Breast cancer treatment-induced cardiotoxicity

Cardiovascular Events Associated with CDK4/6 Inhibitors: A Safety Meta-Analysis of Randomized Controlled Trials and a Pharmacovigilance Study of the FAERS Database

BACKGROUND

CDK4/6 inhibitors are highly valued, but the incidence of cardiovascular adverse events (CVAEs) associated with CDK4/6 inhibitors is not clear.

OBJECTIVE

Our aim was therefore to assess the risk of developing CVAEs associated with CDK4/6 inhibitors, by conducting a systematic review and meta-analysis of randomized controlled trials (RCTs), along with a pharmacovigilance study of the FDA Adverse Event Reporting System (FAERS) database.

METHODS

Eligible CVAEs were extracted from the ClinicalTrials.gov registry. A systematic search of electronic databases (PubMed, Embase, Cochrane Library, and important meetings) until 3 September 2023 was conducted. A disproportionality analysis was performed from the first quarter (Q1) of 2013 to Q1 of 2023 using data from the FAERS database. Study heterogeneity was assessed using the I2 statistic. Using Peto odds ratio (Peto OR) and inverse variance methods to calculate the risk and incidence of CVAEs associated with CDK4/6 inhibitors.

RESULTS

In total, 17 RCTs with 23,437 patients were included in our meta-analysis. During the follow-up period of 8.4-34.0 months, CDK4/6 inhibitors significantly increased the risk of CVAEs (Peto OR, 1.86, 95% confidence interval, 1.30-2.68, P < 0.01). The rates of hypertension and QT prolongation were 68.07 (62.87-73.27) and 57.15 (50.83-63.48) per 1000 patients, respectively. Moreover, we identified nine CVAEs that were not reported in RCTs. These included acute coronary syndrome, arrhythmia, lymphoedema, hot flush, vein rupture, thrombophlebitis migrans, embolism venous, angiopathy and intracardiac thrombus, which were found to be strongly correlated with CDK4/6 inhibitors. Furthermore, the risk of CVAEs varied depending on the specific CDK4/6 inhibitors used, its combination with different endocrine therapies, and the patient's treatment stage.

CONCLUSION

CDK4/6 inhibitors increase the risk of CVAEs, some of which may lead to serious consequences. Early recognition and management of CVAEs is of great importance in clinical practice.

REGISTRATION

PROSPERO registration number CRD42023462059.

Polypharmacy and drug-drug interactions in metastatic breast cancer patients receiving cyclin-dependent kinase (CDK) 4/6 inhibitors

INTRODUCTION

Cyclin-dependent kinase (CDK) 4/6 inhibitors have significantly changed the treatment strategy for patients with locally advanced or metastatic hormone receptor positive (HR+), human epidermal growth factor 2 negative (HER2) breast cancer. The purpose of the study was to determine the prevalence of drug-drug interactions (DDI) in breast cancer patients using CDK 4/6 inhibitors and the extent of DDI reflected in the clinic and to increase clinical awareness among physicians.

METHOD

The data of 115 metastatic breast cancer patients using CDK 4/6 inhibitors who were admitted to the Medical Oncology outpatient clinic between July 2021 and July 2023 were retrospectively reviewed. The Drugs.com® Drug Interaction Checker application was used for the interaction between the CDK 4/6 inhibitor and other drugs.

RESULTS

Among patients included in the study, 97.3% had at least one additional drug use. We have identified a total of 170 potential DDI risks in 63.5 % of patients. Among these, 50.5% had a major potential DDI. In our study, there was a potential risk of QT prolongation in 45.2% of 170 DDI, an increase in the potential toxicity of the additional drug in 44.1%, an increase in the potential toxicity of the CDK 4/6 inhibitor in 5.3%, a decrease in the potential efficacy of the CDK 4/6 inhibitor in 2.9%, a decrease in the potential efficacy of the additional drug in 1.1%, and a serious potential infection risk in 1.1%. Most of the drug interactions were QT prolongation and increased toxicity of the additional drug. In terms of cardiovascular events, grade-2 and grade-3 QTc prolongation was found in 4.3% and 1.7% of these interactions, respectively. When evaluated in terms of CDK 4/6 inhibitor subtype, there was a potential risk of DDI at major level with Ribocilib and at moderate level with Palbociclib.

CONCLUSION

If CDK 4/6 inhibitors interact with concomitant drugs, they may cause an increase in the incidence of cardiac side effects and a decrease in the effect of the CDK 4/6 inhibitor or additional drug or an increase in toxicity. Increasing awareness of this issue will help to reduce the rates of side effects or toxicity and provide effective antitumour therapy.

