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Salam RA, Khan MH, Meerza SSA, Das JK, Lewis-Watts L, Bhutta ZA. An evidence gap map of interventions for noncommunicable diseases and risk factors among children and adolescents. Nat Med 2024; 30:290-301. [PMID: 38195753 DOI: 10.1038/s41591-023-02737-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 11/27/2023] [Indexed: 01/11/2024]
Abstract
Substance misuse, obesity, mental health conditions, type 1 diabetes, cancers, and cardiovascular and chronic respiratory diseases together account for 41% of disability-adjusted life years linked to noncommunicable diseases (NCDs) among children and adolescents worldwide. However, the evidence on risk factors and interventions for this age group is scarce. Here we searched four databases to generate an evidence gap map of existing interventions and research gaps for these risk factors and NCDs. We mapped 159 reviews with 2,611 primary studies; most (96.2%) were conducted in high-income countries, and only 100 studies (3.8%) were from low- and middle-income countries (LMICs). The efficacy of therapeutic interventions on biomarkers and adverse events for NCDs appears to be well evidenced. Interventions for mental health conditions appear to be moderately evidenced, while interventions for obesity and substance misuse appear to be moderate to very low evidenced. Priority areas for future research include evaluating digital health platforms to support primary NCD prevention and management, and evaluating the impact of policy changes on the prevalence of obesity and substance misuse. Our findings highlight the wide disparity of evidence between high-income countries and LMICs. There is an urgent need for increased, targeted financing to address the research gaps in LMICs.
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Affiliation(s)
- Rehana A Salam
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, New South Wales, Australia
| | - Maryam Hameed Khan
- Institute for Global Health and Development, Aga Khan University Hospital, Karachi, Pakistan
| | - Syed Saqlain Ali Meerza
- Institute for Global Health and Development, Aga Khan University Hospital, Karachi, Pakistan
| | - Jai K Das
- Institute for Global Health and Development, Aga Khan University Hospital, Karachi, Pakistan
| | - Laura Lewis-Watts
- Centre for Global Child Health, The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada.
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Zhang XY, Wang Q, Yang KL, Wei D, Liu XN. Preventive strategies of cancer therapeutics-related cardiotoxicity in childhood cancer survivors: a protocol of systematic review. BMJ Open 2022; 12:e065776. [PMID: 36127118 PMCID: PMC9490564 DOI: 10.1136/bmjopen-2022-065776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Five-year survival in childhood cancer has been improved markedly in the past decades. Childhood cancer survivors are at high risk of cardiovascular diseases due to anticancer therapy-induced cardiotoxicity. The comprehensive evidence for the prevention of anticancer therapy-induced cardiovascular disease is, however, sparse. The systematic review described in the protocol aims to summarise the effect of current prevention for anticancer therapy-induced cardiotoxicity among childhood cancer survivors. METHODS AND ANALYSIS This protocol is reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols checklist. We will search PubMed (via Medline), Embase and the Cochrane Library and include the studies investigating the effect of prevention against anticancer therapy-induced cardiotoxicity of childhood cancer. To assess the risk of bias, we will use the Cochrane Collaboration's risk of bias tool for randomised control trials and the Newcastle-Ottawa Scale for cohort studies and case-control studies. Furthermore, we will conduct meta-analyses if there is no substantial clinical heterogeneity between included studies. The Grading of Recommendations, Assessment, Development and Evaluation will be used to evaluate the quality of evidence. ETHICS AND DISSEMINATION Ethical approval is not needed for systematic review of published data. The findings will be published in a peer-reviewed journal and disseminated at scientific conferences. PROSPERO REGISTRATION NUMBER CRD42022333877.
