101
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Rygiel K. Benefits of antihypertensive medications for anthracycline- and trastuzumab-induced cardiotoxicity in patients with breast cancer: Insights from recent clinical trials. Indian J Pharmacol 2017; 48:490-497. [PMID: 27721532 PMCID: PMC5051240 DOI: 10.4103/0253-7613.190719] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Advances in oncologic therapies have allowed many patients with breast cancer to achieve better outcomes and longer survival. However, this progress has been tempered by cardiotoxicity, associated with anticancer therapies, ranging from subclinical abnormalities to irreversible life-threatening complications, such as congestive heart failure or cardiomyopathy. In particular, exposure to chemotherapy (CHT), including anthracyclines and trastuzumab, can lead to cardiac dysfunction with short- or long-term consequences, among patients with breast cancer. The aim of this study is to highlight the potential role of commonly used cardiac medications in the prevention of anthracycline- and trastuzumab-mediated cardiotoxicity, in women with breast cancer, based on evidence from recent clinical trials. This overview is focused on the use of antihypertensive medications, such as angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, outlining their cardioprotective effects in this patient population. In addition, the importance of biomarkers and modern imaging tests, as potential tools for detection and monitoring of cardiac dysfunction, induced by CHT, as well as some practical preventive and therapeutic strategies for cardio-oncology treatment teams, involved in the management of a growing number of women with breast cancer have been outlined. The content of this overview is based on a literature search of PubMed, within the last 5 years, mostly in relevance to the human epidermal growth factor receptor 2-positive patients with breast cancer, treated with anthracycline or trastuzumab therapy (in addition to surgery and/or radiation therapy [RT] regimen).
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Affiliation(s)
- Katarzyna Rygiel
- Department of Family Practice, Medical University of Silesia (SUM), Katowice, Poland
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102
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Controversial issues in the management of older adults with early breast cancer. J Geriatr Oncol 2017; 8:397-402. [PMID: 28602710 DOI: 10.1016/j.jgo.2017.05.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 04/05/2017] [Accepted: 05/24/2017] [Indexed: 12/12/2022]
Abstract
It is well recognized that the incidence of breast cancer increases significantly with age. Despite this, older people remain under-represented in many clinical trials and their management relies on extrapolation of data from younger patients. Providing an aggressive intervention can be challenging, particularly in less fit older patients where a conservative approach is commonly perceived to be more appropriate. The optimal management of this population is unknown and treatment decision should be personalized. This review article will discuss several controversial issues in managing older adults with early breast cancer in a multidisciplinary setting, including the role of surgical treatment of the axilla in clinically node negative disease, radiotherapy after breast conservation surgery in low-risk tumours, personalizing adjuvant systemic therapy, and geriatric assessments in breast cancer treatment decisions.
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103
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Wang HY, Yin BB, Jia DY, Hou YL. Association between obesity and trastuzumab-related cardiac toxicity in elderly patients with breast cancer. Oncotarget 2017; 8:79289-79297. [PMID: 29108307 PMCID: PMC5668040 DOI: 10.18632/oncotarget.17808] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 04/25/2017] [Indexed: 12/19/2022] Open
Abstract
Purpose Trastuzumab can improve the prognosis for patients with breast cancer, but its related cardiac toxicity is concerning. This study aimed to identify the risk factors associated with trastuzumab-related cardiac toxicity in elderly patients with HER2-positive breast cancer. Patients and methods A total of 133 elderly (≥ 65 years) patients who were diagnosed with breast cancer between June 1, 2007, and January 31, 2016, and received trastuzumab treatment were retrospectively reviewed. Cardiac events were defined as: (1) LVEF reduction of >10% from baseline echocardiography, (2) reduction of LVEF to <50%, and (3) signs and symptoms of heart failure as defined by the Common Terminology Criteria for Adverse Events (CTCAE) accompanied by a decrease in the LVEF. Univariate and multivariate regression analyses were used to determine the contribution of different clinical variables to trastuzumab-related cardiac events. Results The median age of the cohort was 71.0 years (range, 65–81 years). The median follow-up period for measurement of left ventricular ejection fraction was 11.0 months (range, 2–71 months). Fifteen patients (11.2%) experienced cardiac events during the follow-up. Multivariate regression analysis revealed that obesity (odd ratio[OR], 4.706; 95% CI, 1.984-10.147; P = 0.002) was a statistically significant risk factor associated with cardiac events. Conclusion Obesity is an independent risk factor for trastuzumab-related cardiac toxicity in elderly patients with breast cancer, receiving trastuzumab. Further studies are needed to establish the independent predictive value of obesity on cardiotoxicity in these patients.
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Affiliation(s)
- Hai-Yan Wang
- Department of Echocardiography, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan, Shandong Province, China
| | - Bei-Bei Yin
- Department of Oncology, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan, Shandong Province, China
| | - Dan-Yan Jia
- Jinan Medical Emergency Center, Jinan, Shandong Province, China
| | - Ying-Long Hou
- Department of Cardiology, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan, Shandong Province, China
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104
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Tyrosine kinase-targeting drugs-associated heart failure. Br J Cancer 2017; 116:1366-1373. [PMID: 28399109 PMCID: PMC5482733 DOI: 10.1038/bjc.2017.88] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Revised: 01/17/2017] [Accepted: 02/23/2017] [Indexed: 02/02/2023] Open
Abstract
Background: The impact of cancer therapies on cardiac disease in the general adult cancer survivor population is largely unknown. Our objective was to evaluate which tyrosine kinase-targeting drugs are associated with greater risk for new-onset heart failure (HF). Methods: A nested case–control analysis was conducted within a cohort of 27 992 patients of Clalit Health Services, newly treated with a tyrosine kinase-targeting, and/or chemotherapeutic drug, for a malignant disease, between 1 January 2005 and 31 December 2012. Each new case of HF was matched to up to 30 controls from the cohort on calendar year of cohort entry, age, gender, and duration of follow-up. Main outcome measure was odds ratio (OR) with 95% confidence interval (CI) of new-onset HF. Results: There were 936 incident cases of HF during 71 742 person-years of follow-up. Trastuzumab (OR 1.90, 95% CI 1.46–2.49), cetuximab (OR 1.72, 1.10–2.69), panitumumab (OR 3.01, 1.02–8.85), and sunitinib (OR 3.39, 1.78–6.47) were associated with increased HF risk. Comorbidity independently associated with higher risk in a multivariable conditional regression model was diabetes mellitus, hypertension, chronic renal failure, ischaemic heart disease, valvular heart disease, arrhythmia, and smoking. Conclusions: Trastuzumab, cetuximab, panitumumab, and sunitinib are associated with increased risk for new-onset HF.
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105
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Lynce F, Barac A, Tan MT, Asch FM, Smith KL, Dang C, Isaacs C, Swain SM. SAFE-HEaRt: Rationale and Design of a Pilot Study Investigating Cardiac Safety of HER2 Targeted Therapy in Patients with HER2-Positive Breast Cancer and Reduced Left Ventricular Function. Oncologist 2017; 22:518-525. [PMID: 28314836 DOI: 10.1634/theoncologist.2016-0412] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 12/19/2016] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Human epidermal growth receptor 2 (HER2) targeted therapies have survival benefit in adjuvant and metastatic HER2 positive breast cancer but are associated with cardiac dysfunction. Current U.S. Food and Drug Administration recommendations limit the use of HER2 targeted agents to patients with normal left ventricular (LV) systolic function. METHODS The objective of the SAFE-HEaRt study is to evaluate the cardiac safety of HER2 targeted therapy in patients with HER2 positive breast cancer and mildly reduced left ventricular ejection fraction (LVEF) with optimized cardiac therapy. Thirty patients with histologically confirmed HER2 positive breast cancer (stage I-IV) and reduced LVEF (40% to 49%) who plan to receive HER2 targeted therapy for ≥3 months will be enrolled. Prior to initiation on study, optimization of heart function with beta-blockers and angiotensin converting enzyme inhibitors will be initiated. Patients will be followed by serial echocardiograms and cardiac visits during and 6 months after completion of HER2 targeted therapy. Myocardial strain and blood biomarkers, including cardiac troponin I and high-sensitivity cardiac troponin T, will be examined at baseline and during the study. DISCUSSION LV dysfunction in patients with breast cancer poses cardiac and oncological challenges and limits the use of HER2 targeted therapies and its oncological benefits. Strategies to prevent cardiac dysfunction associated with HER2 targeted therapy have been limited to patients with normal LVEF, thus excluding patients who may receive the highest benefit from those strategies. SAFE-HEaRt is the first prospective pilot study of HER2 targeted therapies in patients with reduced LV function while on optimized cardiac treatment that can provide the basis for clinical practice changes. The Oncologist 2017;22:518-525 IMPLICATIONS FOR PRACTICE: Human epidermal growth receptor 2 (HER2) targeted therapies have survival benefit in adjuvant and metastatic HER2 positive breast cancer but are associated with cardiac dysfunction. To our knowledge, SAFE-HEaRt is the first clinical trial that prospectively tests the hypothesis that HER2 targeted therapies may be safely administered in patients with mildly reduced cardiac function in the setting of ongoing cardiac treatment and monitoring. The results of this study will provide cardiac safety data and inform consideration of clinical practice changes in patients with HER2 positive breast cancer and reduced cardiac function, as well as provide information regarding cardiovascular monitoring and treatment in this population.
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Affiliation(s)
- Filipa Lynce
- Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, Washington, D.C., USA
| | - Ana Barac
- Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, Washington, D.C., USA
- MedStar Washington Hospital Center, Washington, D.C., USA
- MedStar Heart and Vascular Institute, Washington, D.C., USA
| | - Ming T Tan
- Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, Washington, D.C., USA
| | - Federico M Asch
- MedStar Washington Hospital Center, Washington, D.C., USA
- MedStar Heart and Vascular Institute, Washington, D.C., USA
| | - Karen L Smith
- Johns Hopkins Kimmel Cancer Center, Sibley Memorial Hospital, Washington, D.C., USA
| | - Chau Dang
- Memorial Sloan Kettering Cancer Center, New, York New York, USA
| | - Claudine Isaacs
- Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, Washington, D.C., USA
| | - Sandra M Swain
- Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, Washington, D.C., USA
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106
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Armenian SH, Lacchetti C, Barac A, Carver J, Constine LS, Denduluri N, Dent S, Douglas PS, Durand JB, Ewer M, Fabian C, Hudson M, Jessup M, Jones LW, Ky B, Mayer EL, Moslehi J, Oeffinger K, Ray K, Ruddy K, Lenihan D. Prevention and Monitoring of Cardiac Dysfunction in Survivors of Adult Cancers: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol 2017; 35:893-911. [DOI: 10.1200/jco.2016.70.5400] [Citation(s) in RCA: 652] [Impact Index Per Article: 93.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Purpose Cardiac dysfunction is a serious adverse effect of certain cancer-directed therapies that can interfere with the efficacy of treatment, decrease quality of life, or impact the actual survival of the patient with cancer. The purpose of this effort was to develop recommendations for prevention and monitoring of cardiac dysfunction in survivors of adult-onset cancers. Methods Recommendations were developed by an expert panel with multidisciplinary representation using a systematic review (1996 to 2016) of meta-analyses, randomized clinical trials, observational studies, and clinical experience. Study quality was assessed using established methods, per study design. The guideline recommendations were crafted in part using the Guidelines Into Decision Support methodology. Results A total of 104 studies met eligibility criteria and compose the evidentiary basis for the recommendations. The strength of the recommendations in these guidelines is based on the quality, amount, and consistency of the evidence and the balance between benefits and harms. Recommendations It is important for health care providers to initiate the discussion regarding the potential for cardiac dysfunction in individuals in whom the risk is sufficiently high before beginning therapy. Certain higher risk populations of survivors of cancer may benefit from prevention and screening strategies implemented during cancer-directed therapies. Clinical suspicion for cardiac disease should be high and threshold for cardiac evaluation should be low in any survivor who has received potentially cardiotoxic therapy. For certain higher risk survivors of cancer, routine surveillance with cardiac imaging may be warranted after completion of cancer-directed therapy, so that appropriate interventions can be initiated to halt or even reverse the progression of cardiac dysfunction.
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Affiliation(s)
- Saro H. Armenian
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
| | - Christina Lacchetti
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
| | - Ana Barac
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
| | - Joseph Carver
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
| | - Louis S. Constine
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
| | - Neelima Denduluri
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
| | - Susan Dent
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
| | - Pamela S. Douglas
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
| | - Jean-Bernard Durand
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
| | - Michael Ewer
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
| | - Carol Fabian
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
| | - Melissa Hudson
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
| | - Mariell Jessup
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
| | - Lee W. Jones
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
| | - Bonnie Ky
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
| | - Erica L. Mayer
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
| | - Javid Moslehi
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
| | - Kevin Oeffinger
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
| | - Katharine Ray
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
| | - Kathryn Ruddy
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
| | - Daniel Lenihan
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
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107
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Daniels B, Lord SJ, Kiely BE, Houssami N, Haywood P, Lu CY, Ward RL, Pearson SA. Use and outcomes of targeted therapies in early and metastatic HER2-positive breast cancer in Australia: protocol detailing observations in a whole of population cohort. BMJ Open 2017; 7:e014439. [PMID: 28119394 PMCID: PMC5278255 DOI: 10.1136/bmjopen-2016-014439] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 12/22/2016] [Accepted: 12/29/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The management of human epidermal growth factor receptor 2 (HER2)-positive breast cancer (BC) has changed dramatically with the introduction and widespread use of HER2-targeted therapies. However, there is relatively limited real-world information on patterns of use, effectiveness and safety in whole of population cohorts. The research programme detailed in this protocol will generate evidence on the prescribing patterns, safety monitoring and outcomes of patients with BC treated with HER2-targeted therapies in Australia. METHODS/DESIGN Our ongoing research programme will involve a series of retrospective cohort studies that include every patient accessing Commonwealth-funded HER2-targeted therapies for the treatment of early BC and advanced BC in Australia. At the time of writing, our cohorts consist of 11 406 patients with early BC and 5631 with advanced BC who accessed trastuzumab and lapatinib between 2001 and 2014. Pertuzumab and trastuzumab emtansine were publicly funded for metastatic BC in 2015, and future data updates will include patients accessing these medicines. We will use dispensing claims for cancer and other medicines, medical service claims and demographics data for each patient accessing HER2-targeted therapies to undertake this research. ETHICS AND DISSEMINATION Ethics approval has been granted by the Population Health Service Research Ethics Committee and data access approval has been granted by the Australian Department of Human Services (DHS) External Review Evaluation Committee. Our findings will be reported in peer-reviewed publications, conference presentations and policy forums. By providing detailed information on the use and outcomes associated with HER2-targeted therapies in a national cohort treated in routine clinical care, our research programme will better inform clinicians and patients about the real-world use of these treatments and will assist third-party payers to better understand the use and economic costs of these treatments.