A review on endoplasmic reticulum-dependent anti-breast cancer activity of herbal drugs: possible challenges and opportunities

Breast cancer (BC) is a major cause of cancer-related mortality across the globe and is especially highly prevalent in females. Based on the poor outcomes and several limitations of present management approaches in BC, there is an urgent need to focus and explore an alternate target and possible drug candidates against the target in the management of BC. The accumulation of misfolded proteins and subsequent activation of unfolded protein response (UPR) alters the homeostasis of endoplasmic reticulum (ER) lumen that ultimately causes oxidative stress in ER. The UPR activates stress-detecting proteins such as IRE1α, PERK, and ATF6, these proteins sometimes may lead to the activation of pro-apoptotic signaling pathways in cancerous cells. The ER stress-dependent antitumor activity could be achieved either through suppressing the adaptive UPR to make cells susceptible to ER stress or by causing chronic ER stress that may lead to triggering of pro-apoptotic signaling pathways. Several herbal drugs trigger ER-dependent apoptosis in BC cells. Therefore, this review discussed the role of fifty-two herbal drugs and their active constituents, focusing on disrupting the balance of the ER within cancer cells. Further, several challenges and opportunities have also been discussed in ER-dependent management in BC.Breast cancer (BC) is a major cause of cancer-related mortality across the globe and is especially highly prevalent in females. Based on the poor outcomes and several limitations of present management approaches in BC, there is an urgent need to focus and explore an alternate target and possible drug candidates against the target in the management of BC. The accumulation of misfolded proteins and subsequent activation of unfolded protein response (UPR) alters the homeostasis of endoplasmic reticulum (ER) lumen that ultimately causes oxidative stress in ER. The UPR activates stress-detecting proteins such as IRE1α, PERK, and ATF6, these proteins sometimes may lead to the activation of pro-apoptotic signaling pathways in cancerous cells. The ER stress-dependent antitumor activity could be achieved either through suppressing the adaptive UPR to make cells susceptible to ER stress or by causing chronic ER stress that may lead to triggering of pro-apoptotic signaling pathways. Several herbal drugs trigger ER-dependent apoptosis in BC cells. Therefore, this review discussed the role of fifty-two herbal drugs and their active constituents, focusing on disrupting the balance of the ER within cancer cells. Further, several challenges and opportunities have also been discussed in ER-dependent management in BC.

Cardiovascular Considerations Before Cancer Therapy: Gaps in Evidence and JACC: CardioOncology Expert Panel Recommendations

Baseline cardiovascular assessment before the initiation of potentially cardiotoxic cancer therapies is a key component of cardio-oncology, aiming to reduce cardiovascular complications and morbidity in patients and survivors. Recent clinical practice guidelines provide both general and cancer therapy-specific recommendations for baseline cardiovascular toxicity risk assessment and management, including the use of dedicated risk scores, cardiovascular imaging, and biomarker testing. However, the value of such interventions in altering disease trajectories has not been established, with many recommendations based on expert opinion or Level of Evidence: C, studies with a potential for high risk of bias. Advances in understanding underlying mechanisms of cardiotoxicity and the increased availability of genetic and immunologic profiling present new opportunities for personalized risk assessment. This paper evaluates the existing evidence on cardiovascular care of cancer patients before cardiotoxic cancer therapy and highlights gaps in evidence and priorities for future research.

Role of Global Left Ventricle Longitudinal Strain and Cardiac Biomarkers in the Early Detection of Cancer Therapy-Related Dysfunction in Patients Treated With Cardiotoxic Chemotherapeutic Drugs in a Cardio-Oncology Clinic

Background Breast cancer (BC) affects many women, and with the prevalence of anthracyclines (AC) used in treatment, cardiotoxicity is a commonly encountered problem. Objective The aim is to early detect subclinical cancer therapy-related cardiac dysfunction (CTRCD) using noninvasive imaging techniques and cardiac biomarkers. Methods Eighty-eight patients with cancer who planned to receive AC or trastuzumab (TZB) were enrolled. Baseline screening included two-dimensional (2D) transthoracic echocardiogram (TTE), global longitudinal strain (GLS), cardiac troponin I (cTnI), and N-terminal pro-brain natriuretic peptide (NT-ProBNP) measurements. Follow-up was done at three and six months to early detect CTRCD. Results Twenty-six patients developed CTRCD, defined by a relative decline in GLS and left ventricular ejection fraction (LVEF). The percentage of change in GLS from baseline and at three and six months was able to detect CTRCD in both groups in our population, which was >16.6% at three months with a p-value of <0.001* and CI 0.783-0.934 and >10.10% at six months with a p-value of <0.001* and CI 0.765-0.935. At three months, GLS values of ≤-18.6 were able to detect CTRCD with a p-value of <0.001* and CI 0.673 0.885. Compared to patients who did not develop CRTD, patients with mild asymptomatic CTRCD had double levels of NT-ProBNP with a median of (99.5) (interquartile range (IQR): 44.0-154.0) at three months. Conclusion The relative decline of GLS and elevation of NT-proBNP were able to diagnose patients with subclinical CTRCD in patients receiving AC with early start of cardioprotective treatments.

Frequency of and sex differences in cancer treatment-related cardiac dysfunction in trastuzumab-treated patients with salivary gland cancer: a retrospective cohort study

BACKGROUND

Trastuzumab treatment for salivary gland, gastric, and breast cancer commonly causes cancer treatment-related cardiac dysfunction (CTRCD). CTRCD incidence by sex has not been well studied.

METHODS

This retrospective cohort study investigated frequency of and sex differences in CTRCD in patients with salivary gland cancer treated with trastuzumab at our hospital from April 2017 to March 2022. All patients underwent echocardiography at baseline and after the first, third, and sixth trastuzumab courses. We measured changes in global and regional longitudinal strain (LS) after trastuzumab administration. CTRCD was defined by left ventricular ejection fraction (LVEF) or global LS (GLS). The results were compared by sex.