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Affiliation(s)
- Xin-Yu Zhang
- Ambulatory Surgery Center, Xijing Hospital, Air Force Military Medical University, Xi'an, Shaanxi, China
- Nursing Department, Chengdu BOE Hospital, Chengdu, Sichuan, China
| | - Quan Wang
- Ambulatory Surgery Center, Xijing Hospital, Air Force Military Medical University, Xi'an, Shaanxi, China
| | - Ke-Lu Yang
- Academic Center for Nursing and Midwifery, Department of Public Health and Primary Care, University of Leuven (KU Leuven), Leuven, Belgium
| | - Dang Wei
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Xiao-Nan Liu
- Ambulatory Surgery Center, Xijing Hospital, Air Force Military Medical University, Xi'an, Shaanxi, China
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3
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Dong Y, Wu Q, Hu C. Early Predictive Value of NT-proBNP Combined With Echocardiography in Anthracyclines Induced Cardiotoxicity. Front Surg 2022; 9:898172. [PMID: 35846969 PMCID: PMC9283786 DOI: 10.3389/fsurg.2022.898172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 05/31/2022] [Indexed: 11/15/2022] Open
Abstract
Objective Determine the predictive value of N-terminal pro-B-type natriuretic peptide (NT-proBNP) combined with echocardiography in the diagnosis of anthracyclines-induced chronic cardiotoxicity. Methods A total of 80 female breast cancer patients from January 2019 to October 2021 were included in our hospital. Twenty-six patients with cardiotoxicity were divided into the cardiac impairment group, and the 54 patients without cardiotoxicity were classified into the normal control group. NT-proBNP levels and cardiac echocardiography were measured before the start of the chemotherapy cycle, in cycle 3 of the chemotherapy, and after the chemotherapy cycle in all patients. Results After three cycles of chemotherapy and chemotherapy, the levels of NT-proBNP in patients of the two groups were significantly higher than those before chemotherapy (P < 0.05). The levels of NT-proBNP in the cardiac injury group after three cycles of chemotherapy and chemotherapy were higher than those in the normal control group at the same time point (P < 0.05). The LVEF of patients in the cardiac impairment group after chemotherapy was lower than that before chemotherapy, and the LVEF after chemotherapy was lower than that in the normal control group (P < 0.05). NT-proBNP had a negative correlation with LVEF (r = −0.549, P < 0.001). The AUC of NT-proBNP in combination with LVEF for predicting cardiotoxicity in our patient was 0.898(95%CI:0.829–0.966). Conclusion NT-proBNP combined with echocardiography has clinical significance in the detection of anthracyclines-induced cardiotoxicity, and it can detect early myocardial injury induced by anthracyclines, with early prediction value. It is important to protect heart function and judge prognosis.
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Affiliation(s)
- Yingjun Dong
- Shanxi Province Cancer Hospital/Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences/Cancer Hospital Affiliated to Shanxi Medical University, Taiyuan, China
| | - Qiong Wu
- Shanxi Province Cancer Hospital/Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences/Cancer Hospital Affiliated to Shanxi Medical University, Taiyuan, China
| | - Changqing Hu
- Department of Cardiology, Shanxi Provincial People’s Hospital, Taiyuan, China
- Correspondence: Changqing Hu
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Brickler M, Raskin A, Ryan TD. Current State of Pediatric Cardio-Oncology: A Review. CHILDREN 2022; 9:children9020127. [PMID: 35204848 PMCID: PMC8870613 DOI: 10.3390/children9020127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/23/2021] [Accepted: 11/30/2021] [Indexed: 01/03/2023]
Abstract
The landscape of pediatric oncology has dramatically changed over the course of the past several decades with five-year survival rates surpassing 80%. Anthracycline therapy has been the cornerstone of many chemotherapy regimens for pediatric patients since its introduction in the 1960s, and recent improved survival has been in large part due to advancements in chemotherapy, refinement of supportive care treatments, and development of novel therapeutics such as small molecule inhibitors, chimeric antigen receptor T-cell therapy, and immune checkpoint inhibitors. Unfortunately, many cancer-targeted therapies can lead to acute and chronic cardiovascular pathologies. The range of cardiotoxicity can vary but includes symptomatic or asymptotic heart failure, arrhythmias, coronary artery disease, valvar disease, pericardial disease, hypertension, and peripheral vascular disease. There is lack of data guiding primary prevention and treatment strategies in the pediatric population, which leads to substantial practice variability. Several important future research directions have been identified, including as they relate to cardiac disease, prevention strategies, management of cardiovascular risk factors, risk prediction, early detection, and the role of genetic susceptibility in development of cardiotoxicity. Continued collaborative research will be key in advancing the field. The ideal model for pediatric cardio-oncology is a proactive partnership between pediatric cardiologists and oncologists in order to better understand, treat, and ideally prevent cardiac disease in pediatric oncology patients.
