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Seferina SC, de Boer M, Derksen MW, van den Berkmortel F, van Kampen RJW, van de Wouw AJ, Joore M, Peer PGM, Voogd AC, Tjan-Heijnen VCG. Cardiotoxicity and Cardiac Monitoring During Adjuvant Trastuzumab in Daily Dutch Practice: A Study of the Southeast Netherlands Breast Cancer Consortium. Oncologist 2016; 21:555-62. [PMID: 27009939 DOI: 10.1634/theoncologist.2015-0230] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [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: 04/04/2015] [Accepted: 02/01/2016] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION We assessed the incidence and timing of first cardiac events, impact on trastuzumab prescription, and role of left ventricular ejection fraction (LVEF) monitoring in daily practice of trastuzumab-treated patients with human epidermal growth receptor 2 (HER2)-positive early breast cancer. METHODS We included all patients with stage I-III breast cancer diagnosed in the early years (2005-2007) after the introduction of adjuvant trastuzumab in five hospitals in Southeast Netherlands. We studied the incidence and timing of cardiotoxicity in patients treated with adjuvant trastuzumab, using similar cardiac endpoints as in the Herceptin Adjuvant (HERA) trial. RESULTS Of 2,684 included patients, 476 (17.7%) had a HER2-positive tumor. Of these, 269 (56.9%) were treated with adjuvant chemotherapy, and of these, 230 (85.5%) also received trastuzumab. Cardiotoxicity was observed in 29 of 230 patients (12.6%). Twenty of the 230 patients (8.7%) had symptomatic cardiotoxicity, defined as a drop in LVEF of at least 10 percentage points and to below 50%, accompanied by symptoms of congestive heart failure. Trastuzumab was definitely discontinued because of supposed cardiotoxicity in 36 patients (15.6%), of whom only 15 (6.5%) had a significant LVEF drop. Of the 36 patients who prematurely discontinued trastuzumab (including the 29 in whom cardiotoxicity was observed), 84.8% stopped in the first 6 months. No cardiac deaths were seen. CONCLUSION In the first years after implementation of trastuzumab for treatment of early breast cancer, physicians frequently based their decision to discontinue treatment on patient symptoms apart from LVEF outcome. We suggest that focusing LVEF monitoring on the first 6 months might be more cost-effective without compromising patient safety. Nonetheless, further research is needed. IMPLICATIONS FOR PRACTICE Knowledge of when cardiotoxicity occurs in daily practice will help shape the best follow-up method for cardiac monitoring in trastuzumab-treated patients with human epidermal growth receptor 2-positive early breast cancer. In the first years after implementation of trastuzumab for treatment of early breast cancer, physicians frequently based their decision to discontinue treatment on patient symptoms apart from left ventricular ejection fraction (LVEF) outcome. When cardiotoxicity was found in daily practice, it occurred mainly in the first 6 months after start of trastuzumab. This study suggests that focusing LVEF monitoring on the first 6 months might be more cost-effective without compromising patient safety. This insight stresses the relevance of performing real-world analyses.