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Affiliation(s)
- Benjamin Daniels
- Medicines Policy Research Unit, Centre for Big Data Research in Health, UNSW, Sydney, New South Wales, Australia
| | - Sarah J Lord
- School of Medicine, University of Notre Dame Australia, Sydney, New South Wales, Australia
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Belinda E Kiely
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Nehmat Houssami
- Sydney School of Public Health, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Philip Haywood
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Christine Y Lu
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
| | - Robyn L Ward
- University of Queensland, Brisbane, Queensland, Australia
| | - Sallie-Anne Pearson
- Medicines Policy Research Unit, Centre for Big Data Research in Health, UNSW, Sydney, New South Wales, Australia
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108
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Pagani O. Endocrine Therapies in the Adjuvant and Advanced Disease Settings. Breast Cancer 2017. [DOI: 10.1007/978-3-319-48848-6_45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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109
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Ferraro D, Champ J, Teste B, Serra M, Malaquin L, Descroix S, de Cremoux P, Viovy JL. Droplet Microfluidic and Magnetic Particles Platform for Cancer Typing. Methods Mol Biol 2017; 1547:113-121. [PMID: 28044291 DOI: 10.1007/978-1-4939-6734-6_9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Analyses of nucleic acids are routinely performed in hospital laboratories to detect gene alterations for cancer diagnosis and treatment decision. Among the different possible investigations, mRNA analysis provides information on abnormal levels of genes expression. Standard laboratory methods are still not adapted to the isolation and quantitation of low mRNA amounts and new techniques needs to be developed in particular for rare subsets analysis. By reducing the volume involved, time process, and the contamination risks, droplet microfluidics provide numerous advantages to perform analysis down to the single cell level.We report on a droplet microfluidic platform based on the manipulation of magnetic particles that allows the clinical analysis of tumor tissues. In particular, it allows the extraction of mRNA from the total-RNA sample, Reverse Transcription, and cDNA amplification, all in droplets.
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Affiliation(s)
- Davide Ferraro
- Macromolecules and Microsystems in Biology and Medicine, Institut Curie, Centre National de la Recherche Scientifique, Université Pierre et Marie Curie, PSL Research University, UMR 168, 75005, Paris, France
| | - Jérôme Champ
- Macromolecules and Microsystems in Biology and Medicine, Institut Curie, Centre National de la Recherche Scientifique, Université Pierre et Marie Curie, PSL Research University, UMR 168, 75005, Paris, France
- University Paris-Diderot, PRES Paris Cité, INSERM/CNRS UMR944/7212, Paris, France
- Molecular Oncology Unit, APHP, Saint-Louis Hospital, Paris, France
| | - Bruno Teste
- Macromolecules and Microsystems in Biology and Medicine, Institut Curie, Centre National de la Recherche Scientifique, Université Pierre et Marie Curie, PSL Research University, UMR 168, 75005, Paris, France
| | - M Serra
- Macromolecules and Microsystems in Biology and Medicine, Institut Curie, Centre National de la Recherche Scientifique, Université Pierre et Marie Curie, PSL Research University, UMR 168, 75005, Paris, France
| | - Laurent Malaquin
- Macromolecules and Microsystems in Biology and Medicine, Institut Curie, Centre National de la Recherche Scientifique, Université Pierre et Marie Curie, PSL Research University, UMR 168, 75005, Paris, France
| | - Stéphanie Descroix
- Macromolecules and Microsystems in Biology and Medicine, Institut Curie, Centre National de la Recherche Scientifique, Université Pierre et Marie Curie, PSL Research University, UMR 168, 75005, Paris, France
| | - Patricia de Cremoux
- University Paris-Diderot, PRES Paris Cité, INSERM/CNRS UMR944/7212, Paris, France
- Molecular Oncology Unit, APHP, Saint-Louis Hospital, Paris, France
| | - Jean-Louis Viovy
- Macromolecules and Microsystems in Biology and Medicine, Institut Curie, Centre National de la Recherche Scientifique, Université Pierre et Marie Curie, PSL Research University, UMR 168, 75005, Paris, France.
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110
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Thavendiranathan P, Amir E. Left Ventricular Dysfunction With Trastuzumab Therapy: Is Primary Prevention the Best Option? J Clin Oncol 2016; 35:820-825. [PMID: 28029315 DOI: 10.1200/jco.2016.71.0038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice. A 51-year-old women with left-sided, T2N1, grade 3, estrogen receptor- and progesterone receptor-negative, human epidermal growth factor receptor 2 (HER2)-positive breast cancer was referred to a cardio-oncology clinic for pre-cancer treatment cardiovascular risk assessment. The planned cancer treatment was 3 cycles of FEC (fluorouracil, epirubicin [100 mg/m2 per dose], and cyclophosphamide), followed by 3 cycles of concurrent docetaxel and trastuzumab, followed by maintenance trastuzumab to complete a 1-year course. Other than a prior history of hysterectomy, there was no relevant medical history. Her cardiac history was notable for the absence of prior cardiovascular disease, hypertension, diabetes, or hypercholesterolemia. She was a nonsmoker. At initial clinic visit, her blood pressure was 138/84 with an unremarkable cardiovascular examination. Her echocardiography demonstrated normal sinus rhythm at 73 beats per minute. During cancer treatment, she was observed with echocardiography (baseline left ventricular ejection fraction [LVEF], 61%; global longitudinal strain, -21.5%), cardiac magnetic resonance imaging (CMR, as part of an ongoing study), high-sensitivity troponin I, and B-type natriuretic peptide ( Table 1 ). Given that her baseline evaluations were negative at her initial visit, we discussed whether there were agents to prevent the rare, but serious, complication of congestive heart failure (HF) associated with anthracycline- and trastuzumab-based therapy.
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Affiliation(s)
- Paaladinesh Thavendiranathan
- Paaladinesh Thavendiranathan, Ted Rogers Program in Cardiotoxicity Prevention, University Health Network, Toronto, Ontario, Canada; and Eitan Amir, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Eitan Amir
- Paaladinesh Thavendiranathan, Ted Rogers Program in Cardiotoxicity Prevention, University Health Network, Toronto, Ontario, Canada; and Eitan Amir, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
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111
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Daste A, Chakiba C, Domblides C, Gross-goupil M, Quivy A, Ravaud A, Soubeyran P. Targeted therapy and elderly people: A review. Eur J Cancer 2016; 69:199-215. [DOI: 10.1016/j.ejca.2016.10.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 10/05/2016] [Indexed: 11/26/2022]
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112
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Sun J, Chia S. Adjuvant chemotherapy and HER-2-directed therapy for early-stage breast cancer in the elderly. Br J Cancer 2016; 116:4-9. [PMID: 27875517 PMCID: PMC5220141 DOI: 10.1038/bjc.2016.360] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 09/28/2016] [Accepted: 10/06/2016] [Indexed: 02/01/2023] Open
Abstract
There is a lack of sufficient evidence-based data defining the optimal adjuvant systemic therapies in older women. Recommendations are mainly based on retrospective studies, subgroup analyses within larger randomised trials and expert opinion. Treatment decisions should consider the functional fitness of the patient, co-morbidities, in addition to chronological age with the aim to balance risks and potential benefits from treatment(s). In this review, we discuss assessment tools to aid clinicians to select elderly patients who are ‘fit' for chemotherapy, and review the literature on the use of chemotherapy and of the anti-HER 2 antibody trastuzumab in this population. We will also review two commonly used prediction models to assess their accuracy in predicting survival outcomes in elderly patients. Ongoing clinical trials specifically focusing on older patients may help to clarify the absolute benefits and risks of adjuvant systemic therapy in this age group.
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Affiliation(s)
- J Sun
- Department of Medical Oncology, British Columbia Cancer Agency, 600 West 10th Avenue, Vancouver, British Columbia V5Z 4E6, Canada
| | - S Chia
- Department of Medical Oncology, British Columbia Cancer Agency, 600 West 10th Avenue, Vancouver, British Columbia V5Z 4E6, Canada
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113
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Joensuu H. Escalating and de-escalating treatment in HER2-positive early breast cancer. Cancer Treat Rev 2016; 52:1-11. [PMID: 27866067 DOI: 10.1016/j.ctrv.2016.11.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 10/30/2016] [Accepted: 11/03/2016] [Indexed: 01/26/2023]
Abstract
The current standard adjuvant systemic treatment of early HER2-positive breast cancer consists of chemotherapy plus 12months of trastuzumab, with or without endocrine therapy. Several trials have investigated modifications of the standard treatment that are shorter and less resource-demanding (de-escalation) or regimens that aim at dual HER2 inhibition or include longer than 12months of HER2-targeted treatment (escalation). Seven randomized trials investigate shorter than 12months of trastuzumab treatment duration. The shorter durations were not statistically inferior to the 1-year duration in the 3 trials with survival results available, but 2 of the trials were small and 1 had a relatively short follow-up time of the patients at the time of reporting. The pathological complete response (pCR) rates were numerically higher in all 9 randomized trials that compared chemotherapy plus dual HER2 inhibition consisting of trastuzumab plus either lapatinib, neratinib, or pertuzumab with chemotherapy plus trastuzumab as neoadjuvant treatments, but the superiority of chemotherapy plus dual HER2-inhibition over chemotherapy plus trastuzumab remains to be demonstrated in the adjuvant setting. One year of adjuvant trastuzumab was as effective as 2years of trastuzumab in the HERA trial, and was associated with fewer side-effects. Extending 1-year adjuvant trastuzumab treatment with 1year of neratinib improved disease-free survival in the ExteNET trial, but the patient follow-up times are still short, and no overall survival benefit was reported. Several important trials are expected to report results in the near future and may modify the current standard.
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Affiliation(s)
- Heikki Joensuu
- Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
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114
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Jawa Z, Perez RM, Garlie L, Singh M, Qamar R, Khandheria BK, Jahangir A, Shi Y. Risk factors of trastuzumab-induced cardiotoxicity in breast cancer: A meta-analysis. Medicine (Baltimore) 2016; 95:e5195. [PMID: 27858859 PMCID: PMC5591107 DOI: 10.1097/md.0000000000005195] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Trastuzumab targets the human epidermal growth factor receptor 2 oncogene and in combination with first-line therapy results in significantly improved survival outcomes and has thus become standard of care in both adjuvant and metastatic settings. While it is estimated that 1% to 4% of patients treated with trastuzumab will develop heart failure and ∼10% will experience a reduction in left ventricular ejection fraction (LVEF), the patient risk factors associated with trastuzumab-induced cardiotoxicity (TIC) are unclear. This meta-analysis aims to consolidate previously published data to identify the risk factors most likely leading to TIC. METHODS A search of the MEDLINE literature database using the keywords trastuzumab/Herceptin, risk factors, outcomes, cardiac, cardiotoxicity, cardiomyopathy, LVEF, and chemotherapy was performed. Only prospective/retrospective human studies were included, with additional studies excluded if they reported baseline LVEF > 68%, a cohort of <50 patients, or results that were not stratified based on cardiotoxic events. Pooled odds ratio (OR) and 95% confidence interval (CI) for each potential risk factor were calculated, with heterogeneity of data and samples explored using random-effects modeling. RESULTS Data were collected from 17 articles, capturing 6527 patients. Hypertension (OR 1.61, 95% CI 1.14-2.26; P < 0.01), diabetes (OR 1.62; 95% CI 1.10-2.38; P < 0.02), previous anthracycline use (OR 2.14; 95% CI 1.17-3.92; P < 0.02), and older age (P = 0.013) were all shown to be associated with TIC. CONCLUSION Cardiac performance should be closely monitored in women treated with trastuzumab. Recognizing potential risk factors along with careful attention to symptoms/LVEF measurements could minimize the occurrence of TIC in this population.
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Affiliation(s)
- Zeeshan Jawa
- Department of Internal Medicine, Medical College of Wisconsin
| | | | | | | | - Rubina Qamar
- Department of Medical Oncology, Aurora Health Care
| | | | - Arshad Jahangir
- Aurora Cardiovascular Services, Aurora Health Care
- Sheikh Khalifa bin Hamad Al Thani Center for Integrative Research on Cardiovascular Aging, Aurora Health Care, Milwaukee, WI
| | - Yang Shi
- Aurora Research Institute, Aurora Health Care
- Sheikh Khalifa bin Hamad Al Thani Center for Integrative Research on Cardiovascular Aging, Aurora Health Care, Milwaukee, WI
- Correspondence: Yang Shi, Aurora Research Institute, 960 N. 12th Street, Suite 4155, Milwaukee, WI 53233 (e-mail: )
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Cautela J, Lalevée N, Ammar C, Ederhy S, Peyrol M, Debourdeau P, Serin D, Le Dolley Y, Michel N, Orabona M, Barraud J, Laine M, Bonello L, Paganelli F, Barlési F, Thuny F. Management and research in cancer treatment-related cardiovascular toxicity: Challenges and perspectives. Int J Cardiol 2016; 224:366-375. [PMID: 27673693 DOI: 10.1016/j.ijcard.2016.09.046] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 09/01/2016] [Accepted: 09/15/2016] [Indexed: 12/19/2022]
Abstract
Cardiovascular toxicity is a potentially serious complication that can result from the use of various cancer therapies and can impact the short- and long-term prognosis of treated patients as well as cancer survivors. In addition to their potential acute cardiovascular adverse events, new treatments can lead to late toxicity even after their completion because patients who survive longer generally have an increased exposure to the cancer therapies combined to standard cardiovascular risk factors. These complications expose the patient to the risk of cardiovascular morbi-mortality, which makes managing cardiovascular toxicity a significant challenge. Cardio-oncology programs offer the opportunity to improve cardiovascular monitoring, safety, and management through a better understanding of the pathogenesis of toxicity and interdisciplinary collaborations. In this review, we address new challenges, perspectives, and research priorities in cancer therapy-related cardiovascular toxicity to identify strategies that could improve the overall prognosis and survival of cancer patients. We also focus our discussion on the contribution of cardio-oncology in each step of the development and use of cancer therapies.