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Affiliation(s)
| | | | - Thomas D. Ryan
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA;
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Hecker-Nolting S, Langer T, Blattmann C, Kager L, Bielack SS. Current Insights into the Management of Late Chemotherapy Toxicities in Pediatric Osteosarcoma Patients. Cancer Manag Res 2021; 13:8989-8998. [PMID: 34880679 PMCID: PMC8647031 DOI: 10.2147/cmar.s287908] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/02/2021] [Indexed: 12/17/2022] Open
Abstract
With ever increasing long-term, disease free survival rates, long-term toxicities of otherwise successful therapy have gained increasing importance. They can be grouped into potentially life-threatening, especially secondary malignancies and anthracycline cardiomyopathies, potentially disabling, particularly severe hearing loss and renal insufficiency, other, and rare events. Pathophysiology, frequency, and medical treatment approaches are discussed. Finally, fertility issues and quality of life issues are discussed, together with an outlook into the future. The challenge to cure as many patients as possible from osteosarcoma while enabling a life free of late effects will remain.
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Affiliation(s)
- Stefanie Hecker-Nolting
- Pädiatrie 5 (Onkologie, Hämatologie, Immunologie), Zentrum für Kinder-, Jugend- und Frauenmedizin, Stuttgart Cancer Center, Klinikum Stuttgart - Olgahospital, Stuttgart, Germany
| | - Thorsten Langer
- Pädiatrische Onkologie und Hämatologie, Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Claudia Blattmann
- Pädiatrie 5 (Onkologie, Hämatologie, Immunologie), Zentrum für Kinder-, Jugend- und Frauenmedizin, Stuttgart Cancer Center, Klinikum Stuttgart - Olgahospital, Stuttgart, Germany
| | - Leo Kager
- St. Anna Kinderspital, Abteilung für Kinder- und Jugendheilkunde, Medizinische Universität Wien, Vienna, Austria
| | - Stefan S Bielack
- Pädiatrie 5 (Onkologie, Hämatologie, Immunologie), Zentrum für Kinder-, Jugend- und Frauenmedizin, Stuttgart Cancer Center, Klinikum Stuttgart - Olgahospital, Stuttgart, Germany.,Abteilung für Pädiatrische Hämatologie und Onkologie, Klinik für Kinder- und Jugendmedizin - Pädiatrische Hämatologie und Onkologie, Münster, Germany
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Role of Creatine in the Heart: Health and Disease. Nutrients 2021; 13:nu13041215. [PMID: 33917009 PMCID: PMC8067763 DOI: 10.3390/nu13041215] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/02/2021] [Accepted: 04/03/2021] [Indexed: 12/26/2022] Open
Abstract
Creatine is a key player in heart contraction and energy metabolism. Creatine supplementation (throughout the paper, only supplementation with creatine monohydrate will be reviewed, as this is by far the most used and best-known way of supplementing creatine) increases creatine content even in the normal heart, and it is generally safe. In heart failure, creatine and phosphocreatine decrease because of decreased expression of the creatine transporter, and because phosphocreatine degrades to prevent adenosine triphosphate (ATP) exhaustion. This causes decreased contractility reserve of the myocardium and correlates with left ventricular ejection fraction, and it is a predictor of mortality. Thus, there is a strong rationale to supplement with creatine the failing heart. Pending additional trials, creatine supplementation in heart failure may be useful given data showing its effectiveness (1) against specific parameters of heart failure, and (2) against the decrease in muscle strength and endurance of heart failure patients. In heart ischemia, the majority of trials used phosphocreatine, whose mechanism of action is mostly unrelated to changes in the ergogenic creatine-phosphocreatine system. Nevertheless, preliminary data with creatine supplementation are encouraging, and warrant additional studies. Prevention of cardiac toxicity of the chemotherapy compounds anthracyclines is a novel field where creatine supplementation may also be useful. Creatine effectiveness in this case may be because anthracyclines reduce expression of the creatine transporter, and because of the pleiotropic antioxidant properties of creatine. Moreover, creatine may also reduce concomitant muscle damage by anthracyclines.