RESULTS

We recorded clinical data of 49 patients (median age [IQR], 65 [55-71] years; males [75.5%]). The median follow-up period after the sixth trastuzumab course was 120 (111-128) days. One female patient and no male patient had CTRCD defined by LVEF, and two female patients (16.7%) and seven male patients (18.9%) had CTRCD, defined by GLS. The Kaplan-Meier curves showed no significant difference in CTRCD frequency, defined by GLS (log-rank, p = 0.88), between female and male patients. In the univariate analysis, sex was not associated with CTRCD, defined by GLS. A significant difference in apical LS was observed between baseline and the third follow-up results of male patients.

CONCLUSIONS

In this study, CTRCD incidence was not significantly different between male and female patients with salivary gland cancer treated with trastuzumab. Although most previous studies have looked at female patients with breast cancer, a male patient may be found to be at similar risk of myocardial damage.

[The Cardio-Oncology Guideline - A Comprehensive Approach to Managing Cardiovascular Risks in Cancer Patients]

The emerging field of cardio-oncology addresses the critical need for specialized cardiovascular care in cancer patients, given the overlapping risk factors and potential cardiovascular complications of oncological therapies. In collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO), and the European Society of Cardiology (ESC), the first cardio-oncology guideline was developed and published in 2022. This guideline comprises 272 recommendations covering risk stratification before therapy initiation, monitoring during oncological treatment, and the diagnosis and treatment of therapy-associated cardiovascular side effects.A significant innovation in this guideline is the comprehensive risk stratification approach, which categorizes patients into low, moderate, and high-risk groups based on therapy-specific factors. This allows for tailored cardiovascular care during therapy, with varying frequencies of follow-up examinations depending on the patient's risk level. Notably, the guideline emphasizes the importance of interdisciplinary collaboration between oncologists and cardiologists to optimize patient outcomes.Overall, the cardio-oncology guideline represents a significant advancement in addressing the complex cardiovascular needs of cancer patients. Its comprehensive recommendations and emphasis on interdisciplinary care underscore the importance of optimizing cardiovascular health throughout the oncological treatment journey.This review provides an overview of the guidelines and updates on the risk stratification and therapy of patients with immune checkpoint inhibitor-associated myocarditis (ICIM), as well as the role of statins in protecting against anthracycline-associated cardiotoxicity.

Racial disparities in treatment-related cardiovascular toxicities amongst women with breast cancer: a scoping review

PURPOSE

Black women often experience poorer breast cancer-related outcomes and higher mortality than white women. A contributor to this disparity may relate to the disproportionate burden of cancer treatment-related cardiovascular (CV) toxicities. The objective of this review is to identify studies that report racial differences in CV toxicity risk.

METHODS

Medline and Embase were searched for studies that assessed CV toxicities as the outcome(s) and included Black and White women with breast cancer. Studies were selected based on inclusion/exclusion criteria and through the use of multiple reviewers.

RESULTS

The review included 13 studies following a review of 409 citations and 49 full-text articles. All studies were retrospective and 8/13 utilized data from the Surveillance, Epidemiology, and End Results-Medicare linked database. Trastuzumab was the most frequently studied treatment. The proportion of Black women in these studies ranged from 5.5 to 63%. A majority of studies reported a higher risk of CV toxicity amongst Black women when compared to white women (93%). Black women had up to a two times higher risk of CV toxicity (HR, 2.73 (CI, 1.24 to 6.01)) compared to white women. Only one study evaluated the role of socioeconomic factors in explaining racial differences in CV toxicity; however, the disparity remained even after adjusting for these factors.

CONCLUSIONS

There is a critical need for more longitudinal studies that evaluate multilevel factors (e.g., psychosocial, biological) that may help to explain this disparity.

IMPLICATIONS FOR CANCER SURVIVORS

Black cancer survivors may require additional surveillance and mitigation strategies to decrease disproportionate burden of CV toxicities.

Performance of physical, cardiovascular, and psychological functions in middle-aged women with and without breast cancer

PURPOSE

To compare the physical performance, including upper-limb motor and cardiovascular functions, and psychological functions, including anxiety and depression, sleep, and fatigue, between women with and without breast cancer.

METHODS

Thirty-two women with breast cancer and 32 healthy counterparts were recruited for the study. Upper-limb muscle strength, shoulder range of motion, and upper-limb function were assessed using a handheld dynamometer, a goniometer, and the short form of the Disabilities of Arm-Shoulder-Hand Questionnaire, respectively. Exercise endurance and cardiovascular functions were assessed using the 6-min walk test and blood pressure and heart rate variability, respectively. The Hospital Anxiety and Depression Scale, the Pittsburgh Sleep Quality Index, and the Fatigue Assessment Scale were used to assess the symptoms of anxiety and depression, sleep quality, and fatigue, respectively.

RESULTS

Breast cancer participants' body-weight-adjusted upper-limb strength of both the affected and unaffected sides (0.11-0.14) was only 61.1-77.8% of those of the healthy participants (0.18). Their shoulder mobility of the affected side (flexion: 161.64°; abduction: 157.01°) were 94.2% (flexion) and 92.5% (abduction) of those of the healthy participants (flexion: 171.56°; abduction: 169.68°), respectively. Breast cancer participants had higher quickDASH mean score (19.53), HADS-A mean score (6.78), HADS-D mean score (4.72), global PSQI mean score (7.22) and FAS mean score (25.97) as well as shorter mean distance covered by 6 MWT (496.66 m) than those of the healthy participants.