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Affiliation(s)
- Jennifer Cautela
- Aix-Marseille University, Assistance Publique - Hôpitaux de Marseille (AP-HM), Mediterranean university Cardio-Oncology center (MEDI-CO center), Unit of Heart Failure and Valvular Heart Diseases, Department of Cardiology, Hôpital Nord, France; Aix-Marseille University, Assistance Publique - Hôpitaux de Marseille (AP-HM), Oncosafety Network of the Early Phases Cancer Trials Center (CLIP(2)), France; Groupe Méditerranéen de Cardio-Oncologie (gMEDICO), France; Mediterranean Academic association for Research and Studies in Cardiology (MARS Cardio), France
| | - Nathalie Lalevée
- Aix-Marseille University, Technological Advances for Genomics and Clinics (TAGC), UMR/INSERM 1090, France
| | - Chloé Ammar
- Aix-Marseille University, Assistance Publique - Hôpitaux de Marseille (AP-HM), Mediterranean university Cardio-Oncology center (MEDI-CO center), Unit of Heart Failure and Valvular Heart Diseases, Department of Cardiology, Hôpital Nord, France; Aix-Marseille University, Assistance Publique - Hôpitaux de Marseille (AP-HM), Oncosafety Network of the Early Phases Cancer Trials Center (CLIP(2)), France; Groupe Méditerranéen de Cardio-Oncologie (gMEDICO), France; Mediterranean Academic association for Research and Studies in Cardiology (MARS Cardio), France
| | - Stéphane Ederhy
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Cardiology, Saint-Antoine Hospital, France
| | - Michael Peyrol
- Aix-Marseille University, Assistance Publique - Hôpitaux de Marseille (AP-HM), Mediterranean university Cardio-Oncology center (MEDI-CO center), Unit of Heart Failure and Valvular Heart Diseases, Department of Cardiology, Hôpital Nord, France; Aix-Marseille University, Assistance Publique - Hôpitaux de Marseille (AP-HM), Oncosafety Network of the Early Phases Cancer Trials Center (CLIP(2)), France; Groupe Méditerranéen de Cardio-Oncologie (gMEDICO), France; Mediterranean Academic association for Research and Studies in Cardiology (MARS Cardio), France
| | - Philippe Debourdeau
- Groupe Méditerranéen de Cardio-Oncologie (gMEDICO), France; Sainte Catherine Institute, Department of Medical Oncology, Avignon, France
| | - Daniel Serin
- Groupe Méditerranéen de Cardio-Oncologie (gMEDICO), France; Sainte Catherine Institute, Department of Medical Oncology, Avignon, France
| | - Yvan Le Dolley
- Groupe Méditerranéen de Cardio-Oncologie (gMEDICO), France; Hôpital Saint Joseph, Department of Cardiology, Marseille, France
| | - Nicolas Michel
- Groupe Méditerranéen de Cardio-Oncologie (gMEDICO), France; Hôpital Saint Joseph, Department of Cardiology, Marseille, France
| | - Morgane Orabona
- Aix-Marseille University, Assistance Publique - Hôpitaux de Marseille (AP-HM), Mediterranean university Cardio-Oncology center (MEDI-CO center), Unit of Heart Failure and Valvular Heart Diseases, Department of Cardiology, Hôpital Nord, France; Aix-Marseille University, Assistance Publique - Hôpitaux de Marseille (AP-HM), Oncosafety Network of the Early Phases Cancer Trials Center (CLIP(2)), France; Groupe Méditerranéen de Cardio-Oncologie (gMEDICO), France; Mediterranean Academic association for Research and Studies in Cardiology (MARS Cardio), France
| | - Jérémie Barraud
- Aix-Marseille University, Assistance Publique - Hôpitaux de Marseille (AP-HM), Mediterranean university Cardio-Oncology center (MEDI-CO center), Unit of Heart Failure and Valvular Heart Diseases, Department of Cardiology, Hôpital Nord, France; Aix-Marseille University, Assistance Publique - Hôpitaux de Marseille (AP-HM), Oncosafety Network of the Early Phases Cancer Trials Center (CLIP(2)), France; Groupe Méditerranéen de Cardio-Oncologie (gMEDICO), France; Mediterranean Academic association for Research and Studies in Cardiology (MARS Cardio), France
| | - Marc Laine
- Aix-Marseille University, Assistance Publique - Hôpitaux de Marseille (AP-HM), Mediterranean university Cardio-Oncology center (MEDI-CO center), Unit of Heart Failure and Valvular Heart Diseases, Department of Cardiology, Hôpital Nord, France; Mediterranean Academic association for Research and Studies in Cardiology (MARS Cardio), France
| | - Laurent Bonello
- Aix-Marseille University, Assistance Publique - Hôpitaux de Marseille (AP-HM), Mediterranean university Cardio-Oncology center (MEDI-CO center), Unit of Heart Failure and Valvular Heart Diseases, Department of Cardiology, Hôpital Nord, France; Mediterranean Academic association for Research and Studies in Cardiology (MARS Cardio), France; Aix-Marseille University, INSERM, UMRS 1076, France
| | - Franck Paganelli
- Aix-Marseille University, Assistance Publique - Hôpitaux de Marseille (AP-HM), Mediterranean university Cardio-Oncology center (MEDI-CO center), Unit of Heart Failure and Valvular Heart Diseases, Department of Cardiology, Hôpital Nord, France; Mediterranean Academic association for Research and Studies in Cardiology (MARS Cardio), France; Aix-Marseille University, INSERM, UMRS 1076, France
| | - Fabrice Barlési
- Aix-Marseille University, Assistance Publique - Hôpitaux de Marseille (AP-HM), Oncosafety Network of the Early Phases Cancer Trials Center (CLIP(2)), France; Groupe Méditerranéen de Cardio-Oncologie (gMEDICO), France; Aix-Marseille University, Multidisciplinary Oncology & Therapeutic Innovations Department, Assistance Publique - Hôpitaux de Marseille (AP-HM), Hôpital Nord, France
| | - Franck Thuny
- Aix-Marseille University, Assistance Publique - Hôpitaux de Marseille (AP-HM), Mediterranean university Cardio-Oncology center (MEDI-CO center), Unit of Heart Failure and Valvular Heart Diseases, Department of Cardiology, Hôpital Nord, France; Aix-Marseille University, Assistance Publique - Hôpitaux de Marseille (AP-HM), Oncosafety Network of the Early Phases Cancer Trials Center (CLIP(2)), France; Groupe Méditerranéen de Cardio-Oncologie (gMEDICO), France; Mediterranean Academic association for Research and Studies in Cardiology (MARS Cardio), France.
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Adjuvant Chemotherapy and Trastuzumab Is Safe and Effective in Older Women With Small, Node-Negative, HER2-Positive Early-Stage Breast Cancer. Clin Breast Cancer 2016; 16:487-493. [PMID: 27622751 DOI: 10.1016/j.clbc.2016.07.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 07/05/2016] [Accepted: 07/20/2016] [Indexed: 01/03/2023]
Abstract
INTRODUCTION The benefit of adjuvant trastuzumab with chemotherapy is well established for women with higher risk human epidermal growth factor receptor 2-positive (HER2+) breast cancer. However, its role in older patients with smaller, node-negative tumors is less clear. We conducted a retrospective, sequential cohort study of this population to describe the impact of trastuzumab on breast cancer outcomes and cardiac safety. PATIENTS AND METHODS Women ≥ 55 years with ≤ 2 cm, node-negative, HER2+ breast cancer were identified and electronic medical records reviewed. A no-trastuzumab cohort of 116 women diagnosed between January 1, 1999 and May 14, 2004 and a trastuzumab cohort of 128 women diagnosed between May 16, 2006 and December 31, 2010 were identified. Overall survival and distant relapse-free survival were estimated by Kaplan-Meier methods. RESULTS The median ages of the trastuzumab and no-trastuzumab cohorts were 62 and 64 years, respectively. More patients in the trastuzumab cohort had grade III (P = .001), lymphovascular invasion (P = .001), or estrogen receptor-negative (P < .001) cancers. The majority of the trastuzumab cohort received chemotherapy versus one-half of the no-trastuzumab cohort (98% vs. 53%; P < .0001). The median follow-up was 4 versus 9 years in the trastuzumab versus no-trastuzumab cohorts; therefore, outcomes at 4 years are reported. Despite the higher-risk tumor features in the trastuzumab group, the 4-year overall survival was 99% in both cohorts; the distant relapse-free survival was 99% versus 97% in the trastuzumab versus no-trastuzumab cohorts. Four (3.1%; 95% confidence interval, 1.0%-7.8%) women in the trastuzumab cohort and 1 in the no-trastuzumab cohort developed symptomatic heart failure. There were no cardiac-related deaths in either arm. CONCLUSION Following adjuvant trastuzumab with chemotherapy, selected older women with small, node-negative, HER2+ breast cancers have excellent disease control. The rate of cardiac events is low.
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117
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Lancellotti P, Moonen M, Jerusalem G. Predicting Reversibility of Anticancer Drugs-Related Cardiac Dysfunction: A New Piece to the Routine Use of Deformation Imaging. Echocardiography 2016; 33:504-9. [PMID: 27103482 DOI: 10.1111/echo.13187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Affiliation(s)
- Patrizio Lancellotti
- Department of Cardiology, GIGA-Cardiovascular Sciences, University Hospital Sart Tilman, Liège, Belgium.,Gruppo Villa Maria Care and Research, Anthea Hospital, Bari, Italy
| | - Marie Moonen
- Department of Cardiology, GIGA-Cardiovascular Sciences, University Hospital Sart Tilman, Liège, Belgium
| | - Guy Jerusalem
- Medical Oncology, CHU Sart Tilman Liege and Liege University, University Sart Tilman, Liege, Belgium
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118
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Vaz-Luis I, Lin NU, Keating NL, Barry WT, Lii J, Burstein HJ, Winer EP, Freedman RA. Treatment of early-stage human epidermal growth factor 2-positive cancers among medicare enrollees: age and race strongly associated with non-use of trastuzumab. Breast Cancer Res Treat 2016; 159:151-62. [PMID: 27484879 DOI: 10.1007/s10549-016-3927-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 07/20/2016] [Indexed: 11/30/2022]
Abstract
Adjuvant trastuzumab for human epidermal growth factor receptor-2 (HER2)-positive breast cancer is highly efficacious regardless of age. Recent data suggested that many older patients with HER2-positive disease do not receive adjuvant trastuzumab. Nevertheless, some of this 'under-treatment' may be clinically appropriate. We used Surveillance, Epidemiology and End Results (SEER)-Medicare data to identify patients aged ≥ 66 with stage ≥ Ib-III, HER2-positive breast cancer diagnosed during 2010-2011 (HER2 status available) who did not have a history of congestive heart failure. We described all systemic treatments received and sociodemographic and clinical characteristics associated with treatment patterns. Among 770 women 44.4 % did not receive trastuzumab, including 21.8 % who received endocrine therapy only, 6.3 % who received chemotherapy (±endocrine therapy) and 16.2 % who did not receive any systemic therapy. In addition to age and grade, race was strongly associated with non-use of trastuzumab (64.4 % of Non-Hispanic blacks vs. 43.6 % of whites did not receive trastuzumab, adjusted ORNon-Hispanic black vs. white = 3.14, 95 %CI = 1.38-7.17), and many patients with stage III disease did not receive trastuzumab. Further, 16.2 % of patients did not receive any systemic treatment and this occurred more frequently for black patients. Over 40 % of older patients with indication to receive adjuvant trastuzumab did not receive it and nearly 20 % of these patients did not receive any other treatment. Although treatment omission may be appropriate in some cases, we observed concerning differences in trastuzumab receipt, particularly for black women. Strategies to optimize care for older patients and to eliminate treatment disparities are urgently needed.
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Affiliation(s)
- Ines Vaz-Luis
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Nancy U Lin
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Nancy L Keating
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA.,Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - William T Barry
- Department of Biostatistics & Computational Biology, Dana-Farber Cancer Institute, Boston, MA, 02215, USA
| | - Joyce Lii
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Harold J Burstein
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Eric P Winer
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Rachel A Freedman
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA.
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Reuvekamp EJ, Bulten BF, Nieuwenhuis AA, Meekes MRA, de Haan AFJ, Tol J, Maas AHEM, Elias-Smale SE, de Geus-Oei LF. Does diastolic dysfunction precede systolic dysfunction in trastuzumab-induced cardiotoxicity? Assessment with multigated radionuclide angiography (MUGA). J Nucl Cardiol 2016; 23:824-32. [PMID: 26048264 PMCID: PMC4956716 DOI: 10.1007/s12350-015-0164-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 04/10/2015] [Indexed: 01/09/2023]
Abstract
BACKGROUND Trastuzumab is successfully used for the treatment of HER2-positive breast cancer. Because of its association with cardiotoxicity, LVEF is monitored by MUGA, though this is a relatively late measure of cardiac function. Diastolic dysfunction (DD) is believed to be an early predictor of cardiac impairment. We evaluate the merit of MUGA-derived diastolic function parameters in the early detection of trastuzumab-induced cardiotoxicity (TIC). METHODS AND RESULTS 77 trastuzumab-treated patients with normal baseline systolic and diastolic function were retrospectively selected (n = 77). All serial MUGA examinations were re-analyzed for systolic and diastolic function parameters. 36 patients (47%) developed SD and 45 patients (58%) DD during treatment. Both systolic and diastolic parameters significantly decreased. Of the patients with SD, 24 (67%) also developed DD. DD developed prior to systolic impairment in 54% of cases, in 42% vice versa, while time to occurrence did not differ significantly (P = .52). This also applied to the subgroup of advanced stage breast cancer patients (P = .1). CONCLUSIONS Trastzumab-induced SD and DD can be detected by MUGA. An impairment of MUGA-derived diastolic parameters does not occur prior to SD and therefore cannot be used as earlier predictors of TIC.
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Affiliation(s)
- E J Reuvekamp
- Department of Radiology and Nuclear Medicine, Radboudumc, Nijmegen, The Netherlands
| | - B F Bulten
- Biomedical Photonic Imaging Group, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, PO Box 217, 7500 AE, Enschede, The Netherlands.
| | - A A Nieuwenhuis
- Department of Radiology and Nuclear Medicine, Radboudumc, Nijmegen, The Netherlands
| | - M R A Meekes
- Department of Radiology and Nuclear Medicine, Radboudumc, Nijmegen, The Netherlands
| | - A F J de Haan
- Department for Health Evidence, Radboudumc, Nijmegen, The Netherlands
| | - J Tol
- Department of Medical Oncology, Radboudumc, Nijmegen, The Netherlands
| | - A H E M Maas
- Department of Cardiology, Radboudumc, Nijmegen, The Netherlands
| | - S E Elias-Smale
- Department of Cardiology, Radboudumc, Nijmegen, The Netherlands
| | - L F de Geus-Oei
- Biomedical Photonic Imaging Group, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, PO Box 217, 7500 AE, Enschede, The Netherlands
- Department of Radiology, Leiden University Medical Centre, Leiden, The Netherlands
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120
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Dias A, Claudino W, Sinha R, Perez C, Jain D. Human epidermal growth factor antagonists and cardiotoxicity—A short review of the problem and preventative measures. Crit Rev Oncol Hematol 2016; 104:42-51. [DOI: 10.1016/j.critrevonc.2016.04.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 03/09/2016] [Accepted: 04/27/2016] [Indexed: 01/21/2023] Open
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Pondé NF, Lambertini M, de Azambuja E. Twenty years of anti-HER2 therapy-associated cardiotoxicity. ESMO Open 2016; 1:e000073. [PMID: 27843627 PMCID: PMC5070246 DOI: 10.1136/esmoopen-2016-000073] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 06/03/2016] [Accepted: 06/13/2016] [Indexed: 12/26/2022] Open
Abstract
Over the past 20 years, the prognosis of HER2-positive breast cancer has been transformed by the development of anti-HER2 targeted therapies. In early clinical trials of trastuzumab (ie, the first anti-HER2 agent to be developed) cardiotoxicity became a major concern. In the first published phase 3 trial of trastuzumab, 27% of patients receiving anthracyclines and trastuzumab experienced cardiac events and 16% suffered from severe congestive heart failure. In subsequent trials conducted in advanced and early settings, the incidence of cardiac events was reduced through changes in chemotherapy regimens, more strict patient selection and close cardiac assessment. However, cardiotoxicity remains a significant problem in clinical practice that is likely to increase as new agents are approved and exposure times increase through improved patients' survival. Though numerous trials have led to improved understanding of many aspects of anti-HER2 therapy-related cardiotoxicity, its underlying physiopathology mechanisms are not well understood. The purpose of this article is to provide an in-depth review on anti-HER2 therapy-related cardiotoxicity, including data on both trastuzumab and the recently developed anti-HER2 targeted agents.