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Refining the 10-Year Prediction of Left Ventricular Systolic Dysfunction in Long-Term Survivors of Childhood Cancer. JACC: CARDIOONCOLOGY 2021; 3:62-72. [PMID: 34396306 PMCID: PMC8352242 DOI: 10.1016/j.jaccao.2020.11.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 11/11/2020] [Indexed: 12/28/2022]
Abstract
Background In childhood cancer survivors (CCS) at risk for heart failure, echocardiographic surveillance recommendations are currently based on anthracyclines and chest-directed radiotherapy dose. Whether the ejection fraction (EF) measured at an initial surveillance echocardiogram can refine these recommendations is unknown. Objectives The purpose of this study was to assess the added predictive value of EF at >5 years after cancer diagnosis to anthracyclines and chest-directed radiotherapy dose in CCS, for the development of left ventricular dysfunction with an ejection fraction <40% (LVD40). Methods Echocardiographic surveillance was performed in 299 CCS from the Emma Children’s Hospital in the Netherlands. Cox regression models were built including cardiotoxic cancer treatment exposures with and without EF to estimate the probability of LVD40 at 10-year follow-up. Calibration, discrimination, and reclassification were assessed. Results were externally validated in 218 CCS. Results Cumulative incidences of LVD40 at 10-year follow-up were 3.7% and 3.6% in the derivation and validation cohort, respectively. The addition of EF resulted in an integrated area under the curve increase from 0.74 to 0.87 in the derivation cohort and from 0.72 to 0.86 in the validation cohort (likelihood ratio p < 0.001). Reclassification of CCS without LVD40 improved significantly (noncase continuous net reclassification improvement 0.50; 95% confidence interval [CI]: 0.40 to 0.60). A predicted LVD40 probability ≤3%, representing 75% of the CCS, had a negative predictive value of 99% (95% CI: 98% to 100%) for LVD40 within 10 years. However, patients with midrange EF (40% to 49%) at initial screening had an incidence of LVD40 of 11% and a 7.81-fold (95% CI: 2.07- to 29.50-fold) increased risk of LV40 at follow-up. Conclusions In CCS, an initial surveillance EF, in addition to anthracyclines and chest-directed radiotherapy dose, improves the 10-year prediction for LVD40. Through this strategy, both the identification of low-risk survivors in whom the surveillance frequency may be reduced and a group of survivors at increased risk of LVD40 could be identified.