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Affiliation(s)
- Shanly C Seferina
- Department of Medical Oncology, Maastricht University Medical Centre, Maastricht, The Netherlands GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Maaike de Boer
- Department of Medical Oncology, Maastricht University Medical Centre, Maastricht, The Netherlands GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - M Wouter Derksen
- Department of Internal Medicine, Máxima Medical Centre, Veldhoven, The Netherlands
| | | | - Roel J W van Kampen
- Department of Medical Oncology, Maastricht University Medical Centre, Maastricht, The Netherlands Department of Internal Medicine, Orbis Medical Centre, Sittard, The Netherlands
| | - Agnès J van de Wouw
- Department of Internal Medicine, VieCuri Medical Centre, Venlo, The Netherlands
| | - Manuela Joore
- GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Petronella G M Peer
- Department of Medical Oncology, Maastricht University Medical Centre, Maastricht, The Netherlands Radboud Institute for Health Science, Nijmegen, The Netherlands
| | - Adri C Voogd
- Department of Medical Oncology, Maastricht University Medical Centre, Maastricht, The Netherlands GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands Department of Epidemiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Vivianne C G Tjan-Heijnen
- Department of Medical Oncology, Maastricht University Medical Centre, Maastricht, The Netherlands GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
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Seferina SC, Lobbezoo DJA, de Boer M, Dercksen MW, van den Berkmortel F, van Kampen RJW, van de Wouw AJ, de Vries B, Joore MA, Peer PGM, Voogd AC, Tjan-Heijnen VCG. Real-Life Use and Effectiveness of Adjuvant Trastuzumab in Early Breast Cancer Patients: A Study of the Southeast Netherlands Breast Cancer Consortium. Oncologist 2015; 20:856-63. [PMID: 26099745 PMCID: PMC4524770 DOI: 10.1634/theoncologist.2015-0006] [Citation(s) in RCA: 30] [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] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 03/23/2015] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND The impact of drug prescriptions in real life as opposed to strict clinical trial prescription is only rarely assessed, although it is well recognized that incorrect use may harm patients and may have a significant impact on health care resources. We investigated the use and effectiveness of adjuvant trastuzumab in daily practice compared with the effectiveness in clinical trials. METHODS We included all patients with stage I-III invasive breast cancer, irrespective of human epidermal growth factor receptor 2 (HER2) status, diagnosed in five hospitals in the southeast of The Netherlands in 2005-2007. We aimed to assess the actual use of adjuvant trastuzumab in early HER2-positive breast and its efficacy in daily practice. RESULTS Of 2,684 patients included, 476 (17.7%) had a HER2-positive tumor. Of these, 251 (52.7%) patients had an indication for trastuzumab treatment of which 196 (78.1%) patients actually received it. Of the 225 patients without an indication, 34 (15.1%) received trastuzumab. Five-year disease-free survival was 80.7% for (n = 230) patients treated with versus 68.2% for (n = 246) patients not treated with trastuzumab (p = .0023), and 5-year overall survival rates were 90.7% and 77.4%, respectively (p = .0002). The hazard ratio for disease recurrence was 0.63 (95% confidence interval, 0.37-1.06) for trastuzumab when adjusting for potential confounders. CONCLUSION This study shows that in real life, patients treated with trastuzumab in early-stage HER2-positive breast cancer had a 5-year disease-free and overall survival comparable to prior randomized trials. For informative decision making, real-life data are of additional value, providing insight on outcome of patients considered ineligible for treatment.
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Affiliation(s)
- Shanly C Seferina
- Departments of Medical Oncology, Pathology, Clinical Epidemiology and Medical Technology Assessment, and Epidemiology and GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Internal Medicine, Máxima Medical Centre, Veldhoven, The Netherlands; Department of Internal Medicine, Atrium Medical Centre Parkstad, Heerlen, The Netherlands; Department of Internal Medicine, Orbis Medical Centre, Sittard, The Netherlands; Department of Internal Medicine, VieCuri Medical Centre, Venlo, The Netherlands; Biostatistics, Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dorien J A Lobbezoo
- Departments of Medical Oncology, Pathology, Clinical Epidemiology and Medical Technology Assessment, and Epidemiology and GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Internal Medicine, Máxima Medical Centre, Veldhoven, The Netherlands; Department of Internal Medicine, Atrium Medical Centre Parkstad, Heerlen, The Netherlands; Department of Internal Medicine, Orbis Medical Centre, Sittard, The Netherlands; Department of Internal Medicine, VieCuri Medical Centre, Venlo, The Netherlands; Biostatistics, Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maaike de Boer
- Departments of Medical Oncology, Pathology, Clinical Epidemiology and Medical Technology Assessment, and Epidemiology and GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Internal Medicine, Máxima Medical Centre, Veldhoven, The Netherlands; Department of Internal Medicine, Atrium Medical Centre Parkstad, Heerlen, The Netherlands; Department of Internal Medicine, Orbis Medical Centre, Sittard, The Netherlands; Department of Internal Medicine, VieCuri Medical Centre, Venlo, The Netherlands; Biostatistics, Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - M Wouter Dercksen