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Affiliation(s)
- Noam F Pondé
- BrEAST Data Center, Institut Jules Bordet , Brussels , Belgium
| | - Matteo Lambertini
- BrEAST Data Center, Institut Jules Bordet, Brussels, Belgium; Department of Medical Oncology, U.O. Oncologia Medica 2, IRCCS AOU San Martino-IST, Genova, Italy
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Abstract
The HER2 gene is overexpressed in 15-20 % of all breast cancers. With the advent of HER2-directed therapies, HER2 overexpression is no longer considered an adverse prognostic factor. Despite significant improvements in clinical outcomes with the use of trastuzumab [herceptin (H)], women aged >65 years remain under-represented in most clinical trials. Cardiac safety in the elderly woman is a major concern because of pre-existing comorbidities. However, many studies suggest that elderly patients with HER2-positive disease derive the same benefit from trastuzumab as do their younger counterparts in both adjuvant and metastatic settings. Data are limited guiding safety and efficacy of other HER2 inhibitors such as pertuzumab and trastuzumab emtansine in elderly patients; however, in general, these drugs have a favorable toxicity profile.
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Cardiac toxicity of trastuzumab in elderly patients with breast cancer. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2016; 13:355-63. [PMID: 27403145 PMCID: PMC4921548 DOI: 10.11909/j.issn.1671-5411.2016.04.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Breast cancer (BC) is diagnosed in ≥ 65 year old women in about half of cases. Experts currently recommend that systemic therapy is offered to elderly patients with BC, if, based on their overall conditions and life expectancy, it can be reasonably anticipated that the benefits will outweigh the risks of treatment. Like for young subjects, the monoclonal antibody against human epidermal growth factor receptor-2 (HER-2), trastuzumab, represents a valid therapeutic option when BC over-expresses this receptor. Unfortunately, administration of trastuzumab is associated with the occurrence of left ventricular dysfunction and chronic heart failure (CHF), possibly because of interference with the homeostatic functions of HER-2 in the heart. Registry-based, retrospective analyses have reported an incidence of CHF around 25% in elderly women receiving trastuzumab compared with 10%-15% in those not given any therapy for BC, and the risk of CHF has been estimated to be two-fold higher in > 60-65 year old trastuzumab users vs. non-users. Extremely advanced age and preexisting cardiac disease have been shown to predispose to trastuzumab cardiotoxicity. Therefore, selection of older patients for treatment with trastuzumab should be primarily based on their general status and the presence of comorbidities; previous chemotherapy, especially with anthracyclines, should be also taken into account. Once therapy has started, efforts should be made to ensure regular cardiac surveillance. The role of selected biomarkers, such as cardiac troponin, or new imaging techniques (three-dimension, tissue Doppler echocardiography, magnetic resonance imaging) is promising, but must be further investigated especially in the elderly. Moreover, additional studies are needed in order to better understand the mechanisms by which trastuzumab affects the old heart.
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124
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Dang C, Guo H, Najita J, Yardley D, Marcom K, Albain K, Rugo H, Miller K, Ellis M, Shapira I, Wolff AC, Carey LA, Moy B, Groarke J, Moslehi J, Krop I, Burstein HJ, Hudis C, Winer EP, Tolaney SM. Cardiac Outcomes of Patients Receiving Adjuvant Weekly Paclitaxel and Trastuzumab for Node-Negative, ERBB2-Positive Breast Cancer. JAMA Oncol 2016; 2:29-36. [PMID: 26539793 DOI: 10.1001/jamaoncol.2015.3709] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
IMPORTANCE Trastuzumab is a life-saving therapy but is associated with symptomatic and asymptomatic left ventricular ejection fraction (LVEF) decline. We report the cardiac toxic effects of a nonanthracycline and trastuzumab-based treatment for patients with early-stage human epidermal growth factor receptor 2 (ERBB2, formerly HER2 or HER2/neu)-positive breast cancer. OBJECTIVE To determine the cardiac safety of paclitaxel with trastuzumab and the utility of LVEF monitoring in patients with node-negative, ERBB2-positive breast cancer. DESIGN, SETTING, AND PARTICIPANTS In this secondary analysis of an uncontrolled, single group study across 14 medical centers, enrollment of 406 patients with node-negative, ERBB2-positive breast cancer 3 cm, or smaller, and baseline LVEF of greater than or equal to 50% occurred from October 9, 2007, to September 3, 2010. Patients with a micrometastasis in a lymph node were later allowed with a study amendment. Median patient age was 55 years, 118 (29%) had hypertension, and 30 (7%) had diabetes. Patients received adjuvant paclitaxel for 12 weeks with trastuzumab, and trastuzumab was continued for 1 year. Median follow-up was 4 years. INTERVENTIONS Treatment consisted of weekly 80-mg/m2 doses of paclitaxel administered concurrently with trastuzumab intravenously for 12 weeks, followed by trastuzumab monotherapy for 39 weeks. During the monotherapy phase, trastuzumab could be administered weekly 2-mg/kg or every 3 weeks as 6-mg/kg. Radiation and hormone therapy were administered per standard guidelines after completion of the 12 weeks of chemotherapy. Patient LVEF was assessed at baseline, 12 weeks, 6 months, and 1 year. MAIN OUTCOMES AND MEASURES Cardiac safety data, including grade 3 to 4 left ventricular systolic dysfunction (LVSD) and significant asymptomatic LVEF decline, as defined by our study, were reported. RESULTS Overall, 2 patients (0.5%) (95% CI, 0.1%-1.8%) developed grade 3 LVSD and came off study, and 13 (3.2%) (95% CI, 1.9%-5.4%) had significant asymptomatic LVEF decline, 11 of whom completed study treatment. Median LVEF at baseline was 65%; 12 weeks, 64%; 6 months, 64%; and 1 year, 64%. CONCLUSIONS AND RELEVANCE Cardiac toxic effects from paclitaxel with trastuzumab, manifesting as grade 3 or 4 LVSD or asymptomatic LVEF decline, were low. Patient LVEF was assessed at baseline, 12 weeks, 6 months, and 1 year, and our findings suggest that LVEF monitoring during trastuzumab therapy without anthracyclines could be simplified for many individuals.
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Affiliation(s)
- Chau Dang
- Department of Medicine, Memorial Sloan Kettering Cancer Center, West Harrison, New York
| | - Hao Guo
- Department of Biostatistics & Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Julie Najita
- Department of Biostatistics & Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Denise Yardley
- Breast Cancer Research, Sarah Cannon Research Institute, Nashville, Tennessee
| | - Kelly Marcom
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Kathy Albain
- Department of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago, Chicago, Illinois
| | - Hope Rugo
- Department of Medicine, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco
| | - Kathy Miller
- Department of Medicine, Melvin and Bren Simon Cancer Center, Indiana University, Indianapolis
| | - Matthew Ellis
- Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Iuliana Shapira
- Department of Hematology Oncology, Hofstra North Shore-Long Island Jewish School of Medicine, Hempstead, New York
| | - Antonio C Wolff
- Department of Oncology, The Sydney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Lisa A Carey
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill
| | - Beverly Moy
- Department of Medicine, Massachusetts General Hospital, Boston
| | - John Groarke
- Department of Biostatistics & Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Javid Moslehi
- Department of Medicine, Cardio-Oncology Program, Vanderbilt School of Medicine, Nashville, Tennessee
| | - Ian Krop
- Department of Biostatistics & Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Harold J Burstein
- Department of Biostatistics & Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Clifford Hudis
- Department of Medicine, Memorial Sloan Kettering Cancer Center, West Harrison, New York
| | - Eric P Winer
- Department of Biostatistics & Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Sara M Tolaney
- Department of Biostatistics & Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
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Long-term cardiovascular outcomes and overall survival of early-stage breast cancer patients with early discontinuation of trastuzumab: a population-based study. Breast Cancer Res Treat 2016; 157:535-44. [PMID: 27271767 DOI: 10.1007/s10549-016-3823-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 04/13/2016] [Indexed: 12/12/2022]
Abstract
We critically examined long-term cardiovascular (CV) outcomes and overall survival (OS) of breast cancer (BC) patients who had cardiotoxicity during adjuvant trastuzumab treatment requiring discontinuation in a population-based sample. This was a retrospective cohort of early-stage BC patients diagnosed before 2010 and treated with trastuzumab in Ontario. Patients were stratified based on trastuzumab doses received: 1-8, 9-15, ≥16 (therapy completion). Time-dependent multivariable Cox models were used to analyze primary endpoint OS, and the following composite endpoints: hospitalization/emergency room visit for heart failure (HF) or death; non-HF CV (myocardial infarction, stroke) or death; and clinically significant relapse (palliative systemic therapy initiation >90 days after last trastuzumab dose) or death. Of the 3134 women, 6, 10, and 85 % received 1-8, 9-15, and ≥16 doses, respectively. Over 5-year median follow-up, early trastuzumab discontinuation was associated with more HF/death [1-8 doses hazard ratio (HR) 4.0, 95 % confidence interval (CI) 2.7-6.0; 9-15 doses HR 2.97, 95 % CI 2.1-4.3], non-HF/death (1-8 doses HR 4.3, 95 % CI 3.0-6.1; 9-15 doses HR 3.1, 95 % CI 2.2-4.4), clinically significant relapse/death (1-8 doses HR 3.1, 95 % CI 2.2-4.4; 9-15 doses HR 2.4, 95 % CI 1.8-3.3), and importantly lower OS (77, 80, 93 %; P < 0.001). Early discontinuation (1-8 doses HR 2.41, 95 % CI 1.5-3.8; 9-15 doses HR 2.9, 95 % CI 2.0-4.1) and clinically significant relapse (HR 34.0, 95 % CI 24.9-46.6) were both independent predictors of mortality. Of note, early discontinuation remained a critical independent predictor of OS even after adjusting for incident HF. Early trastuzumab discontinuation is a powerful independent predictor of cardiac events and clinically significant relapse, and both may contribute to poor survival. Both adequate cancer control and optimal CV management are required to improve long-term outcomes.
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126
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Honda K, Takeshita K, Murotani K, Mitsuma A, Hayashi H, Tsunoda N, Kikumori T, Murohara T, Ando Y. Assessment of left ventricular diastolic function during trastuzumab treatment in patients with HER2-positive breast cancer. Breast Cancer 2016; 24:312-318. [DOI: 10.1007/s12282-016-0705-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 05/16/2016] [Indexed: 10/21/2022]
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127
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Thavendiranathan P, Abdel-Qadir H, Fischer HD, Camacho X, Amir E, Austin PC, Lee DS. Breast Cancer Therapy-Related Cardiac Dysfunction in Adult Women Treated in Routine Clinical Practice: A Population-Based Cohort Study. J Clin Oncol 2016; 34:2239-46. [PMID: 27091709 DOI: 10.1200/jco.2015.65.1505] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Most women diagnosed with breast cancer are younger than 65 years of age. Population-based studies on cancer therapy-related cardiotoxicity have focused on older women. We sought to determine the risk of cardiotoxicity with breast cancer therapy in women with an age distribution representative of routine clinical practice. METHODS This was a population-based retrospective cohort study including 14 regional cancer centers in Ontario, Canada. Adult women receiving chemotherapy for stage I to III breast cancer between 2007 and 2012 were included. Cancer treatment was categorized as follows: anthracycline-based chemotherapy without trastuzumab, trastuzumab with nonanthracycline chemotherapy, anthracyclines followed by trastuzumab (sequential therapy), and chemotherapy without anthracycline/trastuzumab (other chemotherapy). The primary outcome was a composite of hospitalization or emergency room visit for congestive heart failure (CHF), outpatient diagnosis of CHF, or cardiovascular death. A sensitivity analysis limited the outcomes to hospital-based CHF events. Cause-specific hazard models were used accounting for the competing risk of noncardiovascular death. RESULTS Of 18,540 women included (median age, 54 years; interquartile range, 47 to 63 years), 79% were younger than age 65 years. The cumulative incidence of the primary outcome was 3.08% (95% CI, 2.81% to 3.36%) by 3 years of follow-up, whereas in an age-matched sample of Ontario women (n = 92,700) without breast cancer, it was 0.96% (95% CI, 0.89% to 1.04%). Compared with those receiving other chemotherapy, patients receiving trastuzumab with nonanthracycline chemotherapy and sequential therapy were at a higher risk of cardiotoxicity (hazard ratio, 1.76 [95% CI, 1.19 to 2.60] and 3.96 [95% CI, 3.01 to 5.22], respectively). Hospital-based CHF events were only increased with sequential therapy (hazard ratio, 1.86; 95% CI, 1.07 to 3.22). CONCLUSION In women with breast cancer and an age distribution representative of routine clinical practice, trastuzumab-based regimens, including those without anthracyclines, were associated with an increased risk of cardiotoxicity. Sequential therapy increased the risk of hospital-based CHF events.
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Affiliation(s)
- Paaladinesh Thavendiranathan
- Paaladinesh Thavendiranathan and Douglas S. Lee, Peter Munk Cardiac Centre and the Ted Rogers Program in Cardiotoxicity Prevention, University Health Network, Toronto General Hospital, University of Toronto; Husam Abdel-Qadir, Women's College Hospital; Hadas D. Fischer, Ximena Camacho, Peter C. Austin, and Douglas S. Lee, Institute for Clinical Evaluative Sciences; and Eitan Amir, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Husam Abdel-Qadir
- Paaladinesh Thavendiranathan and Douglas S. Lee, Peter Munk Cardiac Centre and the Ted Rogers Program in Cardiotoxicity Prevention, University Health Network, Toronto General Hospital, University of Toronto; Husam Abdel-Qadir, Women's College Hospital; Hadas D. Fischer, Ximena Camacho, Peter C. Austin, and Douglas S. Lee, Institute for Clinical Evaluative Sciences; and Eitan Amir, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Hadas D Fischer
- Paaladinesh Thavendiranathan and Douglas S. Lee, Peter Munk Cardiac Centre and the Ted Rogers Program in Cardiotoxicity Prevention, University Health Network, Toronto General Hospital, University of Toronto; Husam Abdel-Qadir, Women's College Hospital; Hadas D. Fischer, Ximena Camacho, Peter C. Austin, and Douglas S. Lee, Institute for Clinical Evaluative Sciences; and Eitan Amir, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Ximena Camacho
- Paaladinesh Thavendiranathan and Douglas S. Lee, Peter Munk Cardiac Centre and the Ted Rogers Program in Cardiotoxicity Prevention, University Health Network, Toronto General Hospital, University of Toronto; Husam Abdel-Qadir, Women's College Hospital; Hadas D. Fischer, Ximena Camacho, Peter C. Austin, and Douglas S. Lee, Institute for Clinical Evaluative Sciences; and Eitan Amir, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Eitan Amir
- Paaladinesh Thavendiranathan and Douglas S. Lee, Peter Munk Cardiac Centre and the Ted Rogers Program in Cardiotoxicity Prevention, University Health Network, Toronto General Hospital, University of Toronto; Husam Abdel-Qadir, Women's College Hospital; Hadas D. Fischer, Ximena Camacho, Peter C. Austin, and Douglas S. Lee, Institute for Clinical Evaluative Sciences; and Eitan Amir, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Peter C Austin
- Paaladinesh Thavendiranathan and Douglas S. Lee, Peter Munk Cardiac Centre and the Ted Rogers Program in Cardiotoxicity Prevention, University Health Network, Toronto General Hospital, University of Toronto; Husam Abdel-Qadir, Women's College Hospital; Hadas D. Fischer, Ximena Camacho, Peter C. Austin, and Douglas S. Lee, Institute for Clinical Evaluative Sciences; and Eitan Amir, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Douglas S Lee
- Paaladinesh Thavendiranathan and Douglas S. Lee, Peter Munk Cardiac Centre and the Ted Rogers Program in Cardiotoxicity Prevention, University Health Network, Toronto General Hospital, University of Toronto; Husam Abdel-Qadir, Women's College Hospital; Hadas D. Fischer, Ximena Camacho, Peter C. Austin, and Douglas S. Lee, Institute for Clinical Evaluative Sciences; and Eitan Amir, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
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128
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Pondé N, Dal Lago L, Azim HA. Adjuvant chemotherapy in elderly patients with breast cancer: key challenges. Expert Rev Anticancer Ther 2016; 16:661-71. [PMID: 27010772 DOI: 10.1586/14737140.2016.1170595] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Elderly women with early breast cancer (BC) form a heterogeneous and large subgroup (41.8% of women with BC are over 65). Decision making in this subgroup is made more difficult by lack of familiarity with their physical, cognitive and social issues. Adequate management depends on biological factors and accurate clinical evaluation through comprehensive geriatric assessment (CGA). CGA can help to better select and determine potential risks factors for patients who are candidates for adjuvant chemotherapy. It is still recently introduced in geriatric oncology and there is a lack of awareness of its importance. Available data on adjuvant chemotherapy for BC is limited but suggests it can be of benefit for well selected patients, though the risk of short and long-term toxicity is significant. Here we provide a discussion of the key practical issues in decision making in the setting of adjuvant chemotherapy for elderly BC patients.