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Caspani F, Tralongo AC, Campiotti L, Asteggiano R, Guasti L, Squizzato A. Prevention of anthracycline-induced cardiotoxicity: a systematic review and meta-analysis. Intern Emerg Med 2021; 16:477-486. [PMID: 33011930 DOI: 10.1007/s11739-020-02508-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 09/12/2020] [Indexed: 12/23/2022]
Abstract
Anthracyclines are extensively used in oncologic patients, in particular for breast cancer and hematological malignancies. Cardiac injury is a potentially dangerous side effect of these drugs. In this systematic review, we analyzed published randomized controlled trials (RCTs) to assess if potential cardioprotective drugs (i.e., renin-angiotensin-aldosterone system [RAAS] blockers and β-blockers) may prevent heart damage by anthracyclines. Studies were identified by electronic search of MEDLINE and EMBASE database until August 2020. The impact of cardioprotective drugs to prevent anthracyclines-induced cardiac injury was expressed as mean difference (MD) or odds ratio (OR) and 95% confidence intervals (95% CI). Statistical heterogeneity was assessed with the I2 statistic. Twelve RCTs for a total of 1.035 cancer patients treated with anthracyclines were included. RAAS blockers, β-blockers, and aldosterone antagonists showed a statistically significant benefit in preventing left ventricular ejection fraction (LVEF) reduction (MD 3.57, 95% CI 1.04, 6.09) in 11 studies. A non-statistically significant difference was observed in preventing E/A velocity decrease (MD 0.09, 95% CI 0.00, 0.17; 9 studies), left ventricular end-systolic diameter (LVESD) increase (MD - 0.88, 95% CI, - 2.75,0.99; 6 studies), left ventricular end-diastolic diameter (LVEDD) increase (MD -0.95, 95% CI - 2.67,0.76; 6 studies), and mitral A velocity decrease (MD - 1.42, 95% CI - 3.01,0.17; 4 studies). Heart failure was non-significantly reduced in the cardioprotective arm (OR 0.31, 95% CI 0.06, 1.59; 5 studies). Hypotension was non-significantly increased in the cardioprotective arm (OR 3.91, 95% CI 0.42, 36.46, 3 studies). Cardioprotective drugs reduce anthracycline-induced cardiac damage as assessed by echocardiographic parameters. The clinical relevance of this positive effect is still to be defined.
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Affiliation(s)
| | | | - Leonardo Campiotti
- Department of Medicine and Surgery, University of Insubria, Varese, Como, Italy
| | | | - Luigina Guasti
- Department of Medicine and Surgery, University of Insubria, Varese, Como, Italy
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Leerink JM, de Baat EC, Feijen EA, Bellersen L, van Dalen EC, Grotenhuis HB, Kapusta L, Kok WE, Loonen J, van der Pal HJ, Pluijm SM, Teske AJ, Mavinkurve-Groothuis AM, Merkx R, Kremer LC. Cardiac Disease in Childhood Cancer Survivors: Risk Prediction, Prevention, and Surveillance: JACC CardioOncology State-of-the-Art Review. JACC CardioOncol 2020; 2:363-378. [PMID: 34396245 PMCID: PMC8352294 DOI: 10.1016/j.jaccao.2020.08.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/07/2020] [Accepted: 08/08/2020] [Indexed: 02/06/2023] Open
Abstract
Cardiac diseases in the growing population of childhood cancer survivors are of major concern. Cardiotoxicity as a consequence of anthracyclines and chest radiotherapy continues to be relevant in the modern treatment era. Mitoxantrone has emerged as an important treatment-related risk factor and evidence on traditional cardiovascular risk factors in childhood cancer survivors is accumulating. International surveillance guidelines have been developed with the aim to detect and manage cardiac diseases early and prevent symptomatic disease. There is growing interest in risk prediction models to individualize prevention and surveillance. This State-of-the-Art Review summarizes literature from a systematic PubMed search focused on cardiac diseases after treatment for childhood cancer. Here, we discuss the prevalence, risk factors, prevention, risk prediction, and surveillance of cardiac diseases in survivors of childhood cancer.