CONCLUSIONS

Rehabilitative interventions, such as mind-body interventions and exercise training, target physical fitness and promote the psychological health of women with breast cancer are necessary.

Mechanism of breast cancer immune microenvironment in prognosis of heart failure

The treatment of breast cancer can potentially impose a burden on the heart, leading to an increased risk of heart failure. Studies have shown that more than half of breast cancer patients die from non-tumor-related causes, with cardiovascular disease (CVD) being the leading cause of death. However, the underlying mechanism linking breast cancer prognosis and heart failure remains unclear. To investigate this, we conducted an analysis where we compared the differentially expressed genes (DEGs) in early and advanced breast cancer with genes associated with heart failure. This analysis revealed 18 genes that overlapped between the two conditions, with 15 of them being related to immune function. This suggests that immune pathways may play a role in the prognosis of breast cancer patients with heart failure. Using gene expression data from 1260 breast cancer patients, we further examined the impact of these 15 genes on survival time. Additionally, through enrichment analysis, we explored the functions and pathways associated with these genes in relation to breast cancer and heart failure. By constructing a transformer model, we discovered that the expression patterns of these 15 genes can accurately predict the occurrence of heart failure. The model achieved an AUC of 0.86 and an AUPR of 0.91. Moreover, through analysis of single-cell sequencing data from breast cancer patients undergoing PD-1 treatment and experiencing heart failure, we identified a significant number of cell-type-specific genes that were shared between both diseases. This suggests that changes in gene expression in immune cells following breast cancer treatment may be associated with the development of heart failure.

Radiation therapy in the thoracic region: Radio-induced cardiovascular disease, cardiac delineation and sparing, cardiac dose constraints, and cardiac implantable electronic devices

Radiation therapy in the thoracic region may deliver incidental ionizing radiation to the surrounding healthy structures, including the heart. Radio-induced heart toxicity has long been a concern in breast cancer and Hodgkin's lymphoma and was deemed a long-term event. However, recent data highlight the need to limit the dose to the heart in less favorable thoracic cancers too, such as lung and esophageal cancers in which incidental irradiation led to increased mortality. This article will summarize available cardiac dose constraints in various clinical settings and the types of radio-induced cardiovascular diseases encountered as well as delineation of cardiac subheadings and management of cardiac devices. Although still not completely deciphered, heart dose constraints remain intensively investigated and the mean dose to the heart is no longer the only dosimetric parameter to consider since the left anterior descending artery as well as the left ventricle should also be part of dosimetry constraints.

New Insights in the Era of Clinical Biomarkers as Potential Predictors of Systemic Therapy-Induced Cardiotoxicity in Women with Breast Cancer: A Systematic Review

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.

Chemotherapy Induced Cardiotoxicity: A State of the Art Review on General Mechanisms, Prevention, Treatment and Recent Advances in Novel Therapeutics

As medicine advances to employ sophisticated anticancer agents to treat a vast array of oncological conditions, it is worth considering side effects associated with several chemotherapeutics. One adverse effect observed with several classes of chemotherapy agents is cardiotoxicity which leads to reduced ejection fraction (EF), cardiac arrhythmias, hypertension and Ischemia/myocardial infarction that can significantly impact the quality of life and patient outcomes. Research into possible mechanisms has elucidated several mechanisms, such as ROS generation, calcium overload and apoptosis. However, there is a relative scarcity of literature detailing the relationship between the exact mechanism of cardiotoxicity for each anticancer agent and observed clinical effects. This review comprehensively describes cardiotoxicity associated with various classes of anticancer agents and possible mechanisms. Further research exploring possible mechanisms for cardiotoxicity observed with anticancer agents could provide valuable insight into susceptibility for developing symptoms and management guidelines. Chemotherapeutics are associated with several side effects. Several classes of chemotherapy agents cause cardiotoxicity leading to a reduced ejection fraction (EF), cardiac arrhythmias, hypertension, and Ischemia/myocardial infarction. Research into possible mechanisms has elucidated several mechanisms, such as ROS generation, calcium overload, and apoptosis. However, there is a relative scarcity of literature detailing the relationship between the exact mechanism of cardiotoxicity for each anticancer agent and observed clinical effects. This review describes cardiotoxicity associated with various classes of anticancer agents and possible mechanisms. Further research exploring mechanisms for cardiotoxicity observed with anticancer agents could provide insight that will guide management.

Effect of a 1-year tailored exercise program according to cancer trajectories in patients with breast cancer: study protocol for a randomized controlled trial

BACKGROUND

Patients with breast cancer undergo various treatments according to their tumor subtype and cancer stages within 1 year after being diagnosed. Each treatment may cause treatment-related symptoms that have negative impacts on patients' health and quality of life (QoL) The symptoms can be mitigated when exercise interventions are appropriately applied to patients' physical and mental conditions. Although many exercise programs were developed and implemented during this period, the effects of tailored exercise programs according to symptoms and cancer trajectories on patients' long-term health outcomes have not yet been fully elucidated. Therefore, this randomized controlled trial (RCT) aims to investigate the effect of tailored home-based exercise programs on short-term and long-term physiological outcomes in patients with breast cancer.

