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Alexandraki A, Papageorgiou E, Zacharia M, Keramida K, Papakonstantinou A, Cipolla CM, Tsekoura D, Naka K, Mazzocco K, Mauri D, Tsiknakis M, Manikis GC, Marias K, Marcou Y, Kakouri E, Konstantinou I, Daniel M, Galazi M, Kampouroglou E, Ribnikar D, Brown C, Karanasiou G, Antoniades A, Fotiadis D, Filippatos G, Constantinidou A. New Insights in the Era of Clinical Biomarkers as Potential Predictors of Systemic Therapy-Induced Cardiotoxicity in Women with Breast Cancer: A Systematic Review. Cancers (Basel) 2023; 15:3290. [PMID: 37444400 PMCID: PMC10340234 DOI: 10.3390/cancers15133290] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/09/2023] [Accepted: 06/19/2023] [Indexed: 07/15/2023] Open
Abstract
Cardiotoxicity induced by breast cancer therapies is a potentially serious complication associated with the use of various breast cancer therapies. Prediction and better management of cardiotoxicity in patients receiving chemotherapy is of critical importance. However, the management of cancer therapy-related cardiac dysfunction (CTRCD) lacks clinical evidence and is based on limited clinical studies. AIM To provide an overview of existing and potentially novel biomarkers that possess a promising predictive value for the early and late onset of CTRCD in the clinical setting. METHODS A systematic review of published studies searching for promising biomarkers for the prediction of CTRCD in patients with breast cancer was undertaken according to PRISMA guidelines. A search strategy was performed using PubMed, Google Scholar, and Scopus for the period 2013-2023. All subjects were >18 years old, diagnosed with breast cancer, and received breast cancer therapies. RESULTS The most promising biomarkers that can be used for the development of an alternative risk cardiac stratification plan for the prediction and/or early detection of CTRCD in patients with breast cancer were identified. CONCLUSIONS We highlighted the new insights associated with the use of currently available biomarkers as a standard of care for the management of CTRCD and identified potentially novel clinical biomarkers that could be further investigated as promising predictors of CTRCD.
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Affiliation(s)
- Alexia Alexandraki
- A.G. Leventis Clinical Trials Unit, Bank of Cyprus Oncology Centre, 32 Acropoleos Avenue, Nicosia 2006, Cyprus; (E.P.); (M.Z.)
| | - Elisavet Papageorgiou
- A.G. Leventis Clinical Trials Unit, Bank of Cyprus Oncology Centre, 32 Acropoleos Avenue, Nicosia 2006, Cyprus; (E.P.); (M.Z.)
| | - Marina Zacharia
- A.G. Leventis Clinical Trials Unit, Bank of Cyprus Oncology Centre, 32 Acropoleos Avenue, Nicosia 2006, Cyprus; (E.P.); (M.Z.)
| | - Kalliopi Keramida
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece;
- Cardiology Department, General Anti-Cancer Oncological Hospital, Agios Savvas, 11522 Athens, Greece
| | - Andri Papakonstantinou
- Department of Oncology-Pathology, Karolinska Institute, 17176 Stockholm, Sweden;
- Department for Breast, Endocrine Tumours and Sarcoma, Karolinska University Hospital, 17176 Stockholm, Sweden
| | - Carlo M. Cipolla
- Cardioncology and Second Opinion Division, European Institute of Oncology (IEO), IRCCS, Via Ripamonti 435, 20141 Milan, Italy;
| | - Dorothea Tsekoura
- 2nd Department of Surgery, Aretaieio University Hospital, National and Kapodistrian University of Athens, 76 Vas. Sofias Av., 11528 Athens, Greece; (D.T.); (E.K.)
| | - Katerina Naka
- 2nd Cardiology Department, University of Ioannina Medical School, 45110 Ioannina, Greece;
| | - Ketti Mazzocco
- Applied Research Division for Cognitive and Psychological Science, European Institute of Oncology IRCCS, 20139 Milan, Italy;
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
| | - Davide Mauri
- Department of Medical Oncology, University of Ioannina, 45110 Ioannina, Greece;
| | - Manolis Tsiknakis
- Department of Electrical and Computer Engineering, Hellenic Mediterranean University, 71410 Heraklion, Greece; (M.T.); (K.M.)