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Key Words
- CAD, coronary artery disease
- CCS, childhood cancer survivors
- ECG, electrocardiogram
- FS, fractional shortening
- GLS, global longitudinal strain
- IGHG, International Late Effects of Childhood Cancer Guideline Harmonization Group
- LV, left ventricle
- LVEF, left ventricular ejection fraction
- RCT, randomized controlled trial
- cardiotoxicity
- cardiovascular risk factors
- chest RT, chest-directed radiotherapy
- childhood cancer survivors
- prevention
- risk prediction
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Affiliation(s)
- Jan M. Leerink
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Esmée C. de Baat
- Department of Pediatric Oncology, Princess Máxima Center, Utrecht, the Netherlands
| | | | - Louise Bellersen
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Elvira C. van Dalen
- Department of Pediatric Oncology, Princess Máxima Center, Utrecht, the Netherlands
| | - Heynric B. Grotenhuis
- Department of Pediatric Cardiology, Wilhelmina Children's Hospital, University of Utrecht, Utrecht, the Netherlands
| | - Livia Kapusta
- Department of Pediatric Cardiology, Radboud University Medical Center, Amalia Children’s Hospital, Nijmegen, the Netherlands
- Department of Pediatrics, Tel Aviv University, Sackler School of Medicine, Tel Aviv Sourasky Medical Center, Pediatric Cardiology Unit, Tel Aviv, Israel
| | - Wouter E.M. Kok
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Jacqueline Loonen
- Department of Pediatric Hematology and Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Saskia M.F. Pluijm
- Department of Pediatric Oncology, Princess Máxima Center, Utrecht, the Netherlands
| | - Arco J. Teske
- Department of Cardiology, Utrecht University Medical Center, Utrecht, the Netherlands
| | | | - Remy Merkx
- Department of Medical Imaging, Radboud University Medical Center, Medical UltraSound Imaging Center, Nijmegen, the Netherlands
| | - Leontien C.M. Kremer
- Department of Pediatric Oncology, Princess Máxima Center, Utrecht, the Netherlands
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Bansal N, Adams MJ, Ganatra S, Colan SD, Aggarwal S, Steiner R, Amdani S, Lipshultz ER, Lipshultz SE. Strategies to prevent anthracycline-induced cardiotoxicity in cancer survivors. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2019; 5:18. [PMID: 32154024 PMCID: PMC7048046 DOI: 10.1186/s40959-019-0054-5] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 10/16/2019] [Indexed: 12/11/2022]
Abstract
Cancer diagnostics and therapies have improved steadily over the last few decades, markedly increasing life expectancy for patients at all ages. However, conventional and newer anti-neoplastic therapies can cause short- and long-term cardiotoxicity. The clinical implications of this cardiotoxicity become more important with the increasing use of cardiotoxic drugs. The implications are especially serious among patients predisposed to adverse cardiac effects, such as youth, the elderly, those with cardiovascular comorbidities, and those receiving additional chemotherapies or thoracic radiation. However, the optimal strategy for preventing and managing chemotherapy-induced cardiotoxicity remains unknown. The routine use of neurohormonal antagonists for cardioprotection is not currently justified, given the marginal benefits and associated adverse events, particularly with long-term use. The only United States Food and Drug Administration and European Medicines Agency approved treatment for preventing anthracycline-related cardiomyopathy is dexrazoxane. We advocate administering dexrazoxane during cancer treatment to limit the cardiotoxic effects of anthracycline chemotherapy.
