
Rassaf T, Totzeck M, Backs J, Bokemeyer C, Hallek M, Hilfiker-Kleiner D, Hochhaus A, Lüftner D, Müller OJ, Neudorf U, Pfister R, von Haehling S, Lehmann LH, Bauersachs J. Onco-Cardiology: Consensus Paper of the German Cardiac Society, the German Society for Pediatric Cardiology and Congenital Heart Defects and the German Society for Hematology and Medical Oncology. Clin Res Cardiol 2020; 109:1197-1222. [PMID: 32405737 PMCID: PMC7515958 DOI: 10.1007/s00392-020-01636-7] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 03/13/2020] [Indexed: 12/11/2022]
Abstract
The acute and long-lasting side effects of modern multimodal tumour therapy significantly impair quality of life and survival of patients afflicted with malignancies. The key components of this therapy include radiotherapy, conventional chemotherapy, immunotherapy and targeted therapies. In addition to established tumour therapy strategies, up to 30 new therapies are approved each year with only incompletely characterised side effects. This consensus paper discusses the risk factors that contribute to the development of a potentially adverse reaction to tumour therapy and, in addition, defines specific side effect profiles for different treatment groups. The focus is on novel therapeutics and recommendations for the surveillance and treatment of specific patient groups.
Collapse
Affiliation(s)
- Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Centre Essen, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany.
| | - Matthias Totzeck
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Centre Essen, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Johannes Backs
- Institute for Experimental Cardiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Carsten Bokemeyer
- Department of Oncology, Hematology and Bone Marrow Transplantation with the Section Pneumology, Centre for Oncology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Hallek
- Department I of Internal Medicine, Center for Integrated Oncology ABCD, University Hospital of Cologne, Cologne, Germany
| | | | - Andreas Hochhaus
- Department of Hematology and Medical Oncology, University Hospital Jena, Jena, Germany
| | - Diana Lüftner
- Department of Haematology, Oncology and Tumour Immunology, Charité, Humboldt University Berlin, Berlin, Germany
| | - Oliver J Müller
- Department of Internal Medicine III (Cardiology, Angiology and Internal Intensive Care Medicine), University Hospital Schleswig-Holstein, University of Kiel, Kiel, Germany
| | - Ulrich Neudorf
- Department of Pediatrics III, West German Heart and Vascular Centre Essen, University Hospital Essen, Essen, Germany
| | - Roman Pfister
- Clinic III for Internal Medicine, General and Interventional Cardiology, Electrophysiology, Angiology, Pneumology and Internal Intensive Care Medicine, University Hospital Cologne, Cologne, Germany
| | - Stephan von Haehling
- Department of Cardiology and Pneumology, Heart Center Göttingen, University of Göttingen Medical Center and German Center for Cardiovascular Research (DZHK), partner site Göttingen, Göttingen, Germany
| | - Lorenz H Lehmann
- Department of Cardiology, Angiology, Pneumology, University Hospital Heidelberg, Heidelberg, Germany
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| |
Collapse
|
20
|
Mercurio V, Cuomo A, Cadeddu Dessalvi C, Deidda M, Di Lisi D, Novo G, Manganaro R, Zito C, Santoro C, Ameri P, Spallarossa P, Arboscello E, Tocchetti CG, Penna C. Redox Imbalances in Ageing and Metabolic Alterations: Implications in Cancer and Cardiac Diseases. An Overview from the Working Group of Cardiotoxicity and Cardioprotection of the Italian Society of Cardiology (SIC). Antioxidants (Basel) 2020; 9:E641. [PMID: 32708201 PMCID: PMC7402085 DOI: 10.3390/antiox9070641] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/14/2020] [Accepted: 07/16/2020] [Indexed: 12/14/2022] Open
Abstract
Metabolic syndrome (MetS) is a well established risk factor for cardiovascular (CV) diseases. In addition, several studies indicate that MetS correlates with the increased risk of cancer in adults. The mechanisms linking MetS and cancer are not fully understood. Several risk factors involved in MetS are also cancer risk factors, such as the consumption of high calorie-food or high fat intake, low fibre intake, and sedentary lifestyle. Other common aspects of both cancer and MetS are oxidative stress and inflammation. In addition, some anticancer treatments can induce cardiotoxicity, including, for instance, left ventricular (LV) dysfunction and heart failure (HF), endothelial dysfunction and hypertension. In this review, we analyse several aspects of MetS, cancer and cardiotoxicity from anticancer drugs. In particular, we focus on oxidative stress in ageing, cancer and CV diseases, and we analyse the connections among CV risk factors, cancer and cardiotoxicity from anticancer drugs.