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Affiliation(s)
- Noam Pondé
- a BrEAST Data Centre, Department of Medicine, Institut Jules Bordet , Université Libre de Bruxelles , Brussels , Belgium
| | - Lissandra Dal Lago
- b Medicine Department, Institut Jules Bordet , Université Libre de Bruxelles , Brussels , Belgium
| | - Hatem A Azim
- a BrEAST Data Centre, Department of Medicine, Institut Jules Bordet , Université Libre de Bruxelles , Brussels , Belgium
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129
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Dang CT, Yu AF, Jones LW, Liu J, Steingart RM, Argolo DF, Norton L, Hudis CA. Cardiac Surveillance Guidelines for Trastuzumab-Containing Therapy in Early-Stage Breast Cancer: Getting to the Heart of the Matter. J Clin Oncol 2016; 34:1030-3. [PMID: 26834055 PMCID: PMC5070558 DOI: 10.1200/jco.2015.64.5515] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Chau T Dang
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Anthony F Yu
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Lee W Jones
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jennifer Liu
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - Larry Norton
- Memorial Sloan Kettering Cancer Center, New York, NY
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130
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Engels CC, Kiderlen M, Bastiaannet E, van Eijk R, Mooyaart A, Smit VTHBM, de Craen AJM, Kuppen PJK, Kroep JR, van de Velde CJH, Liefers GJ. The clinical value of HER-2 overexpression and PIK3CA mutations in the older breast cancer population: a FOCUS study analysis. Breast Cancer Res Treat 2016; 156:361-70. [PMID: 26968397 PMCID: PMC4819549 DOI: 10.1007/s10549-016-3734-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 02/23/2016] [Indexed: 01/17/2023]
Abstract
Studies to confirm the effect of acknowledged prognostic markers in older breast cancer patients are scarce. The aim of this study was to evaluate the prognostic value of HER-2 overexpression and PIK3CA mutations in older breast cancer patients. Female breast cancer patients aged 65 years or older, diagnosed between 1997 and 2004 in a geographical region in The Netherlands, with an invasive, non-metastatic tumour and tumour material available, were included in the study. The primary endpoint was relapse-free period and secondary endpoint was relative survival. Determinants were immunochemical HER-2 scores (0/1+, 2+ or 3+) and PIK3CA as a binary measure. Overall, 1698 patients were included, and 103 had a HER-2 score of 3+. HER-2 overexpression was associated with a higher recurrence risk (5 years recurrence risk 34 % vs. 12 %, adjusted p = 0.005), and a worse relative survival (10 years relative survival 48 % vs. 84 % for HER-2 negative; p = 0.004). PIK3CA mutations had no significant prognostic effect. We showed, in older breast cancer patients, that HER-2 overexpression was significantly associated with a worse outcome, but PIK3CA mutations had no prognostic effect. These results imply that older patients with HER-2 overexpressing breast cancer might benefit from additional targeted anti-HER-2 therapy.
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Affiliation(s)
- Charla C Engels
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Mandy Kiderlen
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands. .,Department of Geriatrics and Gerontology, Leiden University Medical Center, Leiden, The Netherlands.
| | - Esther Bastiaannet
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands.,Department of Geriatrics and Gerontology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ronald van Eijk
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - Antien Mooyaart
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - Vincent T H B M Smit
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - Anton J M de Craen
- Department of Geriatrics and Gerontology, Leiden University Medical Center, Leiden, The Netherlands
| | - Peter J K Kuppen
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Judith R Kroep
- Department of Clinical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Cornelis J H van de Velde
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Gerrit Jan Liefers
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
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131
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Krug D. Kardiale Toxizität von Trastuzumab in der adjuvanten Therapie von Mammakarzinompatientinnen. Strahlenther Onkol 2016; 192:193-5. [DOI: 10.1007/s00066-015-0938-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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132
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Velásquez CA, González M, Berrouet MC, Jaramillo N. Cardiotoxicidad inducida por la quimioterapia desde las bases moleculares hasta la perspectiva clínica. REVISTA COLOMBIANA DE CARDIOLOGÍA 2016. [DOI: 10.1016/j.rccar.2015.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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133
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Jafri M, Rea D. Cardiac safety of simultaneous anti-HER2 and anthracycline therapy. BREAST CANCER MANAGEMENT 2016. [DOI: 10.2217/bmt.16.3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
A long established oncological dogma requires that trastuzumab should not be given in combination with anthracyclines due to excessive synergistic cardiac morbidity. However, trastuzumab has been recently granted a license in the neoadjuvant setting with concurrent anthracylines. We discuss the role of anti-HER2 agents in breast cancer and their associated toxicities. Anthracycline chemotherapies are a central component of most adjuvant and neoadjuvant breast cancer regimens. Cardiac toxicity due to anthracyclines is explored. Finally, in this article, we will discuss the evidence for concurrent administration of anthracyclines and HER2-targeted agents.
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Affiliation(s)
- Mariam Jafri
- Department of Oncology, University Hospital Birmingham Foundation Trust, Mendelsohn Drive, Birmingham, UK
- Breast Unit, City Hospital, Sandwell & West Birmingham NHS Trust, Dudley Road, Birmingham, UK
| | - Daniel Rea
- Department of Oncology, University Hospital Birmingham Foundation Trust, Mendelsohn Drive, Birmingham, UK
- Breast Unit, City Hospital, Sandwell & West Birmingham NHS Trust, Dudley Road, Birmingham, UK
- Institute of Cancer & Genomic Medicine, University of Birmingham, Edgbaston, UK
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134
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Ibraheem A, Stankowski-Drengler TJ, Gbolahan OB, Engel JM, Onitilo AA. Chemotherapy-induced cardiotoxicity in breast cancer patients. BREAST CANCER MANAGEMENT 2016. [DOI: 10.2217/bmt-2016-0002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Chemotherapy-induced cardiotoxicity (CIC) is a well-documented side effect of breast cancer treatment. Nearly all chemotherapeutic agents can cause CIC with the highest occurrence found in anthracycline and trastuzumab use. Treatment- and patient-related risk factors contribute to the development of CIC making risk modification an important consideration during breast cancer treatment. Prevention and early detection of cardiotoxicity are key to minimizing permanent and devastating cardiac damage; therefore, early involvement of a cardiologist including periodic cardiac monitoring during and after chemotherapy exposure is recommended.
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Affiliation(s)
| | | | | | - Jessica M Engel
- Marshfield Clinic Cancer Care at St Michaels, Stevens Point, WI 54481, USA
| | - Adedayo A Onitilo
- Marshfield Clinic Weston Center, Oncology/Hematology Department, Weston, WI 54481, USA
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135
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Armenian SH, Xu L, Ky B, Sun C, Farol LT, Pal SK, Douglas PS, Bhatia S, Chao C. Cardiovascular Disease Among Survivors of Adult-Onset Cancer: A Community-Based Retrospective Cohort Study. J Clin Oncol 2016; 34:1122-30. [PMID: 26834065 DOI: 10.1200/jco.2015.64.0409] [Citation(s) in RCA: 344] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
PURPOSE Cardiovascular diseases (CVDs), including ischemic heart disease, stroke, and heart failure, are well-established late effects of therapy in survivors of childhood and young adult (< 40 years at diagnosis) cancers; less is known regarding CVD in long-term survivors of adult-onset (≥ 40 years) cancer. METHODS A retrospective cohort study design was used to describe the magnitude of CVD risk in 36,232 ≥ 2-year survivors of adult-onset cancer compared with matched (age, sex, and residential ZIP code) noncancer controls (n = 73,545) within a large integrated managed care organization. Multivariable regression was used to examine the impact of cardiovascular risk factors (CVRFs; hypertension, diabetes, dyslipidemia) on long-term CVD risk in cancer survivors. RESULTS Survivors of multiple myeloma (incidence rate ratio [IRR], 1.70; P < .01), carcinoma of the lung/bronchus (IRR, 1.58; P < .01), non-Hodgkin lymphoma (IRR, 1.41; P < .01), and breast cancer (IRR, 1.13; P < .01) had significantly higher CVD risk when compared with noncancer controls. Conversely, prostate cancer survivors had a lower CVD risk (IRR, 0.89; P < .01) compared with controls. Cancer survivors with two or more CVRFs had the highest risk of CVD when compared with noncancer controls with less than two CVRFs (IRR, 1.83 to 2.59; P < .01). Eight-year overall survival was significantly worse among cancer survivors who developed CVD (60%) when compared with cancer survivors without CVD (81%; P < .01). CONCLUSION The magnitude of subsequent CVD risk varies according to cancer subtype and by the presence of CVRFs. Overall survival in survivors who develop CVD is poor, emphasizing the need for targeted prevention strategies for individuals at highest risk of developing CVD.
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Affiliation(s)
- Saro H Armenian
- Saro H. Armenian, Canlan Sun, and Sumanta Kumar Pal, City of Hope Comprehensive Cancer Center, Duarte; Lanfang Xu and Chun Chao, Kaiser Permanente Southern California, Pasadena; Leonardo T. Farol, City of Hope-Kaiser Permanente, Los Angeles, CA; Bonnie Ky, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Pamela S. Douglas, Duke Clinical Research Institute, Duke University, Durham, NC; and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL.
| | - Lanfang Xu
- Saro H. Armenian, Canlan Sun, and Sumanta Kumar Pal, City of Hope Comprehensive Cancer Center, Duarte; Lanfang Xu and Chun Chao, Kaiser Permanente Southern California, Pasadena; Leonardo T. Farol, City of Hope-Kaiser Permanente, Los Angeles, CA; Bonnie Ky, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Pamela S. Douglas, Duke Clinical Research Institute, Duke University, Durham, NC; and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL
| | - Bonnie Ky
- Saro H. Armenian, Canlan Sun, and Sumanta Kumar Pal, City of Hope Comprehensive Cancer Center, Duarte; Lanfang Xu and Chun Chao, Kaiser Permanente Southern California, Pasadena; Leonardo T. Farol, City of Hope-Kaiser Permanente, Los Angeles, CA; Bonnie Ky, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Pamela S. Douglas, Duke Clinical Research Institute, Duke University, Durham, NC; and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL
| | - Canlan Sun
- Saro H. Armenian, Canlan Sun, and Sumanta Kumar Pal, City of Hope Comprehensive Cancer Center, Duarte; Lanfang Xu and Chun Chao, Kaiser Permanente Southern California, Pasadena; Leonardo T. Farol, City of Hope-Kaiser Permanente, Los Angeles, CA; Bonnie Ky, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Pamela S. Douglas, Duke Clinical Research Institute, Duke University, Durham, NC; and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL
| | - Leonardo T Farol
- Saro H. Armenian, Canlan Sun, and Sumanta Kumar Pal, City of Hope Comprehensive Cancer Center, Duarte; Lanfang Xu and Chun Chao, Kaiser Permanente Southern California, Pasadena; Leonardo T. Farol, City of Hope-Kaiser Permanente, Los Angeles, CA; Bonnie Ky, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Pamela S. Douglas, Duke Clinical Research Institute, Duke University, Durham, NC; and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL
| | - Sumanta Kumar Pal
- Saro H. Armenian, Canlan Sun, and Sumanta Kumar Pal, City of Hope Comprehensive Cancer Center, Duarte; Lanfang Xu and Chun Chao, Kaiser Permanente Southern California, Pasadena; Leonardo T. Farol, City of Hope-Kaiser Permanente, Los Angeles, CA; Bonnie Ky, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Pamela S. Douglas, Duke Clinical Research Institute, Duke University, Durham, NC; and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL
| | - Pamela S Douglas
- Saro H. Armenian, Canlan Sun, and Sumanta Kumar Pal, City of Hope Comprehensive Cancer Center, Duarte; Lanfang Xu and Chun Chao, Kaiser Permanente Southern California, Pasadena; Leonardo T. Farol, City of Hope-Kaiser Permanente, Los Angeles, CA; Bonnie Ky, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Pamela S. Douglas, Duke Clinical Research Institute, Duke University, Durham, NC; and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL
| | - Smita Bhatia
- Saro H. Armenian, Canlan Sun, and Sumanta Kumar Pal, City of Hope Comprehensive Cancer Center, Duarte; Lanfang Xu and Chun Chao, Kaiser Permanente Southern California, Pasadena; Leonardo T. Farol, City of Hope-Kaiser Permanente, Los Angeles, CA; Bonnie Ky, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Pamela S. Douglas, Duke Clinical Research Institute, Duke University, Durham, NC; and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL
| | - Chun Chao
- Saro H. Armenian, Canlan Sun, and Sumanta Kumar Pal, City of Hope Comprehensive Cancer Center, Duarte; Lanfang Xu and Chun Chao, Kaiser Permanente Southern California, Pasadena; Leonardo T. Farol, City of Hope-Kaiser Permanente, Los Angeles, CA; Bonnie Ky, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Pamela S. Douglas, Duke Clinical Research Institute, Duke University, Durham, NC; and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL
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Biganzoli L, Aapro M, Loibl S, Wildiers H, Brain E. Taxanes in the treatment of breast cancer: Have we better defined their role in older patients? A position paper from a SIOG Task Force. Cancer Treat Rev 2016; 43:19-26. [DOI: 10.1016/j.ctrv.2015.11.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 11/24/2015] [Accepted: 11/25/2015] [Indexed: 10/22/2022]
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Tumor characteristics and therapy of elderly patients with breast cancer. J Cancer Res Clin Oncol 2016; 142:1109-16. [PMID: 26809246 DOI: 10.1007/s00432-015-2111-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 12/28/2015] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Elderly breast cancer patients aged ≥75 years are underrepresented in most studies. Therefore, data on cancer characteristics, adjuvant treatment and survival in elderly patients are missing. PATIENTS AND METHODS In this retrospective study, we compared tumor characteristics and adjuvant therapy in 973 women with invasive, non-metastasized breast cancer aged ≥75 years with 3377 younger postmenopausal patients (50-74 years old). Time dynamics of tumor characteristics were investigated, comparing two observation periods between the years 2000-2004 versus 2005-2008. RESULTS Compared to younger women, older patients were more often treated with mastectomy and less likely to receive adjuvant treatment. Although the overall survival rate increased over the observation period in both age groups, the older study group was characterized by shorter disease-free survival. Additionally, we observed an increase in about 1.65 years in the age at diagnosis as well as an increasing rate of breast-conserving surgery and sentinel lymph node biopsy for the whole study population between 2000 and 2008. Furthermore, we found a reduction in the proportion of estrogen receptor-positive tumors in the younger women and a decrease in G3-tumors in both age groups over the study time. CONCLUSION The older group's reduced disease-free survival could be explained by the tumor characteristics and differences in the adjuvant treatment. Remarkably, elderly women are more likely to be overtreated surgically while being undertreated in terms of adjuvant therapy.