- Departments of Medical Oncology, Pathology, Clinical Epidemiology and Medical Technology Assessment, and Epidemiology and GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Internal Medicine, Máxima Medical Centre, Veldhoven, The Netherlands; Department of Internal Medicine, Atrium Medical Centre Parkstad, Heerlen, The Netherlands; Department of Internal Medicine, Orbis Medical Centre, Sittard, The Netherlands; Department of Internal Medicine, VieCuri Medical Centre, Venlo, The Netherlands; Biostatistics, Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Franchette van den Berkmortel
- Departments of Medical Oncology, Pathology, Clinical Epidemiology and Medical Technology Assessment, and Epidemiology and GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Internal Medicine, Máxima Medical Centre, Veldhoven, The Netherlands; Department of Internal Medicine, Atrium Medical Centre Parkstad, Heerlen, The Netherlands; Department of Internal Medicine, Orbis Medical Centre, Sittard, The Netherlands; Department of Internal Medicine, VieCuri Medical Centre, Venlo, The Netherlands; Biostatistics, Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Roel J W van Kampen
- Departments of Medical Oncology, Pathology, Clinical Epidemiology and Medical Technology Assessment, and Epidemiology and GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Internal Medicine, Máxima Medical Centre, Veldhoven, The Netherlands; Department of Internal Medicine, Atrium Medical Centre Parkstad, Heerlen, The Netherlands; Department of Internal Medicine, Orbis Medical Centre, Sittard, The Netherlands; Department of Internal Medicine, VieCuri Medical Centre, Venlo, The Netherlands; Biostatistics, Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Agnès J van de Wouw
- Departments of Medical Oncology, Pathology, Clinical Epidemiology and Medical Technology Assessment, and Epidemiology and GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Internal Medicine, Máxima Medical Centre, Veldhoven, The Netherlands; Department of Internal Medicine, Atrium Medical Centre Parkstad, Heerlen, The Netherlands; Department of Internal Medicine, Orbis Medical Centre, Sittard, The Netherlands; Department of Internal Medicine, VieCuri Medical Centre, Venlo, The Netherlands; Biostatistics, Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bart de Vries
- Departments of Medical Oncology, Pathology, Clinical Epidemiology and Medical Technology Assessment, and Epidemiology and GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Internal Medicine, Máxima Medical Centre, Veldhoven, The Netherlands; Department of Internal Medicine, Atrium Medical Centre Parkstad, Heerlen, The Netherlands; Department of Internal Medicine, Orbis Medical Centre, Sittard, The Netherlands; Department of Internal Medicine, VieCuri Medical Centre, Venlo, The Netherlands; Biostatistics, Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Manuela A Joore
- Departments of Medical Oncology, Pathology, Clinical Epidemiology and Medical Technology Assessment, and Epidemiology and GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Internal Medicine, Máxima Medical Centre, Veldhoven, The Netherlands; Department of Internal Medicine, Atrium Medical Centre Parkstad, Heerlen, The Netherlands; Department of Internal Medicine, Orbis Medical Centre, Sittard, The Netherlands; Department of Internal Medicine, VieCuri Medical Centre, Venlo, The Netherlands; Biostatistics, Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Petronella G M Peer
- Departments of Medical Oncology, Pathology, Clinical Epidemiology and Medical Technology Assessment, and Epidemiology and GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Internal Medicine, Máxima Medical Centre, Veldhoven, The Netherlands; Department of Internal Medicine, Atrium Medical Centre Parkstad, Heerlen, The Netherlands; Department of Internal Medicine, Orbis Medical Centre, Sittard, The Netherlands; Department of Internal Medicine, VieCuri Medical Centre, Venlo, The Netherlands; Biostatistics, Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Adri C Voogd
- Departments of Medical Oncology, Pathology, Clinical Epidemiology and Medical Technology Assessment, and Epidemiology and GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Internal Medicine, Máxima Medical Centre, Veldhoven, The Netherlands; Department of Internal Medicine, Atrium Medical Centre Parkstad, Heerlen, The Netherlands; Department of Internal Medicine, Orbis Medical Centre, Sittard, The Netherlands; Department of Internal Medicine, VieCuri Medical Centre, Venlo, The Netherlands; Biostatistics, Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Vivianne C G Tjan-Heijnen
- Departments of Medical Oncology, Pathology, Clinical Epidemiology and Medical Technology Assessment, and Epidemiology and GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Internal Medicine, Máxima Medical Centre, Veldhoven, The Netherlands; Department of Internal Medicine, Atrium Medical Centre Parkstad, Heerlen, The Netherlands; Department of Internal Medicine, Orbis Medical Centre, Sittard, The Netherlands; Department of Internal Medicine, VieCuri Medical Centre, Venlo, The Netherlands; Biostatistics, Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
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