METHODS

This 12-month RCT includes 96 patients with (stages 1-3) breast cancer randomly assigned to the exercise or control groups. Participants in the exercise group will receive an exercise program tailored to their phase of treatment, type of surgery, and physical function. During post-operative recovery, exercise interventions will be emphasized to improve shoulder range of motion (ROM) and strength. During chemoradiation therapy, exercise intervention will focus on improving physical function and preventing loss of muscle mass. Once chemoradiation therapy is completed, exercise intervention will focus on improving cardiopulmonary fitness and insulin resistance. All interventions will be home-based exercise programs supplemented with once-monthly exercise education and counseling sessions. The main outcome of the study is fasting insulin level at baseline, 6 months, and 1 year post-intervention. Our secondary outcomes include shoulder ROM and strength at 1 month and 3 months, body composition, inflammatory markers, microbiome, QoL, and physical activity levels at 1 month, 6 months, and 1 year post-intervention.

CONCLUSION

This trial is the first tailored home-based exercise oncology trial to better understand the comprehensive phase-dependent short- and long-term effects of exercise on shoulder function, body composition, fasting insulin, biomarkers, and microbiome. The results of this study will inform the development of effective exercise programs tailored to the needs of patients with breast cancer post-operatively.

TRIAL REGISTRATION

The protocol for this study is registered with the Korean Clinical Trials Registry (KCT0007853).

Cardiac safety of dual anti-HER2 blockade with pertuzumab plus trastuzumab in early HER2-positive breast cancer in the APHINITY trial

BACKGROUND

Trastuzumab increases the incidence of cardiac events (CEs) in patients with breast cancer (BC). Dual blockade with pertuzumab (P) and trastuzumab (T) improves BC outcomes and is the standard of care for high-risk human epidermal growth factor receptor 2 (HER2)-positive early BC patients. We analyzed the cardiac safety of P and T in the phase III APHINITY trial.

PATIENTS AND METHODS

Left ventricular ejection fraction (LVEF) ≥ 55% was required at study entry. LVEF assessment was carried out every 3 months during treatment, every 6 months up to month 36, and yearly up to 10 years. Primary CE was defined as heart failure class III/IV and a significant decrease in LVEF (defined as ≥10% from baseline and to <50%), or cardiac death. Secondary CE was defined as a confirmed significant decrease in LVEF, or CEs confirmed by the cardiac advisory board.

RESULTS

The safety analysis population consisted of 4769 patients. With 74 months of median follow-up, CEs were observed in 159 patients (3.3%): 83 (3.5%) in P + T and 76 (3.2%) in T arms, respectively. Most CEs occurred during anti-HER2 therapy (123; 77.4%) and were asymptomatic or mildly symptomatic decreases in LVEF (133; 83.6%). There were two cardiac deaths in each arm (0.1%). Cardiac risk factors indicated were age > 65 years, body mass index ≥ 25 kg/m², baseline LVEF between 55% and <60%, and use of an anthracycline-containing chemotherapy regimen. Acute recovery from a CE based on subsequent LVEF values was observed in 127/155 patients (81.9%).

CONCLUSIONS

Dual blockade with P + T does not increase the risk of CEs compared with T alone. The use of anthracycline-based chemotherapy increases the risk of a CE; hence, non-anthracycline chemotherapy may be considered, particularly in patients with cardiovascular risk factors.

Hazard-based risk grouping effectively stratifying breast cancer patients in post-irradiation long-term heart diseases: a population-based cohort study

Background

Even though advanced radiotherapy techniques provide a better protective effect on surrounding normal tissues, the late sequelae from radiation exposure to the heart are still considerable in breast cancer patients. The present population-based study explored the role of cox-regression-based hazard risk grouping and intended to stratify patients with post-irradiation long-term heart diseases.

Materials and methods

The present study investigated the Taiwan National Health Insurance (TNHI) database. From 2000 to 2017, we identified 158,798 breast cancer patients. Using a propensity score match of 1:1, we included 21,123 patients in each left and right breast irradiation cohort. Heart diseases, including heart failure (HF), ischemic heart disease (IHD), and other heart diseases (OHD), and anticancer agents, including epirubicin, doxorubicin, and trastuzumab, were included for analysis.

Results

Patients received left breast irradiation demonstrated increased risks on IHD (aHR, 1.16; 95% CI, 1.06-1.26; p < 0.01) and OHD (aHR, 1.08; 95% CI, 1.01-1.15; p < 0.05), but not HF (aHR, 1.11; 95% CI, 0.96-1.28; p = 0.14), when compared with patients received right breast irradiation. In patients who received left breast irradiation dose of >6,040 cGy, subsequent epirubicin might have a trend to increase the risk of heart failure (aHR, 1.53; 95% CI, 0.98-2.39; p = 0.058), while doxorubicin (aHR, 0.59; 95% CI, 0.26-1.32; p = 0.19) and trastuzumab (aHR, 0.93; 95% CI, 0.33-2.62; p = 0.89) did not. Older age was the highest independent risk factor for post-irradiation long-term heart diseases.