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Singh JC, Lichtman SM. Effect of age on drug metabolism in women with breast cancer. Expert Opin Drug Metab Toxicol 2016; 11:757-66. [PMID: 25940027 DOI: 10.1517/17425255.2015.1037277] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The aging of the population will increase the number of breast cancer patients requiring treatment in both the adjuvant and metastatic setting. Hormones, chemotherapy and targeted drugs all have a role in treatment. Older patients have been underrepresented in clinical trials making evidence-based decisions difficult. The increase in comorbidity and aging, polypharmacy and changes in function make pharmacotherapy decisions more complicated. Knowledge of the issues is critical in the prescribing of effective and safe therapy. There are factors associated with advancing age that can result in pharmacokinetic and pharmacodynamic variations in processing of hormonal agents, chemotherapy and targeted drugs. AREAS COVERED A review of the literature pertaining to pharmacokinetic changes in aging in breast cancer was untaken. Studies are reviewed involving single agents and some combinations. EXPERT OPINION Older patients should be considered for standard therapies. Their specific problems need to be evaluated by geriatric-specific assessment including functional status, end organ dysfunction and polypharmacy. There are few instances for age-related changes in pharmacokinetics and when present are usually not clinically significant. When changes are present, they are often the result of comorbidity, drug interactions and drug scheduling issues. The older patients may be more sensitive to certain toxicities such as cardiac toxicity, neuropathy and myelosuppression.
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Affiliation(s)
- Jasmeet C Singh
- Memorial Sloan Kettering Cancer Center , 650 Commack Road, Commack, NY 11725 , USA +1 631 623 4100 ; +1 631 864 3827 ;
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Chin-Yee NJ, Yan AT, Kumachev A, Ko D, Earle C, Tomlinson G, Trudeau ME, Krahn M, Krzyzanowska M, Pal R, Brezden-Masley C, Gavura S, Lien K, Chan K. Association of hospital and physician case volumes with cardiac monitoring and cardiotoxicity during adjuvant trastuzumab treatment for breast cancer: a retrospective cohort study. CMAJ Open 2016; 4:E66-72. [PMID: 27280116 PMCID: PMC4866921 DOI: 10.9778/cmajo.20150033] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Adjuvant trastuzumab is the standard of care for patients with HER2 overexpressing breast cancer, but use of trastuzumab may lead to cardiotoxicity. Our goal was to evaluate the relationship between hospital and physician case volume and cardiac outcomes in this population. METHODS In this retrospective cohort study, we identified all female patients in Ontario with a breast cancer diagnosis in 2003-2009 who underwent treatment with trastuzumab through a provincial drug-funding program and linked these patients to administrative databases to ascertain patient demographics, treating hospital and physician characteristics, admissions to hospital, cardiac risk factors, cardiac imaging and comorbidities. Insufficient cardiac monitoring was defined as per the Canadian Trastuzumab Working Group guideline. Cardiotoxicity was defined as receiving fewer than 16 of 18 doses of trastuzumab because of heart failure admission, heart failure diagnosis or discontinuation of the drug after cardiac imaging. We constructed hierarchical multivariable logistic regression models to evaluate the effect of annual hospital volume, cumulative physician volume and treatment period on cardiac monitoring and cardiotoxicity. RESULTS Of 3777 women treated by 214 oncologists at 68 hospitals, 918 (24.3%) had insufficient cardiac monitoring and cardiotoxicity developed in 640 (16.9%). Cardiotoxicity occurred in 389 (42.4%) and 251 (8.8%) patients in the insufficient- and sufficient-monitoring groups, respectively. Higher annual hospital and cumulative physician volumes, and more recent calendar period, were all independent predictors for decreased cardiotoxicity. Adjustment for rates of cardiac monitoring annulled the relationships between case volume and cardiotoxicity. INTERPRETATION Greater hospital and physician case volumes are associated with reduced rates of trastuzumab-related cardiotoxicity, most likely because of better cardiac monitoring at higher volume centres.
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Affiliation(s)
- Nicolas J Chin-Yee
- University of Toronto (Chin-Yee, Yan, Kumachev, Ko, Tomlinson, Trudeau, Krahn, Brezden-Masley, Chan); St. Michael's Hospital (Yan, Brezden-Masley); Institute for Clinical and Evaluative Sciences (Ko, Earle); Sunnybrook Health Sciences Centre (Ko, Earle, Trudeau, Chan); University Health Network (Tomlinson, Krzyzanowska), Toronto, Ont.; Kingston General Hospital (Pal), Kingston; Cancer Care Ontario (Gavura); Canadian Centre for Applied Research in Cancer Control (Chan), Toronto, Ont
| | - Andrew T Yan
- University of Toronto (Chin-Yee, Yan, Kumachev, Ko, Tomlinson, Trudeau, Krahn, Brezden-Masley, Chan); St. Michael's Hospital (Yan, Brezden-Masley); Institute for Clinical and Evaluative Sciences (Ko, Earle); Sunnybrook Health Sciences Centre (Ko, Earle, Trudeau, Chan); University Health Network (Tomlinson, Krzyzanowska), Toronto, Ont.; Kingston General Hospital (Pal), Kingston; Cancer Care Ontario (Gavura); Canadian Centre for Applied Research in Cancer Control (Chan), Toronto, Ont
| | - Alexander Kumachev
- University of Toronto (Chin-Yee, Yan, Kumachev, Ko, Tomlinson, Trudeau, Krahn, Brezden-Masley, Chan); St. Michael's Hospital (Yan, Brezden-Masley); Institute for Clinical and Evaluative Sciences (Ko, Earle); Sunnybrook Health Sciences Centre (Ko, Earle, Trudeau, Chan); University Health Network (Tomlinson, Krzyzanowska), Toronto, Ont.; Kingston General Hospital (Pal), Kingston; Cancer Care Ontario (Gavura); Canadian Centre for Applied Research in Cancer Control (Chan), Toronto, Ont
| | - Dennis Ko
- University of Toronto (Chin-Yee, Yan, Kumachev, Ko, Tomlinson, Trudeau, Krahn, Brezden-Masley, Chan); St. Michael's Hospital (Yan, Brezden-Masley); Institute for Clinical and Evaluative Sciences (Ko, Earle); Sunnybrook Health Sciences Centre (Ko, Earle, Trudeau, Chan); University Health Network (Tomlinson, Krzyzanowska), Toronto, Ont.; Kingston General Hospital (Pal), Kingston; Cancer Care Ontario (Gavura); Canadian Centre for Applied Research in Cancer Control (Chan), Toronto, Ont
| | - Craig Earle
- University of Toronto (Chin-Yee, Yan, Kumachev, Ko, Tomlinson, Trudeau, Krahn, Brezden-Masley, Chan); St. Michael's Hospital (Yan, Brezden-Masley); Institute for Clinical and Evaluative Sciences (Ko, Earle); Sunnybrook Health Sciences Centre (Ko, Earle, Trudeau, Chan); University Health Network (Tomlinson, Krzyzanowska), Toronto, Ont.; Kingston General Hospital (Pal), Kingston; Cancer Care Ontario (Gavura); Canadian Centre for Applied Research in Cancer Control (Chan), Toronto, Ont
| | - George Tomlinson
- University of Toronto (Chin-Yee, Yan, Kumachev, Ko, Tomlinson, Trudeau, Krahn, Brezden-Masley, Chan); St. Michael's Hospital (Yan, Brezden-Masley); Institute for Clinical and Evaluative Sciences (Ko, Earle); Sunnybrook Health Sciences Centre (Ko, Earle, Trudeau, Chan); University Health Network (Tomlinson, Krzyzanowska), Toronto, Ont.; Kingston General Hospital (Pal), Kingston; Cancer Care Ontario (Gavura); Canadian Centre for Applied Research in Cancer Control (Chan), Toronto, Ont
| | - Maureen E Trudeau
- University of Toronto (Chin-Yee, Yan, Kumachev, Ko, Tomlinson, Trudeau, Krahn, Brezden-Masley, Chan); St. Michael's Hospital (Yan, Brezden-Masley); Institute for Clinical and Evaluative Sciences (Ko, Earle); Sunnybrook Health Sciences Centre (Ko, Earle, Trudeau, Chan); University Health Network (Tomlinson, Krzyzanowska), Toronto, Ont.; Kingston General Hospital (Pal), Kingston; Cancer Care Ontario (Gavura); Canadian Centre for Applied Research in Cancer Control (Chan), Toronto, Ont
| | - Murray Krahn
- University of Toronto (Chin-Yee, Yan, Kumachev, Ko, Tomlinson, Trudeau, Krahn, Brezden-Masley, Chan); St. Michael's Hospital (Yan, Brezden-Masley); Institute for Clinical and Evaluative Sciences (Ko, Earle); Sunnybrook Health Sciences Centre (Ko, Earle, Trudeau, Chan); University Health Network (Tomlinson, Krzyzanowska), Toronto, Ont.; Kingston General Hospital (Pal), Kingston; Cancer Care Ontario (Gavura); Canadian Centre for Applied Research in Cancer Control (Chan), Toronto, Ont
| | - Monika Krzyzanowska
- University of Toronto (Chin-Yee, Yan, Kumachev, Ko, Tomlinson, Trudeau, Krahn, Brezden-Masley, Chan); St. Michael's Hospital (Yan, Brezden-Masley); Institute for Clinical and Evaluative Sciences (Ko, Earle); Sunnybrook Health Sciences Centre (Ko, Earle, Trudeau, Chan); University Health Network (Tomlinson, Krzyzanowska), Toronto, Ont.; Kingston General Hospital (Pal), Kingston; Cancer Care Ontario (Gavura); Canadian Centre for Applied Research in Cancer Control (Chan), Toronto, Ont
| | - Raveen Pal
- University of Toronto (Chin-Yee, Yan, Kumachev, Ko, Tomlinson, Trudeau, Krahn, Brezden-Masley, Chan); St. Michael's Hospital (Yan, Brezden-Masley); Institute for Clinical and Evaluative Sciences (Ko, Earle); Sunnybrook Health Sciences Centre (Ko, Earle, Trudeau, Chan); University Health Network (Tomlinson, Krzyzanowska), Toronto, Ont.; Kingston General Hospital (Pal), Kingston; Cancer Care Ontario (Gavura); Canadian Centre for Applied Research in Cancer Control (Chan), Toronto, Ont
| | - Christine Brezden-Masley
- University of Toronto (Chin-Yee, Yan, Kumachev, Ko, Tomlinson, Trudeau, Krahn, Brezden-Masley, Chan); St. Michael's Hospital (Yan, Brezden-Masley); Institute for Clinical and Evaluative Sciences (Ko, Earle); Sunnybrook Health Sciences Centre (Ko, Earle, Trudeau, Chan); University Health Network (Tomlinson, Krzyzanowska), Toronto, Ont.; Kingston General Hospital (Pal), Kingston; Cancer Care Ontario (Gavura); Canadian Centre for Applied Research in Cancer Control (Chan), Toronto, Ont
| | - Scott Gavura
- University of Toronto (Chin-Yee, Yan, Kumachev, Ko, Tomlinson, Trudeau, Krahn, Brezden-Masley, Chan); St. Michael's Hospital (Yan, Brezden-Masley); Institute for Clinical and Evaluative Sciences (Ko, Earle); Sunnybrook Health Sciences Centre (Ko, Earle, Trudeau, Chan); University Health Network (Tomlinson, Krzyzanowska), Toronto, Ont.; Kingston General Hospital (Pal), Kingston; Cancer Care Ontario (Gavura); Canadian Centre for Applied Research in Cancer Control (Chan), Toronto, Ont
| | - Kelly Lien
- University of Toronto (Chin-Yee, Yan, Kumachev, Ko, Tomlinson, Trudeau, Krahn, Brezden-Masley, Chan); St. Michael's Hospital (Yan, Brezden-Masley); Institute for Clinical and Evaluative Sciences (Ko, Earle); Sunnybrook Health Sciences Centre (Ko, Earle, Trudeau, Chan); University Health Network (Tomlinson, Krzyzanowska), Toronto, Ont.; Kingston General Hospital (Pal), Kingston; Cancer Care Ontario (Gavura); Canadian Centre for Applied Research in Cancer Control (Chan), Toronto, Ont
| | - Kelvin Chan
- University of Toronto (Chin-Yee, Yan, Kumachev, Ko, Tomlinson, Trudeau, Krahn, Brezden-Masley, Chan); St. Michael's Hospital (Yan, Brezden-Masley); Institute for Clinical and Evaluative Sciences (Ko, Earle); Sunnybrook Health Sciences Centre (Ko, Earle, Trudeau, Chan); University Health Network (Tomlinson, Krzyzanowska), Toronto, Ont.; Kingston General Hospital (Pal), Kingston; Cancer Care Ontario (Gavura); Canadian Centre for Applied Research in Cancer Control (Chan), Toronto, Ont
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Abstract
Twenty-four monoclonal antibodies (mAbs) targeted to a total of 16 different antigens are currently approved for the treatment of an increasing number of cancers. Six are directed against antigens expressed on B lymphocytes (ibritumomab tiuxetan, obinutuzumab, ofatumumab, and rituximab to CD20, brentuximab vedotin to CD30, and alemtuzumab to CD52); cetuximab, panitumumab, and necitumumab target EGFR; bevacizumab and ramucirumab are specific for VEGF and VEGFR2, respectively; pertuzumab, trastuzumab, and ado-trastuzumab target HER2; nivolumab and pembrolizumab are directed to the programmed cell death protein 1 (PD-1); and denosumab, ipilimumab, siltuximab, and dinutuximab recognize RANKL, CTLA-4, IL-6, and the disialoganglioside (GD2), respectively. In November 2015, the FDA approved daratumumab, the first anti-CD38 mAb and the first mAb to be approved for the treatment of multiple myeloma. Elotuzumab, targeted to the receptor SLAMF7, was also given approval for multiple myeloma soon after. Two antibodies are bispecific: the rat-mouse chimera, catumaxomab, recognizes both EpCAM and CD3, while blinatumomab, a bispecific T-cell-engaging (BiTE) fusion protein, targets both CD19 and CD3. Although mAbs used for cancer immunotherapy are generally better tolerated than small molecule chemotherapeutic drugs, their range of adverse effects is still wide and varied from mild gastrointestinal symptoms and transient rashes to severe cytopenias; anaphylaxis; autoimmunity; pulmonary, cardiac, hepatic, kidney, neurological, and embryofetal toxicities; and rare life-threatening toxidermias. Because of their immunogenic potential, mAbs generally carry warnings of immune reactions, especially anaphylaxis, but the observed incidences of such reactions are actually quite small. Cytopenias occur in some patients treated with mAbs during anticancer immunotherapy, but the underlying mechanisms frequently remain unexplored. Type II and III hypersensitivities induced by mAbs may be underdiagnosed. Severe infusion reactions have been reported for all the mAbs although some show a much higher incidence with the chimeric rituximab and humanized trastuzumab antibodies being the leading offenders. Distinguishing features in the literature between cytokine release syndrome and severe infusion reactions are often not clear. At least ten of the currently approved mAbs for cancer therapy show some pulmonary toxicity. These pulmonary adverse events can be grouped into four categories: interstitial pneumonitis and fibrosis, acute respiratory distress syndrome (ARDS), bronchiolitis obliterans organizing pneumonia (BOOP), and hypersensitivity pneumonitis. Cardiac adverse events, including congestive heart failure, decreased LVEF, myocardial infarction, cardiac arrest, and arrhythmias, have occurred with at least 11 of the mAbs. Papulopustular eruptions, cutaneous reactions that are not immune-mediated, as well as a range of other adverse mucocutaneous effects, are elicited in a large proportion of patients by mAbs targeted to EGFR. Other rare but mAb-induced serious adverse events are tumor lysis syndrome and progressive multifocal leukoencephalopathy.