- Computational BioMedicine Laboratory (CBML), Institute of Computer Science, Foundation for Research and Technology Hellas (FORTH), 70013 Heraklion, Greece;
| | - Georgios C. Manikis
- Computational BioMedicine Laboratory (CBML), Institute of Computer Science, Foundation for Research and Technology Hellas (FORTH), 70013 Heraklion, Greece;
| | - Kostas Marias
- Department of Electrical and Computer Engineering, Hellenic Mediterranean University, 71410 Heraklion, Greece; (M.T.); (K.M.)
- Computational BioMedicine Laboratory (CBML), Institute of Computer Science, Foundation for Research and Technology Hellas (FORTH), 70013 Heraklion, Greece;
| | - Yiola Marcou
- Department of Medical Oncology, Bank of Cyprus Oncology Centre, 32 Acropoleos Avenue, Nicosia 2006, Cyprus; (Y.M.); (E.K.); (I.K.); (M.G.)
| | - Eleni Kakouri
- Department of Medical Oncology, Bank of Cyprus Oncology Centre, 32 Acropoleos Avenue, Nicosia 2006, Cyprus; (Y.M.); (E.K.); (I.K.); (M.G.)
| | - Ifigenia Konstantinou
- Department of Medical Oncology, Bank of Cyprus Oncology Centre, 32 Acropoleos Avenue, Nicosia 2006, Cyprus; (Y.M.); (E.K.); (I.K.); (M.G.)
| | - Maria Daniel
- Department of Radiation Oncology, Bank of Cyprus Oncology Centre, 32 Acropoleos Avenue, Nicosia 2006, Cyprus;
| | - Myria Galazi
- Department of Medical Oncology, Bank of Cyprus Oncology Centre, 32 Acropoleos Avenue, Nicosia 2006, Cyprus; (Y.M.); (E.K.); (I.K.); (M.G.)
| | - Effrosyni Kampouroglou
- 2nd Department of Surgery, Aretaieio University Hospital, National and Kapodistrian University of Athens, 76 Vas. Sofias Av., 11528 Athens, Greece; (D.T.); (E.K.)
| | - Domen Ribnikar
- Division of Medical Oncology, Institute of Oncology Ljubljana, Faculty of Medicine, University of Ljubljana, Zaloska Cesta 2, 1000 Ljubljana, Slovenia;
| | - Cameron Brown
- Translational Medicine, Stremble Ventures Ltd., 59 Christaki Kranou, Limassol 4042, Cyprus;
| | - Georgia Karanasiou
- Biomedical Research Institute, Foundation for Research and Technology, Hellas, 45500 Ioannina, Greece;
| | - Athos Antoniades
- Research and Development, Stremble Ventures Ltd., 59 Christaki Kranou, Limassol 4042, Cyprus;
| | - Dimitrios Fotiadis
- Unit of Medical Technology and Intelligent Information Systems, Department of Materials Science and Engineering, University of Ioannina, 45110 Ioannina, Greece;
| | - Gerasimos Filippatos
- Cardio-Oncology Clinic, Heart Failure Unit, Department of Cardiology, National and Kapodistrian University of Athens Medical School, Athens University Hospital Attikon, 11527 Athens, Greece;
| | - Anastasia Constantinidou
- Department of Medical Oncology, Bank of Cyprus Oncology Centre, 32 Acropoleos Avenue, Nicosia 2006, Cyprus; (Y.M.); (E.K.); (I.K.); (M.G.)