Conclusion

Generally, systemic anticancer agents are safe in conjunction with radiotherapy for managing post-operative breast cancer patients. Hazard-based risk grouping may help stratify breast cancer patients associated with post-irradiation long-term heart diseases. Notably, radiotherapy should be performed cautiously for elderly left breast cancer patients who received epirubicin. Limited irradiation dose to the heart should be critically considered. Regular monitoring of potential signs of heart failure may be conducted.

Recent Advances of Organ-on-a-Chip in Cancer Modeling Research

Although many studies have focused on oncology and therapeutics in cancer, cancer remains one of the leading causes of death worldwide. Due to the unclear molecular mechanism and complex in vivo microenvironment of tumors, it is challenging to reveal the nature of cancer and develop effective therapeutics. Therefore, the development of new methods to explore the role of heterogeneous TME in individual patients' cancer drug response is urgently needed and critical for the effective therapeutic management of cancer. The organ-on-chip (OoC) platform, which integrates the technology of 3D cell culture, tissue engineering, and microfluidics, is emerging as a new method to simulate the critical structures of the in vivo tumor microenvironment and functional characteristics. It overcomes the failure of traditional 2D/3D cell culture models and preclinical animal models to completely replicate the complex TME of human tumors. As a brand-new technology, OoC is of great significance for the realization of personalized treatment and the development of new drugs. This review discusses the recent advances of OoC in cancer biology studies. It focuses on the design principles of OoC devices and associated applications in cancer modeling. The challenges for the future development of this field are also summarized in this review. This review displays the broad applications of OoC technique and has reference value for oncology development.

Early Diagnosis of Chemotherapy-Linked Cardiotoxicity in Breast Cancer Patients Using Conventional Biomarker Panel: A Prospective Study Protocol

The prognosis of cancer treatment depends on, among other aspects, the cardiotoxicity of chemotherapy. This research aims to create a feasible algorithm for the early diagnosis of antitumor therapy cardiotoxicity in breast cancer patients. The paper represents a protocol for a prospective cohort study with N 120 eligible participants admitted for treatment with anthracyclines and/or trastuzumab. These patients will be allocated into four risk groups regarding potential cardiotoxic complications. Patients will be examined five times every three months for six biomarkers,: cardiac troponin I (cTnI), brain natriuretic peptide (BNP), C-reactive protein (CRP), myeloperoxidase (MPO), galectin-3 (Gal-3), and D-dimer, simultaneously with echocardiographic methods, including speckle tracking. The adjusted relative risk (aOR) of interrupting an entire course of chemotherapy due to cardiotoxic events will be assessed using multiple analyses of proportional Cox risks. The Cox model will also assess associations between baseline biomarker values and time to cardiotoxic events. Moreover, partly conditional survival models will be applied to determine associations between repeated assessments of changes in biomarkers from baseline and time to cancer therapy-related cardiac dysfunction. All models will be adjusted for cancer therapy regimen, baseline LVEF, groups at risk, baseline biomarker values, and age. The decision-tree and principal component analysis (PCA) methods will also be applied. Thus, feasible patterns will be detected.

Prediction of drug-induced liver injury and cardiotoxicity using chemical structure and in vitro assay data

Drug-induced liver injury (DILI) and cardiotoxicity (DICT) are major adverse effects triggered by many clinically important drugs. To provide an alternative to in vivo toxicity testing, the U.S. Tox21 consortium has screened a collection of ∼10K compounds, including drugs in clinical use, against >70 cell-based assays in a quantitative high-throughput screening (qHTS) format. In this study, we compiled reference compound lists for DILI and DICT and compared the potential of Tox21 assay data with chemical structure information in building prediction models for human in vivo hepatotoxicity and cardiotoxicity. Models were built with four different machine learning algorithms (e.g., Random Forest, Naïve Bayes, eXtreme Gradient Boosting, and Support Vector Machine) and model performance was evaluated by calculating the area under the receiver operating characteristic curve (AUC-ROC). Chemical structure-based models showed reasonable predictive power for DILI (best AUC-ROC = 0.75 ± 0.03) and DICT (best AUC-ROC = 0.83 ± 0.03), while Tox21 assay data alone only showed better than random performance. DILI and DICT prediction models built using a combination of assay data and chemical structure information did not have a positive impact on model performance. The suboptimal predictive performance of the assay data is likely due to insufficient coverage of an adequately predictive number of toxicity mechanisms. The Tox21 consortium is currently expanding coverage of biological response space with additional assays that probe toxicologically important targets and under-represented pathways that may improve the prediction of in vivo toxicity such as DILI and DICT.

Pharmacogenomics for Prediction of Cardiovascular Toxicity: Landscape of Emerging Data in Breast Cancer Therapies

Pharmacogenomics is an emerging field in oncology, one that could provide valuable input on identifying patients with inherent risk of toxicity, thus allowing for treatment tailoring and personalization on the basis of the clinical and genetic characteristics of a patient. Cardiotoxicity is a well-known side effect of anthracyclines and anti-HER2 agents, although at a much lower incidence for the latter. Data on single-nucleotide polymorphisms related to cardiotoxicity are emerging but are still scarce, mostly being of retrospective character and heterogeneous. A literature review was performed, aiming to describe current knowledge in pharmacogenomics and prediction of cardiotoxicity related to breast cancer systemic therapies and radiotherapies. Most available data regard genes encoding various enzymes related to anthracycline metabolism and HER2 polymorphisms. The available data are presented, together with the challenges and open questions in the field.