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Affiliation(s)
- Neha Bansal
- Division of Pediatric Cardiology, Children’s Hospital at Montefiore, Bronx, NY USA
| | - M. Jacob Adams
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY USA
| | - Sarju Ganatra
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital and Medical Center, Burlington, MA USA
- Cardio-Oncology Program, Dana-Farber Cancer Institute / Brigham and Women’s Hospital, Boston, MA USA
| | - Steven D. Colan
- Department of Pediatric Cardiology, Boston Children’s Hospital, Boston, MA USA
| | - Sanjeev Aggarwal
- Division of Pediatric Cardiology, Department of Pediatrics, Children’s Hospital of Michigan, Detroit, MI USA
| | | | - Shahnawaz Amdani
- Division of Pediatric Cardiology, Cleveland Clinic Children’s Hospital, Cleveland, OH USA
| | - Emma R. Lipshultz
- Dana-Farber Cancer Institute, Boston, MA USA
- University of Miami Miller School of Medicine, Miami, FL USA
| | - Steven E. Lipshultz
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Oishei Children’s Hospital, 1001 Main Street, Buffalo, NY 14203 USA
- Oishei Children’s Hospital, Buffalo, NY USA
- Roswell Park Comprehensive Cancer Center, Buffalo, NY USA
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Zhan T, Daniyal M, Li J, Mao Y. Preventive use of carvedilol for anthracycline-induced cardiotoxicity: a systematic review and meta-analysis of randomized controlled trials. Herz 2019; 45:1-14. [PMID: 30656389 DOI: 10.1007/s00059-018-4779-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 11/13/2018] [Accepted: 12/09/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Clinical or subclinical cardiotoxicity is a concern for cancer patients receiving anthracycline-based chemotherapy. Carvedilol is promising for preventing anthracycline-induced cardiotoxicity (AIC). This review appraised the preventive effects of carvedilol against AIC based on randomized controlled trials (RCTs). METHODS The Cochrane Collaboration Central Register of Controlled Trials, PubMed, and Embase databases were searched from inception to March 27, 2018. RCTs using carvedilol for the prevention of AIC were selected. Risk of bias and methodological quality were assessed. Meta-analysis was conducted, when applicable, for the trial endpoints; otherwise the data were analyzed descriptively. RESULTS Nine RCTs comprising 717 patients were selected. The risk of bias was unclear and the methodological quality differed substantially. Data pooling of five eligible studies indicated no decreased mortality in patients receiving carvedilol (risk difference = -0.02, 95% CI: -0.07-0.04, p = 0.57, I2 = 44%). The impact on the incidence of left ventricular systolic dysfunction (LVSD) was inconsistently reported but meta-analysis was not applicable due to discordant LVSD definitions. Data pooling of eight studies and a subgroup analysis indicated a higher left ventricular ejection fraction (LVEF) with substantial heterogeneity in the carvedilol group (mean difference [MD] = 5.23, 95% CI: 2.20-8.27, p = 0.0007, I2 = 95%, and MD = 4.65, 95% CI: 0.67-8.64, p = 0.02, I2 = 90%, respectively). Further analysis of echocardiographic parameters and biomarkers showed weak evidence of improvement in diastolic function and troponin I level by carvedilol administration. CONCLUSION Preventive use of carvedilol in patients undergoing anthracycline-based chemotherapy may be associated with a reduced incidence of LVSD, higher LVEF value, better diastolic function, and lower troponin I level. RCTs with larger sample size and longer follow-up are needed to verify these findings.
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Affiliation(s)
- T Zhan
- Hunan University of Chinese Medicine, 300 Xueshi Rd., Yuelu District, 410208, Changsha, Hunan, China
- Department of Integrated TCM and Western Medicine, The First Hospital of Changsha, 410005, Changsha, Hunan, China
| | - M Daniyal
- TCM and Ethnomedicine Innovation & Development Laboratory, School of Pharmacy, Hunan University of Chinese Medicine, 410208, Changsha, Hunan, China
| | - J Li
- Hunan University of Chinese Medicine, 300 Xueshi Rd., Yuelu District, 410208, Changsha, Hunan, China.
| | - Y Mao
- Department of Geriatric Medicine, The Second Affiliated Hospital, Hunan University of Chinese Medicine, 233 North Cai'e Rd., Kaifu District, 410005, Changsha, Hunan, China.