- School of Medicine, University of Cyprus, Panepistimiou 1, Aglantzia, Nicosia 2408, Cyprus
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Jacquinot Q, Meneveau N, Falcoz A, Bouhaddi M, Roux P, Degano B, Chatot M, Curtit E, Mansi L, Paillard MJ, Bazan F, Chaigneau L, Dobi E, Meynard G, Vernerey D, Pivot X, Mougin F. Cardiotoxicity is mitigated after a supervised exercise program in HER2-positive breast cancer undergoing adjuvant trastuzumab. Front Cardiovasc Med 2022; 9:1000846. [PMID: 36211552 PMCID: PMC9537598 DOI: 10.3389/fcvm.2022.1000846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 09/05/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundTrastuzumab is used, alone or in conjunction with standard chemotherapy, to treat HER2-positive breast cancer (BC). Although it improves cancer outcomes, trastuzumab. can lead to cardiotoxicity. Physical exercise is a safe and effective supportive therapy in the management of side effects, but the cardioprotective effects of exercise are still unclear.ObjectivesThe primary aim of this study was to test whether trastuzumab-induced cardiotoxicity [left ventricular ejection fraction (LVEF) under 50%, or an absolute drop in LVEF of 10%] was reduced after a supervised exercise program of 3 months in patients with HER2-positive breast cancer. Secondary endpoints were to evaluate (i) cardiotoxicity rates using other criteria, (ii) cardiac parameters, (iii) cardiorespiratory fitness and (iv) whether a change in LVEF influences the cardiorespiratory fitness.Methods89 women were randomized to receive adjuvant trastuzumab in combination with a training program (training group: TG; n = 46) or trastuzumab alone (control group: CG; n = 43). The primary and secondary endpoints were evaluated at the end of the supervised exercise program of 3 months (T3).ResultsAfter exercise program, 90.5 % of TG patients and 81.8% of CG patients did not exhibit cardiotoxicity. Furthermore, whatever the used criterion, percentage of patients without cardiotoxicity were greater in TG (97.6 and 100% respectively) than in CG (90.9 and 93.9% respectively). LVEF and GLS values remained stable in both groups without any difference between the groups. In contrast, at T3, peak VO2 (+2.6 mL.min−1.kg−1; 95%CI, 1.8 to 3.4) and maximal power (+21.3 W; 95%CI, 17.3 to 25.3) increased significantly in TG, whereas they were unchanged in CG (peak VO2: +0.2 mL.min−1.kg−1; 95%CI, −0.5 to 0.9 and maximal power: +0.7 W, 95%CI, −3.6 to 5.1) compared to values measured at T0. No correlation between LVEF changes and peak VO2 or maximal power was observed.ConclusionA 12-week supervised exercise regimen was safe and improved the cardiopulmonary fitness in particular peak VO2, in HER2-positive BC patients treated with adjuvant trastuzumab therapy. The study is under powered to come to any conclusion regarding the effect on cardiotoxicity.Clinical trial registrationwww.ClinicalTrials.gov, identifier: NCT02433067.
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Affiliation(s)
- Quentin Jacquinot
- Regional Federative Cancer Institute of Franche-Comté, Besançon, France
- Research Unit EA3920, University of Franche-Comté, Besançon, France
- *Correspondence: Quentin Jacquinot
| | - Nathalie Meneveau
- Department of Medical Oncology, University Hospital, Besançon, France
| | - Antoine Falcoz
- UMR 1098, Methodology and Quality of Life Unit in Oncology, University Hospital, Besançon, France
| | - Malika Bouhaddi
- Research Unit EA3920, University of Franche-Comté, Besançon, France
- Physiology-Functional Explorations, University Hospital, Besançon, France
| | - Pauline Roux
- Physiology-Functional Explorations, University Hospital, Besançon, France
| | - Bruno Degano
- Heart-Lung Unit, Department of Physiology-Functional Explorations, University Hospital, Grenoble, France
| | - Marion Chatot
- Department of Cardiology, University Hospital, Besançon, France
| | - Elsa Curtit
- Department of Medical Oncology, University Hospital, Besançon, France
- INSERM UMR 1098, Host-Graft-Tumor Interaction, Cell and Gene Engineering, University of Franche-Comté, Besançon, France
| | - Laura Mansi
- Department of Medical Oncology, University Hospital, Besançon, France
- INSERM UMR 1098, Host-Graft-Tumor Interaction, Cell and Gene Engineering, University of Franche-Comté, Besançon, France
| | | | - Fernando Bazan
- Department of Medical Oncology, University Hospital, Besançon, France
| | - Loïc Chaigneau
- Department of Medical Oncology, University Hospital, Besançon, France
| | - Erion Dobi
- Department of Medical Oncology, University Hospital, Besançon, France
| | - Guillaume Meynard
- Department of Medical Oncology, University Hospital, Besançon, France
| | - Dewi Vernerey
- UMR 1098, Methodology and Quality of Life Unit in Oncology, University Hospital, Besançon, France
| | | | - Fabienne Mougin
- Research Unit EA3920, University of Franche-Comté, Besançon, France
- Sports Science Faculty, University of Franche-Comté, Besançon, France
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Yang Z, Wang W, Wang X, Qin Z. Cardiotoxicity of Epidermal Growth Factor Receptor 2-Targeted Drugs for Breast Cancer. Front Pharmacol 2021; 12:741451. [PMID: 34790121 PMCID: PMC8591078 DOI: 10.3389/fphar.2021.741451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 10/08/2021] [Indexed: 12/09/2022] Open