Cold Atmospheric Plasma Apoptotic and Oxidative Effects on MCF7 and HCC1806 Human Breast Cancer Cells

Breast cancer (BC) is a malignant neoplasia with the highest incidence and mortality rates in women worldwide. Currently, therapies include surgery, radiotherapy, and chemotherapy, including targeted therapies in some cases. However, treatments are often associated with serious adverse effects. Looking for new options in BC treatment, we evaluated the therapeutic potential of cold atmospheric plasma (CAP) in two cell lines (MCF7 and HCC1806) with distinct histological features. Apoptosis seemed to be the most prevalent type of death, as corroborated by several biochemical features, including phosphatidylserine exposure, the disruption of mitochondrial membrane potential, an increase in BAX/BCL2 ratio and procaspase 3 loss. Moreover, the accumulation of cells in the G2/M phase of the cell cycle points to the loss of replication ability and decreased survival. Despite reported toxic concentrations of peroxides in culture media exposed to plasma, intracellular peroxide concentration was overall decreased accompanying a reduction in GSH levels shortly after plasma exposure in both cell lines. In HCC1806, elevated nitric oxide (NO) concentration accompanied by reduced superoxide levels suggests that these cells are capable of converting plasma-derived nitrites into NO that competes with superoxide dismutase (SOD) for superoxide to form peroxinitrite. The concomitant inhibition of the antioxidative activity of cells during CAP treatment, particularly the inhibition of cytochrome c oxidase with sodium azide, synergistically increased plasma toxicity. Thus, this in vitro research enlightens the therapeutic potential of CAP in the treatment of breast cancer, elucidating its possible mechanisms of action.

Anticancer Drug-Induced Cardiotoxicity: Insights and Pharmacogenetics

The advancement in therapy has provided a dramatic improvement in the rate of recovery among cancer patients. However, this improved survival is also associated with enhanced risks for cardiovascular manifestations, including hypertension, arrhythmias, and heart failure. The cardiotoxicity induced by chemotherapy is a life-threatening consequence that restricts the use of several chemotherapy drugs in clinical practice. This article addresses the prevalence of cardiotoxicity mediated by commonly used chemotherapeutic and immunotherapeutic agents. The role of susceptible genes and radiation therapy in the occurrence of cardiotoxicity is also reviewed. This review also emphasizes the protective role of antioxidants and future perspectives in anticancer drug-induced cardiotoxicities.

Unravelling the tangled web of hypertension and cancer

Cardiovascular disease remains the primary cause of mortality globally, being responsible for an estimated 17 million deaths every year. Cancer is the second leading cause of death on a global level with roughly 9 million deaths per year being attributed to neoplasms. The two share multiple common risk factors such as obesity, poor physical exercise, older age, smoking and there exists rare monogenic hypertension syndromes. Hypertension is the most important risk factor for cardiovascular disease and affects more than a billion people worldwide and may also be a risk factor for the development of certain types of cancer (e.g. renal cell carcinoma (RCC)). The interaction space of the two conditions becomes more complicated when the well-described hypertensive effect of certain antineoplastic drugs is considered along with the extensive amount of literature on the association of different classes of antihypertensive drugs with cancer risk/prevention. The cardiovascular risks associated with antineoplastic treatment calls for efficient management of relative adverse events and the development of practical strategies for efficient decision-making in the clinic. Pharmacogenetic interactions between cancer treatment and hypertension-related genes is not to be ruled out, but the evidence is not still ample to be incorporated in clinical practice. Precision Medicine has the potential to bridge the gap of knowledge regarding the full spectrum of interactions between cancer and hypertension (and cardiovascular disease) and provide novel solutions through the emerging field of cardio-oncology. In this review, we aimed to examine the bidirectional associations between cancer and hypertension including pharmacotherapy.

A Heart-Breast Cancer-on-a-Chip Platform for Disease Modeling and Monitoring of Cardiotoxicity Induced by Cancer Chemotherapy

Cardiotoxicity is one of the most serious side effects of cancer chemotherapy. Current approaches to monitoring of chemotherapy-induced cardiotoxicity (CIC) as well as model systems that develop in vivo or in vitro CIC platforms fail to notice early signs of CIC. Moreover, breast cancer (BC) patients with preexisting cardiac dysfunctions may lead to different incident levels of CIC. Here, a model is presented for investigating CIC where not only induced pluripotent stem cell (iPSC)-derived cardiac tissues are interacted with BC tissues on a dual-organ platform, but electrochemical immuno-aptasensors can also monitor cell-secreted multiple biomarkers. Fibrotic stages of iPSC-derived cardiac tissues are promoted with a supplement of transforming growth factor-β 1 to assess the differential functionality in healthy and fibrotic cardiac tissues after treatment with doxorubicin (DOX). The production trend of biomarkers evaluated by using the immuno-aptasensors well-matches the outcomes from conventional enzyme-linked immunosorbent assay, demonstrating the accuracy of the authors' sensing platform with much higher sensitivity and lower detection limits for early monitoring of CIC and BC progression. Furthermore, the versatility of this platform is demonstrated by applying a nanoparticle-based DOX-delivery system. The proposed platform would potentially help allow early detection and prediction of CIC in individual patients in the future.