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Neudorf U, Schönecker A, Reinhardt D. Cardio-toxicity in childhood cancer survivors "Cure is not enough". J Thorac Dis 2018; 10:S4344-S4350. [PMID: 30701102 DOI: 10.21037/jtd.2018.11.28] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The number of pediatric cancer survivors is growing, and they are getting older. Therapy-induced cardiotoxicity therefore is debated as an ongoing problem. Recognition of the side effects in the use of anthracyclines and radiation as well as the patients' clinical condition and comorbidities leads back as far as the beginning of systematic cancer treatment in children in the 1980s. Since, numerous case reports, meta-analyses and retrospective surveys were published worldwide. However, randomized clinical trials with standardized protocols yet fail to be designed. This article gives an overview of the recent reports and emphasizes on the heterogeneity of the different approaches. A standardized work-up which may identify the patient at risk-including the patient's history and condition, individual genetic dispositions, dosage and method of drug application, consideration of co-medication, radiation therapy and dose, standardized imaging methods-is the main proposition of our report. The fusion of already established sources, e.g., data of different registries or study centers, might help to create preventive strategies for and a better understanding of patients with therapy induced cardiomyopathy.
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Affiliation(s)
- Ulrich Neudorf
- Clinic of Pediatrics III, University Hospital Essen, D-45122 Essen, Germany
| | - Anne Schönecker
- Clinic of Pediatrics III, University Hospital Essen, D-45122 Essen, Germany
| | - Dirk Reinhardt
- Clinic of Pediatrics III, University Hospital Essen, D-45122 Essen, Germany
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13
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Pharmacologic Management of Cancer Therapeutics-Induced Cardiomyopathy in Adult Cancer Survivors. Curr Heart Fail Rep 2018; 15:270-279. [DOI: 10.1007/s11897-018-0401-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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14
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Lipshultz SE, Herman EH. Anthracycline cardiotoxicity: the importance of horizontally integrating pre-clinical and clinical research. Cardiovasc Res 2018; 114:205-209. [PMID: 29272330 PMCID: PMC5852510 DOI: 10.1093/cvr/cvx246] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- Steven E Lipshultz
- Department of Pediatrics, Wayne State University School of Medicine, Karmanos Cancer Institute, and Children’s Hospital of Michigan, 3901 Beaubien Boulevard, Pediatric Administration-T121A, Detroit, MI 48201, USA
| | - Eugene H Herman
- Toxicology and Pharmacology Branch, Developmental Therapeutics Program, Division of Cancer Treatment and Diagnosis, The National Cancer Institute, Rockville, MD 20850-9734, USA
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15
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Zhang J, Lei W, Chen X, Wang S, Qian W. Oxidative stress response induced by chemotherapy in leukemia treatment. Mol Clin Oncol 2018; 8:391-399. [PMID: 29599981 PMCID: PMC5867396 DOI: 10.3892/mco.2018.1549] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 12/06/2017] [Indexed: 12/14/2022] Open
Abstract
Oxidative stress (OS) has been linked to the etiology and development of leukemia as reactive oxygen species (ROS) and free radicals have been implicated in leukemogenesis. OS has beneficial and deleterious effects in the pathogenesis and progression of leukemia. High-dose chemotherapy, which is frequently used in leukemia treatment, is often accompanied by ROS-induced cytotoxicity. Thus, the utilization of chemotherapy in combination with antioxidants may attenuate leukemia progression, particularly for cases of refractory or relapsed neoplasms. The present review focuses on exploring the roles of OS in leukemogenesis and characterizing the associations between ROS and chemotherapy. Certain examples of treatment regimens wherein antioxidants are combined with chemotherapy are presented, in order to highlight the importance of antioxidant application in leukemia treatment, as well as the conflicting opinions regarding this method of therapy. Understanding the underlying mechanisms of OS generation will facilitate the elucidation of novel approaches to leukemia treatment.
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Affiliation(s)
- Jin Zhang
- Department of Hematology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, P.R. China
| | - Wen Lei
- Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China
| | - Xiaohui Chen
- Department of Hematology, The Affiliated Hospital of Hangzhou Normal University, Hangzhou, Zhejiang 310015, P.R. China
| | - Shibing Wang
- Clinical Research Institute, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang 310014, P.R. China
| | - Wenbin Qian
- Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China
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