Abstract
Breast cancer is the most common form of cancer in women and its incidence has been increasing over the years. Human epidermal growth factor receptor 2 (HER2 or ErbB2) overexpression is responsible for 20 to 25% of invasive breast cancers, and is associated with poor prognosis. HER2-targeted therapy has significantly improved overall survival rates in patients with HER2-positive breast cancer. However, despite the benefits of this therapy, its cardiotoxicity is a major concern, especially when HER2-targeted therapy is used in conjunction with anthracyclines. At present, the mechanism of this cardiotoxicity is not fully understood. It is thought that HER2-targeting drugs inhibit HER2/NRG 1 dimer formation, causing an increase in ROS in the mitochondria of cardiomyocytes and inhibiting the PI3K/Akt and Ras/MAPK pathways, resulting in cell apoptosis. Antioxidants, ACE inhibitors, angiotensin II receptor blockers, β-blockers, statins and other drugs may have a cardioprotective effect when used with ErbB2-targeting drugs. NT-proBNP can be used to monitor trastuzumab-induced cardiotoxicity during HER2-targeted treatment and may serve as a biological marker for clinical prediction of cardiotoxicity. Measuring NT-proBNP is non-invasive, inexpensive and reproducible, therefore is worthy of the attention of clinicians. The aim of this review is to discuss the potential mechanisms, clinical features, diagnostic strategies, and intervention strategies related to cardiotoxicity of ErbB2-targeting drugs.
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Affiliation(s)
- ZiYan Yang
- Department of Oncology Center, Oncology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Wei Wang
- Graduate School of Bengbu Medical College, Bengbu, China
| | - Xiaojia Wang
- Department of Breast Medical Oncology, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, China
| | - ZhiQuan Qin
- Department of Oncology Center, Oncology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
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Herradón E, González C, González A, Uranga JA, López-Miranda V. Cardiovascular Toxicity Induced by Chronic Vincristine Treatment. Front Pharmacol 2021; 12:692970. [PMID: 34366848 PMCID: PMC8333869 DOI: 10.3389/fphar.2021.692970] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 06/23/2021] [Indexed: 12/30/2022] Open
Abstract
Vincristine is an effective anticancer agent for treating leukemias, lymphomas, and other solid tumors. Vincristine's better-known severe side effects include bone marrow depression, hyponatremia, peripheral neuropathy, and gastrointestinal distress. In recent years, cardiovascular damage also has been described during vincristine treatments. However, the vascular toxicity induced by vincristine is little studied. The aim of the present is to evaluate whether these alterations remain after the suspension of chemotherapy treatment (sequelae) and the possible mechanisms involved in this vascular damage. Adult male Wistar rats were used. The animals were divided into four treatment groups: two groups of saline (0.9% NaCl; saline, sequelae saline) and two groups of vincristine (100 μg/kg; vincristine, sequelae vincristine). Saline or vincristine was administered intraperitoneally in two cycles of 5 days each, leaving a rest period between cycles of 2 days. The final cumulative vincristine dose administered was 1 mg/kg. Sequelae groups correspond to 2 weeks after stopping treatment with the antitumor agent. At the end of the different experimental protocols, cardiac and vascular functions were analyzed. Alterations in the expression of different proteins in the cardiovascular tissues were also investigated. Chronic treatment with vincristine did not produce significant changes in basal cardiac function but provoked significant endothelial dysfunction in the aorta and a significant decrease in the mesenteric contractile function. These cardiovascular functional alterations disappeared 2 weeks after the suspension of chemotherapy treatment. Vincristine treatment caused a significant increase in the expression of tumor necrosis factor-alpha (TNFα), endothelial and inducible nitric oxide synthases (eNOS and iNOS), and connexin 43 in cardiac tissue. In the aorta, the chronic treatment with vincristine caused a slight non-significant increase in TNFα expression, a significant increase in eNOS and iNOS, and a significant decrease in connexin 43. After 2 weeks of vincristine treatment (sequelae group), the expression of TNFα increased and eNOS and iNOS expressions disappeared, but a significant decrease in the expression of connexin 43 was still observed in the aorta. In mesenteric arteries, similar data to those found in the aorta were observed. In conclusion, chronic treatment with vincristine causes functional alterations in the vascular function of both conductance and resistance vessels and changes in the expressions of TNFα, eNOS, iNOS, and connexin 43 in cardiovascular tissues, implicating direct toxicity during its treatment. These functional alterations are transitory and disappear after the suspension of its treatment.