Collapse
Affiliation(s)
- Valentina Mercurio
- Department of Translational Medical Sciences, Federico II University, 80131 Naples, Italy; (V.M.); (A.C.)
| | - Alessandra Cuomo
- Department of Translational Medical Sciences, Federico II University, 80131 Naples, Italy; (V.M.); (A.C.)
| | - Christian Cadeddu Dessalvi
- Department of Medical Sciences and Public Health, University of Cagliari, 09042 Cagliari, Italy; (C.C.D.); (M.D.)
| | - Martino Deidda
- Department of Medical Sciences and Public Health, University of Cagliari, 09042 Cagliari, Italy; (C.C.D.); (M.D.)
| | - Daniela Di Lisi
- Cardiology Unit AUOP Policlinico, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, 90127 Palermo, Italy; (D.D.L.); (G.N.)
| | - Giuseppina Novo
- Cardiology Unit AUOP Policlinico, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, 90127 Palermo, Italy; (D.D.L.); (G.N.)
| | - Roberta Manganaro
- Cardiology with Coronary Intensive Care Unit, Department of Clinical and Experimental Medicine, University Hospital Policlinico “G. Martino”, University of Messina, 98124 Messina, Italy; (R.M.); (C.Z.)
| | - Concetta Zito
- Cardiology with Coronary Intensive Care Unit, Department of Clinical and Experimental Medicine, University Hospital Policlinico “G. Martino”, University of Messina, 98124 Messina, Italy; (R.M.); (C.Z.)
| | - Ciro Santoro
- Department of Advanced Biomedical Sciences, Federico II University, 80131 Naples, Italy;
| | - Pietro Ameri
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy—IRCCS Italian Cardiovascular Network & Department of Internal Medicine, University of Genova, 16121 Genova, Italy; (P.A.); (P.S.); (E.A.)
| | - Paolo Spallarossa
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy—IRCCS Italian Cardiovascular Network & Department of Internal Medicine, University of Genova, 16121 Genova, Italy; (P.A.); (P.S.); (E.A.)
| | - Eleonora Arboscello
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy—IRCCS Italian Cardiovascular Network & Department of Internal Medicine, University of Genova, 16121 Genova, Italy; (P.A.); (P.S.); (E.A.)
| | - Carlo Gabriele Tocchetti
- Department of Translational Medical Sciences, Federico II University, 80131 Naples, Italy; (V.M.); (A.C.)
- Interdepartmental Center of Clinical and Translational Sciences, Federico II University, 80131 Naples, Italy
| | - Claudia Penna
- Department of Clinical and Biological Sciences, University of Turin, 10043 Torino, Italy
| |
Collapse
|
21
|
L'Abbate S, Russo I, Kusmic C. The role of metabolic diseases in cardiotoxicity associated with cancer therapy: What we know, what we would know. Life Sci 2020; 255:117843. [PMID: 32464123 DOI: 10.1016/j.lfs.2020.117843] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 05/16/2020] [Accepted: 05/22/2020] [Indexed: 12/12/2022]
Abstract
Metabolic diseases, such as obesity and type 2 diabetes, are known risk factors for cardiovascular (CV) diseases. Thus, patients with those comorbidities could be at increased risk of experiencing cardiotoxicity related to treatment with Anthracyclines and the other new generation targeted anticancer drugs. However, investigations addressing the mechanisms underlying the development of CV complications and poor outcome in such cohort of patients are still few and controversial. Given the importance of a personalized approach against chemotherapy-induced cardiomyopathy, this review summarizes our current knowledge on the pathophysiology of chemotherapy-induced cardiomyopathy and its association with obesity and type 2 diabetes. Along with clinical evidences, future perspectives of preclinical research around this field and its role in addressing important open questions, including the development of more proactive strategies for prevention, and treatment of cardiotoxicity during and after chemotherapy in the presence of metabolic diseases, is also presented.
Collapse
|
22
|
Kikuchi R, Shah NP, Dent SF. Strategies to Prevent Cardiovascular Toxicity in Breast Cancer: Is It Ready for Primetime? J Clin Med 2020; 9:E896. [PMID: 32218132 PMCID: PMC7230166 DOI: 10.3390/jcm9040896] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 03/16/2020] [Accepted: 03/20/2020] [Indexed: 11/16/2022] Open
Abstract
Cardio-oncology is an emerging field tasked with identifying and treating cancer therapy related cardiac dysfunction (e.g., cytotoxic agents, immunotherapies, radiation, and hormone therapies) and optimizing the cardiovascular health of cancer patients exposed to these agents. Novel cancer therapies have led to significant improvements in clinical outcomes for breast cancer patients. In this article, we review the current literature on assessing cardiovascular risk of breast cancer therapies and discuss strategies (including pharmacological and lifestyle interventions) to prevent cardiovascular toxicity.