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Vaduganathan M, Prasad V. Cardiovascular risk assessment in oncological clinical trials: is there a role for centralized events adjudication? Eur J Heart Fail 2015; 18:128-32. [PMID: 26663426 DOI: 10.1002/ejhf.457] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Revised: 09/24/2015] [Accepted: 10/22/2015] [Indexed: 11/07/2022] Open
Affiliation(s)
- Muthiah Vaduganathan
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA, USA
| | - Vinay Prasad
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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da Fonseca Reis Silva D, Ribeiro JM. Infracentimetric HER-2 positive breast tumours-review of the literature. Ecancermedicalscience 2015; 9:593. [PMID: 26635897 PMCID: PMC4659705 DOI: 10.3332/ecancer.2015.593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Indexed: 01/03/2023] Open
Abstract
Breast cancer is the most common malignant neoplasm in the world among women. As a result of the dissemination of population screening programmes, about half of non-metastatic breast cancers are now diagnosed at stage I. 10-15% of T1abN0 tumours over-express human epidermal growth factor (HER-2). These tumours have a globally excellent prognosis, however, treatment with chemotherapy and/or targeted therapy may further improve outcomes in selected cases. In this article, we will review studies with information on prognosis and benefit of adjuvant therapy for T1abN0 HER-2+ breast cancer.
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Affiliation(s)
- Danilo da Fonseca Reis Silva
- Instituto do Câncer do Estado de São Paulo - ICESP - Faculdade de Medicina da Universidade de São Paulo, Av. Doutor Arnaldo, 251 - Cerqueira César, São Paulo - SP 01246-000, Brazil
| | - Joana M Ribeiro
- Breast Unit, Champalimaud Clinical Centre, Av. de Brasília, s/n, Lisbon 1400-038, Portugal
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143
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Nguyen KL, Alrezk R, Mansourian PG, Naeim A, Rettig MB, Lee CC. The Crossroads of Geriatric Cardiology and Cardio-Oncology. CURRENT GERIATRICS REPORTS 2015; 4:327-337. [PMID: 26543801 PMCID: PMC4624825 DOI: 10.1007/s13670-015-0147-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Cancer and cardiovascular disease (CVD) are two major causes of mortality in older adults. With improved survival and outcomes from cancer and CVD, the role of the geriatrician is evolving. Geriatricians provide key skills to facilitate patient-centered and value-based care in the growing older population of cancer patients (and survivors). Cancer treatment in older adults is particularly injurious with respect to complications stemming from cancer therapy and as well as to CVD related to cancer therapy in the context of physiologic aging. To best meet their natural potential as caregiving leaders, geriatricians must hone skills and insights pertaining to oncologic and cardiovascular care, insights that can inform and enhance key management expertise. In this paper, we will review common chemotherapy and radiation-induced cardiovascular complications, screening recommendations, and advance the concept of a geriatric, cardiology, and oncology collaboration. We assert that geriatricians are well suited to a leadership role in the care of older cardio-oncology patients and in the education of primary care physicians and subspecialists on geriatric principles.
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Affiliation(s)
- Kim-Lien Nguyen
- VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, MC 111E, Los Angeles, CA 90073 USA ; Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA 90073 USA
| | - Rami Alrezk
- VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, MC 111E, Los Angeles, CA 90073 USA ; Division of Geriatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA USA ; GRECC, VA Greater Los Angeles Healthcare System, Los Angeles, CA USA
| | - Pejman G Mansourian
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA 90073 USA
| | - Arash Naeim
- Division of Geriatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA USA ; Division of Hematology-Oncology, David Geffen School of Medicine at UCLA, Los Angeles, CA USA
| | - Matthew B Rettig
- VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, MC 111E, Los Angeles, CA 90073 USA ; Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA USA ; Division of Hematology-Oncology, David Geffen School of Medicine at UCLA, Los Angeles, CA USA
| | - Cathy C Lee
- VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, MC 111E, Los Angeles, CA 90073 USA ; Division of Geriatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA USA ; GRECC, VA Greater Los Angeles Healthcare System, Los Angeles, CA USA
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Goldhar HA, Yan AT, Ko DT, Earle CC, Tomlinson GA, Trudeau ME, Krahn MD, Krzyzanowska MK, Pal RS, Brezden-Masley C, Gavura S, Lien K, Chan KKW. The Temporal Risk of Heart Failure Associated With Adjuvant Trastuzumab in Breast Cancer Patients: A Population Study. J Natl Cancer Inst 2015; 108:djv301. [PMID: 26476433 DOI: 10.1093/jnci/djv301] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 09/24/2015] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The late cardiac effect of adjuvant trastuzumab and its potential interaction with anthracycline have not been well-studied on a population level. METHODS In this retrospective population-based cohort study, female breast cancer patients in Ontario, diagnosed between 2003 and 2009, were identified by the Ontario Cancer Registry and linked to administrative databases to ascertain demographics, cardiac risk factors, comorbidities, and use of adjuvant trastuzumab and other chemotherapy. Patients with pre-existing heart failure (HF) were excluded. The main endpoint was new diagnosis of HF. Analyses included Kaplan-Meier (KM) survival analysis, multivariable piecewise Cox regression, and competing risk and propensity score analyses. All statistical tests were two-sided. RESULTS Nineteen thousand seventy-four women with breast cancer treated with adjuvant chemotherapy were identified, of whom 3371 (17.7%) also received adjuvant trastuzumab. Anthracycline use was 84.9% overall. After a median follow-up of 5.9 years, patients treated with trastuzumab and chemotherapy were more likely to develop HF than patients on chemotherapy alone (5-year cumulative incidences of 5.2% vs 2.5%; log-rank P < .001). After adjusting for confounders, adjuvant trastuzumab remained independently associated with incident HF in the first 1.5 years (HR = 5.77, 95% CI = 4.38 to 7.62, P < .001), but not thereafter (HR = 0.87, 95% CI = 0.57 to 1.33, P = .53). Anthracycline use did not increase the risk of HF with trastuzumab synergistically, neither within (P interaction = .92) nor beyond 1.5 years (P interaction = .23). CONCLUSION Adjuvant trastuzumab was associated with increased risk of new incidence of HF in breast cancer survivors during the period of adjuvant treatment but not thereafter. Routine intensive monitoring may not be necessary after completing adjuvant therapy.
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Affiliation(s)
- Hart A Goldhar
- : Faculty of Medicine, University of Toronto, Toronto, ON (HAG, ATY, DTK, CCE, GAT, MET, MDK, MKK, CB, KKWC); Division of Cardiology, St. Michael's Hospital, Toronto, ON (ATY); Institute for Clinical Evaluative Sciences, Toronto, ON (DTK, CCE, MKK); Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, ON (DTK); Division of Medical Oncology, Sunnybrook Health Sciences Centre, Toronto, ON (CCE, MET, KL, KKWC); Ontario Institute for Cancer Research, Toronto, ON (CCE); University Health Network, Toronto, ON (GAT, MKK); Toronto Health Economics and Health Assessment, Toronto, ON (MDK); Division of Hematology/Oncology, St. Michael's Hospital, Toronto, ON (CB); Department of Medicine, Queens University, and Cardiac Program, Kingston General Hospital, Kingston, ON (RSP); Cancer Care Ontario, Toronto, ON (SG)
| | - Andrew T Yan
- : Faculty of Medicine, University of Toronto, Toronto, ON (HAG, ATY, DTK, CCE, GAT, MET, MDK, MKK, CB, KKWC); Division of Cardiology, St. Michael's Hospital, Toronto, ON (ATY); Institute for Clinical Evaluative Sciences, Toronto, ON (DTK, CCE, MKK); Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, ON (DTK); Division of Medical Oncology, Sunnybrook Health Sciences Centre, Toronto, ON (CCE, MET, KL, KKWC); Ontario Institute for Cancer Research, Toronto, ON (CCE); University Health Network, Toronto, ON (GAT, MKK); Toronto Health Economics and Health Assessment, Toronto, ON (MDK); Division of Hematology/Oncology, St. Michael's Hospital, Toronto, ON (CB); Department of Medicine, Queens University, and Cardiac Program, Kingston General Hospital, Kingston, ON (RSP); Cancer Care Ontario, Toronto, ON (SG)
| | - Dennis T Ko
- : Faculty of Medicine, University of Toronto, Toronto, ON (HAG, ATY, DTK, CCE, GAT, MET, MDK, MKK, CB, KKWC); Division of Cardiology, St. Michael's Hospital, Toronto, ON (ATY); Institute for Clinical Evaluative Sciences, Toronto, ON (DTK, CCE, MKK); Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, ON (DTK); Division of Medical Oncology, Sunnybrook Health Sciences Centre, Toronto, ON (CCE, MET, KL, KKWC); Ontario Institute for Cancer Research, Toronto, ON (CCE); University Health Network, Toronto, ON (GAT, MKK); Toronto Health Economics and Health Assessment, Toronto, ON (MDK); Division of Hematology/Oncology, St. Michael's Hospital, Toronto, ON (CB); Department of Medicine, Queens University, and Cardiac Program, Kingston General Hospital, Kingston, ON (RSP); Cancer Care Ontario, Toronto, ON (SG)
| | - Craig C Earle
- : Faculty of Medicine, University of Toronto, Toronto, ON (HAG, ATY, DTK, CCE, GAT, MET, MDK, MKK, CB, KKWC); Division of Cardiology, St. Michael's Hospital, Toronto, ON (ATY); Institute for Clinical Evaluative Sciences, Toronto, ON (DTK, CCE, MKK); Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, ON (DTK); Division of Medical Oncology, Sunnybrook Health Sciences Centre, Toronto, ON (CCE, MET, KL, KKWC); Ontario Institute for Cancer Research, Toronto, ON (CCE); University Health Network, Toronto, ON (GAT, MKK); Toronto Health Economics and Health Assessment, Toronto, ON (MDK); Division of Hematology/Oncology, St. Michael's Hospital, Toronto, ON (CB); Department of Medicine, Queens University, and Cardiac Program, Kingston General Hospital, Kingston, ON (RSP); Cancer Care Ontario, Toronto, ON (SG)
| | - George A Tomlinson
- : Faculty of Medicine, University of Toronto, Toronto, ON (HAG, ATY, DTK, CCE, GAT, MET, MDK, MKK, CB, KKWC); Division of Cardiology, St. Michael's Hospital, Toronto, ON (ATY); Institute for Clinical Evaluative Sciences, Toronto, ON (DTK, CCE, MKK); Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, ON (DTK); Division of Medical Oncology, Sunnybrook Health Sciences Centre, Toronto, ON (CCE, MET, KL, KKWC); Ontario Institute for Cancer Research, Toronto, ON (CCE); University Health Network, Toronto, ON (GAT, MKK); Toronto Health Economics and Health Assessment, Toronto, ON (MDK); Division of Hematology/Oncology, St. Michael's Hospital, Toronto, ON (CB); Department of Medicine, Queens University, and Cardiac Program, Kingston General Hospital, Kingston, ON (RSP); Cancer Care Ontario, Toronto, ON (SG)
| | - Maureen E Trudeau
- : Faculty of Medicine, University of Toronto, Toronto, ON (HAG, ATY, DTK, CCE, GAT, MET, MDK, MKK, CB, KKWC); Division of Cardiology, St. Michael's Hospital, Toronto, ON (ATY); Institute for Clinical Evaluative Sciences, Toronto, ON (DTK, CCE, MKK); Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, ON (DTK); Division of Medical Oncology, Sunnybrook Health Sciences Centre, Toronto, ON (CCE, MET, KL, KKWC); Ontario Institute for Cancer Research, Toronto, ON (CCE); University Health Network, Toronto, ON (GAT, MKK); Toronto Health Economics and Health Assessment, Toronto, ON (MDK); Division of Hematology/Oncology, St. Michael's Hospital, Toronto, ON (CB); Department of Medicine, Queens University, and Cardiac Program, Kingston General Hospital, Kingston, ON (RSP); Cancer Care Ontario, Toronto, ON (SG)
| | - Murray D Krahn
- : Faculty of Medicine, University of Toronto, Toronto, ON (HAG, ATY, DTK, CCE, GAT, MET, MDK, MKK, CB, KKWC); Division of Cardiology, St. Michael's Hospital, Toronto, ON (ATY); Institute for Clinical Evaluative Sciences, Toronto, ON (DTK, CCE, MKK); Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, ON (DTK); Division of Medical Oncology, Sunnybrook Health Sciences Centre, Toronto, ON (CCE, MET, KL, KKWC); Ontario Institute for Cancer Research, Toronto, ON (CCE); University Health Network, Toronto, ON (GAT, MKK); Toronto Health Economics and Health Assessment, Toronto, ON (MDK); Division of Hematology/Oncology, St. Michael's Hospital, Toronto, ON (CB); Department of Medicine, Queens University, and Cardiac Program, Kingston General Hospital, Kingston, ON (RSP); Cancer Care Ontario, Toronto, ON (SG)
| | - Monika K Krzyzanowska
- : Faculty of Medicine, University of Toronto, Toronto, ON (HAG, ATY, DTK, CCE, GAT, MET, MDK, MKK, CB, KKWC); Division of Cardiology, St. Michael's Hospital, Toronto, ON (ATY); Institute for Clinical Evaluative Sciences, Toronto, ON (DTK, CCE, MKK); Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, ON (DTK); Division of Medical Oncology, Sunnybrook Health Sciences Centre, Toronto, ON (CCE, MET, KL, KKWC); Ontario Institute for Cancer Research, Toronto, ON (CCE); University Health Network, Toronto, ON (GAT, MKK); Toronto Health Economics and Health Assessment, Toronto, ON (MDK); Division of Hematology/Oncology, St. Michael's Hospital, Toronto, ON (CB); Department of Medicine, Queens University, and Cardiac Program, Kingston General Hospital, Kingston, ON (RSP); Cancer Care Ontario, Toronto, ON (SG)
| | - Raveen S Pal
- : Faculty of Medicine, University of Toronto, Toronto, ON (HAG, ATY, DTK, CCE, GAT, MET, MDK, MKK, CB, KKWC); Division of Cardiology, St. Michael's Hospital, Toronto, ON (ATY); Institute for Clinical Evaluative Sciences, Toronto, ON (DTK, CCE, MKK); Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, ON (DTK); Division of Medical Oncology, Sunnybrook Health Sciences Centre, Toronto, ON (CCE, MET, KL, KKWC); Ontario Institute for Cancer Research, Toronto, ON (CCE); University Health Network, Toronto, ON (GAT, MKK); Toronto Health Economics and Health Assessment, Toronto, ON (MDK); Division of Hematology/Oncology, St. Michael's Hospital, Toronto, ON (CB); Department of Medicine, Queens University, and Cardiac Program, Kingston General Hospital, Kingston, ON (RSP); Cancer Care Ontario, Toronto, ON (SG)
| | - Christine Brezden-Masley
- : Faculty of Medicine, University of Toronto, Toronto, ON (HAG, ATY, DTK, CCE, GAT, MET, MDK, MKK, CB, KKWC); Division of Cardiology, St. Michael's Hospital, Toronto, ON (ATY); Institute for Clinical Evaluative Sciences, Toronto, ON (DTK, CCE, MKK); Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, ON (DTK); Division of Medical Oncology, Sunnybrook Health Sciences Centre, Toronto, ON (CCE, MET, KL, KKWC); Ontario Institute for Cancer Research, Toronto, ON (CCE); University Health Network, Toronto, ON (GAT, MKK); Toronto Health Economics and Health Assessment, Toronto, ON (MDK); Division of Hematology/Oncology, St. Michael's Hospital, Toronto, ON (CB); Department of Medicine, Queens University, and Cardiac Program, Kingston General Hospital, Kingston, ON (RSP); Cancer Care Ontario, Toronto, ON (SG)
| | - Scott Gavura
- : Faculty of Medicine, University of Toronto, Toronto, ON (HAG, ATY, DTK, CCE, GAT, MET, MDK, MKK, CB, KKWC); Division of Cardiology, St. Michael's Hospital, Toronto, ON (ATY); Institute for Clinical Evaluative Sciences, Toronto, ON (DTK, CCE, MKK); Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, ON (DTK); Division of Medical Oncology, Sunnybrook Health Sciences Centre, Toronto, ON (CCE, MET, KL, KKWC); Ontario Institute for Cancer Research, Toronto, ON (CCE); University Health Network, Toronto, ON (GAT, MKK); Toronto Health Economics and Health Assessment, Toronto, ON (MDK); Division of Hematology/Oncology, St. Michael's Hospital, Toronto, ON (CB); Department of Medicine, Queens University, and Cardiac Program, Kingston General Hospital, Kingston, ON (RSP); Cancer Care Ontario, Toronto, ON (SG)
| | - Kelly Lien
- : Faculty of Medicine, University of Toronto, Toronto, ON (HAG, ATY, DTK, CCE, GAT, MET, MDK, MKK, CB, KKWC); Division of Cardiology, St. Michael's Hospital, Toronto, ON (ATY); Institute for Clinical Evaluative Sciences, Toronto, ON (DTK, CCE, MKK); Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, ON (DTK); Division of Medical Oncology, Sunnybrook Health Sciences Centre, Toronto, ON (CCE, MET, KL, KKWC); Ontario Institute for Cancer Research, Toronto, ON (CCE); University Health Network, Toronto, ON (GAT, MKK); Toronto Health Economics and Health Assessment, Toronto, ON (MDK); Division of Hematology/Oncology, St. Michael's Hospital, Toronto, ON (CB); Department of Medicine, Queens University, and Cardiac Program, Kingston General Hospital, Kingston, ON (RSP); Cancer Care Ontario, Toronto, ON (SG)
| | - Kelvin K W Chan
- : Faculty of Medicine, University of Toronto, Toronto, ON (HAG, ATY, DTK, CCE, GAT, MET, MDK, MKK, CB, KKWC); Division of Cardiology, St. Michael's Hospital, Toronto, ON (ATY); Institute for Clinical Evaluative Sciences, Toronto, ON (DTK, CCE, MKK); Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, ON (DTK); Division of Medical Oncology, Sunnybrook Health Sciences Centre, Toronto, ON (CCE, MET, KL, KKWC); Ontario Institute for Cancer Research, Toronto, ON (CCE); University Health Network, Toronto, ON (GAT, MKK); Toronto Health Economics and Health Assessment, Toronto, ON (MDK); Division of Hematology/Oncology, St. Michael's Hospital, Toronto, ON (CB); Department of Medicine, Queens University, and Cardiac Program, Kingston General Hospital, Kingston, ON (RSP); Cancer Care Ontario, Toronto, ON (SG).