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Affiliation(s)
- Esperanza Herradón
- Departamento de Ciencias Básicas de la Salud, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Alcorcón, Spain.,Unidad Asociada al Instituto de Química Medica (IQM) del Consejo Superior de Investigaciones Científicas (CSIC), Universidad Rey Juan Carlos, Alcorcón, Spain.,High Performance Research Group in Experimental Pharmacology (Pharmakom-URJC), URJC, Alcorcón, Spain
| | - Cristina González
- Departamento de Ciencias Básicas de la Salud, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Alcorcón, Spain.,Unidad Asociada al Instituto de Química Medica (IQM) del Consejo Superior de Investigaciones Científicas (CSIC), Universidad Rey Juan Carlos, Alcorcón, Spain
| | - Antonio González
- Departamento de Ciencias Básicas de la Salud, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Alcorcón, Spain.,Unidad Asociada al Instituto de Química Medica (IQM) del Consejo Superior de Investigaciones Científicas (CSIC), Universidad Rey Juan Carlos, Alcorcón, Spain.,High Performance Research Group in Experimental Pharmacology (Pharmakom-URJC), URJC, Alcorcón, Spain
| | - Jose Antonio Uranga
- Departamento de Ciencias Básicas de la Salud, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Alcorcón, Spain.,High Performance Research Group in Physiopathology and Pharmacology of the Digestive System (NeuGut-URJC), URJC, Alcorcón, Spain
| | - Visitación López-Miranda
- Departamento de Ciencias Básicas de la Salud, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Alcorcón, Spain.,Unidad Asociada al Instituto de Química Medica (IQM) del Consejo Superior de Investigaciones Científicas (CSIC), Universidad Rey Juan Carlos, Alcorcón, Spain.,High Performance Research Group in Experimental Pharmacology (Pharmakom-URJC), URJC, Alcorcón, Spain
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Gonciar D, Mocan L, Zlibut A, Mocan T, Agoston-Coldea L. Cardiotoxicity in HER2-positive breast cancer patients. Heart Fail Rev 2021; 26:919-935. [PMID: 33405000 DOI: 10.1007/s10741-020-10072-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2020] [Indexed: 01/22/2023]
Abstract
Due to the recent advances in diagnosis and management of patients with HER2-positive breast cancer, especially through novel HER2-targeted agents, cardiotoxicity becomes an emerging problem. Although chemotherapy significantly increases survival, the risk of cardiovascular disease development is high and still underestimated and could imply treatment discontinuation. Frequently, due to lack of rigorous diagnosis strategies, cardiotoxicity assessment is delayed, and, moreover, the efficacy of current therapy options in restoring heart function is questionable. For a comprehensive risk assessment, it is vital to characterize the clinical spectrum of HER2-targeted agents and anthracyclines, as well as their pathogenic pathways involved in cardiotoxicity. Advanced cardiovascular multimodal imaging and circulating biomarkers plays primary roles in early assessing cardiotoxicity and also in guiding specific preventive measures. Even though the knowledge in this field is rapidly expanding, there are still questions that arise regarding the optimal approach in terms of timing and methods. The aim of the current review aims to providean overview of currently available data.
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Affiliation(s)
- Diana Gonciar
- 2nd Department of Internal Medicine, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Lucian Mocan
- 3rd Surgery Department, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.,Department of Nanomedicine, Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Alexandru Zlibut
- 2nd Department of Internal Medicine, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Teodora Mocan
- Physiology Department, Iuliu Hațieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania.,Department of Nanomedicine, Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Lucia Agoston-Coldea
- 2nd Department of Internal Medicine, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.
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Abstract
BACKGROUND Cardiac toxicity in patients with cancer results from treatment-related damage to the cardiovascular system by chemotherapy, targeted agents, or thoracic radiation. Cardio-oncology patients with co-occurring cancer and cardiovascular disease frequently experience fatigue. Exercise is recommended in clinical guidelines to manage fatigue during or after cancer treatment. PURPOSE The purpose of this article is to conduct a scoping review of the exercise randomized clinical trials in cardio-oncology patients, focusing on the components and effects of exercise interventions on patient cardiovascular and fatigue outcomes. METHODS A scoping review methodological framework was deemed appropriate and used. Key words for search included "cancer," "oncology," "cardio-oncology," "heart failure," "physical activity," and "exercise." Search involved systematic searches of large databases (PubMed, MEDLINE, Cochrane Review, and CINAHL) and hand searches of reference lists, key journals, webpages, and experts in the field using snowballing techniques. RESULTS There were 12 randomized clinical trials included in this review. Study characteristics, accordance of exercise protocols with recommendations, specific exercise training components, and cardiovascular and fatigue outcomes were mapped. CONCLUSIONS Recommendations for addressing the gaps included focusing on non-breast-cancer patients with cardiac toxicity risks, developing precision-based prescriptions based on various medical and physiological characteristics, and adding fatigue symptom experience as an outcome variable.