Collapse
Affiliation(s)
- Robin Kikuchi
- Division of Medical Oncology, Duke Cancer Institute, Duke University, Durham, NC 27710, USA;
| | - Nishant P. Shah
- Division of Cardiology, Duke Heart Center, Duke University, Durham, NC 27710, USA;
| | - Susan F. Dent
- Division of Medical Oncology, Duke Cancer Institute, Duke University, Durham, NC 27710, USA;
| |
Collapse
|
23
|
Lee MS, Liu DW, Hung SK, Yu CC, Chi CL, Chiou WY, Chen LC, Lin RI, Huang LW, Chew CH, Hsu FC, Chan MWY, Lin HY. Emerging Challenges of Radiation-Associated Cardiovascular Dysfunction (RACVD) in Modern Radiation Oncology: Clinical Practice, Bench Investigation, and Multidisciplinary Care. Front Cardiovasc Med 2020; 7:16. [PMID: 32154267 PMCID: PMC7047711 DOI: 10.3389/fcvm.2020.00016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 01/31/2020] [Indexed: 02/06/2023] Open
Abstract
Radiotherapy (RT) is a crucial treatment modality in managing cancer patients. However, irradiation dose sprinkling to tumor-adjacent normal tissues is unavoidable, generating treatment toxicities, such as radiation-associated cardiovascular dysfunction (RACVD), particularly for those patients with combined therapies or pre-existing adverse features/comorbidities. Radiation oncologists implement several efforts to decrease heart dose for reducing the risk of RACVD. Even applying the deep-inspiration breath-hold (DIBH) technique, the risk of RACVD is though reduced but still substantial. Besides, available clinical methods are limited for early detecting and managing RACVD. The present study reviewed emerging challenges of RACVD in modern radiation oncology, in terms of clinical practice, bench investigation, and multidisciplinary care. Several molecules are potential for serving as biomarkers and therapeutic targets. Of these, miRNAs, endogenous small non-coding RNAs that function in regulating gene expression, are of particular interest because low-dose irradiation, i.e., 200 mGy (one-tenth of conventional RT daily dose) induces early changes of pro-RACVD miRNA expression. Moreover, several miRNAs, e.g., miR-15b and miR21, involve in the development of RACVD, further demonstrating the potential bio-application in RACVD. Remarkably, many RACVDs are late RT sequelae, characterizing highly irreversible and progressively worse. Thus, multidisciplinary care from oncologists and cardiologists is crucial. Combined managements with commodities control (such as hypertension, hypercholesterolemia, and diabetes), smoking cessation, and close monitoring are recommended. Some agents show abilities for preventing and managing RACVD, such as statins and angiotensin-converting enzyme inhibitors (ACEIs); however, their real roles should be confirmed by further prospective trials.
Collapse
Affiliation(s)
- Moon-Sing Lee
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Dalin, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Dai-Wei Liu
- School of Medicine, Tzu Chi University, Hualien, Taiwan.,Department of Radiation Oncology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Shih-Kai Hung
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Dalin, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan.,Cancer Centre, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Dalin, Taiwan
| | - Chih-Chia Yu
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Dalin, Taiwan.,Department of Biomedical Sciences, National Chung Cheng University, Chia-Yi, Taiwan
| | - Chen-Lin Chi
- School of Medicine, Tzu Chi University, Hualien, Taiwan.,Department of Anatomic Pathology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Dalin, Taiwan
| | - Wen-Yen Chiou
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Dalin, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan.,Cancer Centre, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Dalin, Taiwan
| | - Liang-Cheng Chen
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Dalin, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan.,Cancer Centre, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Dalin, Taiwan
| | - Ru-Inn Lin
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Dalin, Taiwan.,Department of Biomedical Sciences, National Chung Cheng University, Chia-Yi, Taiwan
| | - Li-Wen Huang
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Dalin, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan.,Cancer Centre, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Dalin, Taiwan
| | - Chia-Hui Chew
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Dalin, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan.,Cancer Centre, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Dalin, Taiwan
| | - Feng-Chun Hsu
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Dalin, Taiwan
| | - Michael W Y Chan
- Department of Biomedical Sciences, National Chung Cheng University, Chia-Yi, Taiwan
| | - Hon-Yi Lin
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Dalin, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan.,Cancer Centre, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Dalin, Taiwan.,Department of Biomedical Sciences, National Chung Cheng University, Chia-Yi, Taiwan
| |
Collapse
|