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145
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Leung HWC, Chan ALF. Trastuzumab-induced cardiotoxicity in elderly women with HER-2-positive breast cancer: a meta-analysis of real-world data. Expert Opin Drug Saf 2015; 14:1661-71. [DOI: 10.1517/14740338.2015.1089231] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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146
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Turner N, Biganzoli L, Di Leo A. Continued value of adjuvant anthracyclines as treatment for early breast cancer. Lancet Oncol 2015; 16:e362-9. [PMID: 26149888 DOI: 10.1016/s1470-2045(15)00079-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 11/18/2014] [Accepted: 11/18/2014] [Indexed: 01/15/2023]
Abstract
Anthracyclines are frequently used in the adjuvant treatment of early-stage breast cancer. However, with the increasing use of other active drugs--mainly taxanes and trastuzumab in HER2-positive disease--coupled with concerns about anthracycline-associated toxic effects, there is debate about whether anthracyclines are still needed. Three major factors should be taken into consideration with the investigation of the role of anthracyclines in management of early breast cancer; specifically, the proven efficacy of anthracyclines in breast cancer, the absence of superiority of non-anthracycline-based chemotherapy over anthracycline-taxane regimens, and the low risk of toxic effects associated with the cumulative doses of anthracyclines used in contemporary regimens. The risks remain substantially outweighed by the benefits of treatment with anthracyclines, and thus, they maintain an important role in adjuvant treatment of breast cancer, particularly in women with high-risk disease.
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Affiliation(s)
- Natalie Turner
- Sandro Pitigliani Medical Oncology Department, Prato Hospital, Istituto Toscano Tumori, Prato, Italy
| | - Laura Biganzoli
- Sandro Pitigliani Medical Oncology Department, Prato Hospital, Istituto Toscano Tumori, Prato, Italy
| | - Angelo Di Leo
- Sandro Pitigliani Medical Oncology Department, Prato Hospital, Istituto Toscano Tumori, Prato, Italy.
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147
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Advani PP, Ballman KV, Dockter TJ, Colon-Otero G, Perez EA. Long-Term Cardiac Safety Analysis of NCCTG N9831 (Alliance) Adjuvant Trastuzumab Trial. J Clin Oncol 2015; 34:581-7. [PMID: 26392097 DOI: 10.1200/jco.2015.61.8413] [Citation(s) in RCA: 107] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
PURPOSE Significant improvement in survival outcomes has been established with the addition of trastuzumab to adjuvant chemotherapy for human epidermal growth factor receptor 2 (HER2) -positive early breast cancer treatment. However, trastuzumab may increase the risk of cardiac toxicity, and long-term evaluation of its incidence and risk factors are warranted. METHODS NCCTG (Alliance) N9831 trial compared adjuvant doxorubicin and cyclophosphamide (AC) followed by either weekly paclitaxel (arm A); paclitaxel then trastuzumab (arm B); or paclitaxel plus trastuzumab followed by trastuzumab alone (arm C) in patients with HER2-positive breast cancer. Cumulative incidence of cardiac events (CE) and left ventricular ejection fraction (LVEF) were evaluated in 1,944 women who proceeded to post-AC therapy. Risk factors for trastuzumab-induced cardiac toxicity were identified by Cox regression models. RESULTS The 6-year cumulative incidence of CE was 0.6% in arm A, 2.8% in arm B, and 3.4% in arm C. At a median follow-up of 9.2 years, only two additional CHF diagnoses (of 1,046 patients) occurred beyond our previously reported follow-up time of 3.75 years. LVEF recovered in the majority of the patients who developed CHF. There were two cardiac deaths in arm A and one each in arms B and C. Age of 60 years or older, registration LVEF less than 65%, and use of antihypertensive medications were associated with an increased risk of CE in arms B and C. CONCLUSION The cumulative incidence of CE at 6 years was slightly higher with the addition of trastuzumab; however, the late development of CE is infrequent. Trastuzumab (in the context of anthracycline- and taxane-based therapy) continues to have a favorable benefit-risk ratio.
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Affiliation(s)
- Pooja P Advani
- Pooja P. Advani, Gerardo Colon-Otero, and Edith A. Perez, Mayo Clinic, Jacksonville, FL; and Karla V. Ballman and Travis J. Dockter, Mayo Clinic, Rochester, MN
| | - Karla V Ballman
- Pooja P. Advani, Gerardo Colon-Otero, and Edith A. Perez, Mayo Clinic, Jacksonville, FL; and Karla V. Ballman and Travis J. Dockter, Mayo Clinic, Rochester, MN
| | - Travis J Dockter
- Pooja P. Advani, Gerardo Colon-Otero, and Edith A. Perez, Mayo Clinic, Jacksonville, FL; and Karla V. Ballman and Travis J. Dockter, Mayo Clinic, Rochester, MN
| | - Gerardo Colon-Otero
- Pooja P. Advani, Gerardo Colon-Otero, and Edith A. Perez, Mayo Clinic, Jacksonville, FL; and Karla V. Ballman and Travis J. Dockter, Mayo Clinic, Rochester, MN
| | - Edith A Perez
- Pooja P. Advani, Gerardo Colon-Otero, and Edith A. Perez, Mayo Clinic, Jacksonville, FL; and Karla V. Ballman and Travis J. Dockter, Mayo Clinic, Rochester, MN.
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148
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Jerusalem G, Moonen M, Freres P, Lancellotti P. The European Association of Cardiovascular Imaging/Heart Failure Association Cardiac Oncology Toxicity Registry: long-term benefits for breast cancer treatment. Future Oncol 2015; 11:2791-4. [PMID: 26344798 DOI: 10.2217/fon.15.227] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Guy Jerusalem
- Medical Oncology, CHU Sart Tilman Liege & Liege University, Domaine Universitaire du Sart Tilman, B35, 4000 Liege, Belgium
| | - Marie Moonen
- University of Liège Hospital, GIGA Cardiovascular Sciences, Cardio-Oncology Clinic Unit, CHU Sart Tilman Liege & Liege University, Domaine Universitaire du Sart Tilman, B35, 4000 Liege, Belgium
| | - Pierre Freres
- Medical Oncology, CHU Sart Tilman Liege & Liege University, Domaine Universitaire du Sart Tilman, B35, 4000 Liege, Belgium
| | - Patrizio Lancellotti
- University of Liège Hospital, GIGA Cardiovascular Sciences, Cardio-Oncology Clinic Unit, CHU Sart Tilman Liege & Liege University, Domaine Universitaire du Sart Tilman, B35, 4000 Liege, Belgium
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149
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An update on the risk prediction and prevention of anticancer therapy-induced cardiotoxicity. Curr Opin Oncol 2015; 26:590-9. [PMID: 25233068 DOI: 10.1097/cco.0000000000000132] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW Cardiotoxicity is a well established complication of anticancer therapy. As cancer survivorship and life expectancy for cancer patients improves, the morbidity and mortality of anticancer therapy-related cardiotoxicity has become more problematic. It is of utmost importance to identify patients at the highest risk for the development of cardiotoxicity and to determine strategies for prevention, early detection and treatment. RECENT FINDINGS Clinical risk factors, biomarkers, advanced cardiac imaging and pharmacogenomics may be used to classify patients at risk for therapy-induced cardiotoxicity. A much broader armamentarium of imaging modalities for risk prediction, in addition to simple two-dimensional echocardiogram and radionucleotide angiography, has also shown clinical utility in identifying early-onset cardiotoxicity and areas of reversible myocardial injury. Exciting new research aimed at predicting cardiotoxicity and developing cardioprotective strategies may lead to changes in the administration of cardiotoxic chemotherapies. SUMMARY Personalized assessments of the risks and benefits of therapy should be used as opposed to standardized dosing and schedules. Patients at higher risk for cardiotoxicity should receive closer monitoring, cardioprotective agents, dose adjustment or alternative regimens in an effort to reduce cardiovascular morbidity and mortality. Future research will hopefully define specific risk prediction tools and clinical protocols to prevent irreversible cardiotoxicity.
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150
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Elomrani F, Zine M, Afif M, L’annaz S, Ouziane I, Mrabti H, Errihani H. Management of early breast cancer in older women: from screening to treatment. BREAST CANCER (DOVE MEDICAL PRESS) 2015; 7:165-71. [PMID: 26185468 PMCID: PMC4500607 DOI: 10.2147/bctt.s87125] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Breast cancer is a common condition. It is a leading cause of death among women, and its incidence increases with age. Aging of the population and improvement of the quality of life of elders make it a major public health issue. We reviewed the literature to try to determine the management of breast cancer in older women. METHODS We conducted a narrative review by literature searches using key words "breast cancer", "elderly and older", and "women" in Pubmed, Scopus, and Google Scholar. The aim of this review is to summarize the management of early breast cancer in older women by discussing the controversies of screening in older women. Then, we try to define the optimal strategy for these women, either surgery alone or primary endocrine therapy. We also discuss the indications of lymph node dissection, and we evaluate the benefit of adjuvant radiotherapy, chemotherapy, and the anti HER2 treatment for these women. RESULTS More than 50% of patients with breast cancer are 65 years or older, and around 30% are more than 70 years old. Most randomized trials did not include older women. Hence, the treatment of breast cancer in older patients is based on the management provided to younger women. Regardless of age, the treatment must aim for the best efficiency. Advanced age in itself should not be a limitation to treatment. There are no standard guidelines set for elderly patients. Surgical treatment for older patients evolved to avoid mastectomy, and conservative mammary surgery was proposed, similar to that used in younger patients. The proportion of elderly patients receiving adjuvant radiotherapy is increasing. The role of adjuvant radiotherapy in older patients with breast cancer was analyzed. Adjuvant chemotherapy is beneficial to women with hormone receptor-negative tumors. In those with hormone receptor-positive tumors, adjuvant chemotherapy in association to trastuzumab is beneficial for HER2-positive tumors, and for women with HER2-negative tumors adjuvant hormonal therapy is a very good option. CONCLUSION Breast cancer is common in older women. This population requires particular and adapted management. It is essential for older patients to be included in new clinical trials for individualized treatment recommendation.
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Affiliation(s)
- Fadwa Elomrani
- Department of Medical Oncology, National Institute of Oncology, Rabat, Morocco
| | - Maryem Zine
- Department of Onco Hematology, Military Hospital Mohamed V, Rabat, Morocco
| | - Mohamed Afif
- Department of Radiotherapy, National Institute of Oncology, Rabat, Morocco
| | - Saad L’annaz
- Department of Medical Oncology, National Institute of Oncology, Rabat, Morocco
| | - Imane Ouziane
- Department of Medical Oncology, National Institute of Oncology, Rabat, Morocco
| | - Hind Mrabti
- Department of Medical Oncology, National Institute of Oncology, Rabat, Morocco
| | - Hassan Errihani
- Department of Medical Oncology, National Institute of Oncology, Rabat, Morocco
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