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Treatment with Beta-Blockers and ACE-Inhibitors in Breast Cancer Patients Receiving Adjuvant Trastuzumab-Based Therapy and Developing Mild Cardiac Toxicity: A Prospective Study. Cancers (Basel) 2020; 12:cancers12020327. [PMID: 32023877 PMCID: PMC7072182 DOI: 10.3390/cancers12020327] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 01/26/2020] [Accepted: 01/29/2020] [Indexed: 11/16/2022] Open
Abstract
Background: Angiotensin Converting Enzyme inhibitors (ACEis) and beta-blockers (BB) are suggested to prevent and treat trastuzumab-related cardiac toxicity. We performed a prospective clinical trial in women experiencing mild cardiac toxicity (MCT) while on adjuvant treatment with trastuzumab. Methods: MCT was defined as an asymptomatic absolute decrease in LVEF of ≥ 10 percentage units to >50%. Treatment consisted of enalapril 2.5 mg bid and carvedilol 3.75 mg bid, which were up-titrated to 10 mg bid for the enalapril and 6.25 mg bid of carvedilol. In patients receiving study drug, the primary study end-point was LVEF recovery, which was defined as a post-trastuzumab LVEF returning to no less than −5 percentage points of the baseline value. Results: 103 patients were enrolled, 100 started trastuzumab, and 98 completed the planned treatment. Sixteen patients (16%) had MCT and received study drugs until trastuzumab completion. None of these patients achieved a post-trastuzumab LVEF recovery. Nevertheless, treated patients had significantly higher median LVEF recovery from nadir to post-trastuzumab LVEF in (8% points vs. 4% points, respectively, p = 0.004), resulting in no difference in post-treatment LVEF values compared to patients without MCT. Conclusion: Treatment of MCT with ACEis and BB allows faster LVEF recovery from nadir values and should be further studied in this setting.
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The Evolving Design of NIH-Funded Cardio-Oncology Studies to Address Cancer Treatment-Related Cardiovascular Toxicity. JACC: CARDIOONCOLOGY 2019; 1:105-113. [PMID: 32529192 PMCID: PMC7288847 DOI: 10.1016/j.jaccao.2019.08.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Cardiovascular (CV) toxicity from cancer therapy is a significant and growing concern. Conventional oncology clinical trial designs focused solely on cancer treatment efficacy have not provided sufficient information on both CV risk factors and outcomes. Similarly, traditional CV trials evaluating standard interventions typically exclude cancer patients, particularly those actively receiving cancer therapy. Neither trial type simultaneously evaluates the balance between CV toxicity and cancer outcomes; however, there is increasing collaboration among oncologists and cardiologists to design new cardio-oncology trials that address this important need. In this review, we detail 5 ongoing, oncology-based trials with integrated CV endpoints. Key design features include: 1) a careful assessment of CV risk factors and disease before, during, and after cancer therapy with standardized collection of clinical imaging, functional, and biomarker data; 2) an introduction of cardioprotective interventions at various timepoints in cancer therapy; 3) a balance of the risk of subclinical CV injury with the need for ongoing cancer treatment; and 4) an understanding of the time profile for development of clinically apparent CV toxicity. Additional critical priorities in cardio-oncology clinical research include harmonization of data collection and definitions for all physician- and patient-reported exposures and outcomes. Prospective assessment of CV risk factors before, during, and after cancer treatment. Longitudinal monitoring of CV function with standardized review of CV imaging and functional and biomarker endpoints for evidence of subclinical cardiotoxicity. Consideration for the timing of the introduction of the cardioprotective strategy. Need to balance the delivery of cancer treatment with the risk of CV injury. Long-term follow-up beyond cancer treatment intervention to determine clinical cardiotoxicity outcomes. Rigorous collection of cancer and CV endpoints to answer questions about the impact of CV events on the delivery of cancer treatment and the long-term patient outcomes.
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