Proinflammatory circulating markers: new players for evaluating asymptomatic acute cardiovascular toxicity in breast cancer treatment

PURPOSE

This study aimed to evaluate markers of cardiac damage (total CK, CKMB and CRP), inflammatory markers (free iron, homocysteine and TNF-α) as well as lipidogram in breast cancer patients undergoing acute cycles of doxorubicin (DOX), paclitaxel (PTX) or trastuzumab (TZ) and to verify if there is an association between these markers and the toxicity of the chemotherapeutic treatment. Methods: Included in the study were 120 breast cancer patients and 50 healthy controls. All analyzes were performed on automated systems. For the statistical analysis, each group was compared with the controls according to their normality by Student's t-test and Mann-Whitney test. Results: Our results showed that DOX treatment led to increased hsCRP (4.80 ± 1.23 mg/dL, p = 0.0005), triglycerides (187.6 ± 25.06, p = 0.0231), TNF-α (42.31 ± 17.96 pg/mL, p = 0.01) and Fe levels (138.8 ± 18.6 μg/dL, p = 0.0193). In the meantime, PTX induced changes in CK-MB (8.78 ± 4.2 U/L, p = 0.0361), hsCRP (7.12 ± 1.87 mg/dL, p = 0.0006), cholesterol (201.7 ± 19.54, p = 0.05), triglycerides (201.7 ± 19.54, p = 0.0277), TNF-α (38.27 ± 9.12 pg/mL, p = 0.023), homocysteine (10.95 ± 0, 86 μmol/L, p = 0.005), and free iron (113 ± 18 6 μg/dL, p = 0.045) while TZ augmented CK-MB (6.9 ± 1.97 U/L, p < 0.00), hsPCR (3.12 ± 0.68 mg/dL, p = 0.095), cholesterol (218.3 ± 16.79, p = 0.0317), triglycerides (218.3 ± 16.79, p = 0.0127), TNF-α (89.6 ± 12.11, p = 0.032), homocysteine (9.95 ± 1.15 μmol/L, p = 0.0396), free iron (120.5 ± 4.64 μg/dl, p = 0.0058) as well. Conclusions: Our data demonstrated the existence of a proinflammatory net triggered by breast cancer chemotherapy that could increase cardiomyocytes permeability and allow the leakage of circulating proteins as CK-MB and induce the production of hsCRP.

Risk of Cardiac Disease in Patients With Breast Cancer: Impact of Patient-Specific Factors and Individual Heart Dose From Three-Dimensional Radiation Therapy Planning

PURPOSE

This retrospective cohort study aimed to determine whether adjuvant radiation therapy increases the risk of cardiac toxicity in Asian women with breast cancer, with a focus on patient-specific factors.

METHODS AND MATERIALS

We evaluated women who underwent primary breast surgery for breast cancer with (n = 520) or without (n = 774) adjuvant radiation therapy between January 2005 and May 2013. Patients who underwent breast surgery without radiation therapy were categorized as patients who received 0 Gy to the heart. The primary endpoint was the occurrence of a breast cancer treatment-related heart disease (BCT-HD), defined as a diagnosis of angina pectoris, unstable angina, myocardial infarction, ischemic heart disease, heart failure, or atrial fibrillation.

RESULTS

In total, 1294 patients were included. The overall 5- and 10-year BCT-HD rates were 2.4% and 5.7%, respectively. The risk of an BCT-HD significantly increased per 1-Gy increase in the mean heart dose (adjusted hazard ratio: 1.23). Additionally, histories of hypertension (hazard ratio: 1.92), and diabetes (hazard ratio: 2.51) were found to be adverse risk factors, whereas regular physical exercise (hazard ratio: 0.17) was a protective factor. Subgroup analysis according to risk groups showed that the effect of increasing mean heart dose (per Gy) was similar between women without or with minimal risk factors (hazard ratio: 1.23) and women with multiple risk factors (hazard ratio: 1.27).

CONCLUSIONS

The results indicate a radiation dose-effect relationship for cardiac disease in breast cancer patients, highlighting that there remains a considerable risk of cardiac toxicity even with 3-dimensional radiation therapy planning. Thus, measures to minimize the heart dose in breast cancer patients undergoing adjuvant radiation therapy, even in those without any risk factor for cardiac disease, should be routinely implemented.

Prevention, Detection, and Management of Heart Failure in Patients Treated for Breast Cancer

PURPOSE OF REVIEW

Long-term survival has increased significantly in breast cancer patients, and cardiovascular side effects are surpassing cancer-related mortality. We summarize risk factors, prevention strategies, detection, and management of cardiotoxicity, with focus on left ventricular dysfunction and heart failure, during breast cancer treatment.

RECENT FINDINGS

Baseline treatment of cardiovascular risk factors is recommended. Anthracycline and trastuzumab treatment constitute a substantial risk of developing cardiotoxicity. There is growing evidence that this can be treated with beta blockers and angiotensin antagonists. Early detection of cardiotoxicity with cardiac imaging and circulating cardiovascular biomarkers is currently evaluated in clinical trials. Chest wall irradiation accelerates atherosclerotic processes and induces fibrosis. Immune checkpoint inhibitors require consideration for surveillance due to a small risk of severe myocarditis. Cyclin-dependent kinases4/6 inhibitors, cyclophosphamide, taxanes, tyrosine kinase inhibitors, and endocrine therapy have a lower-risk profile for cardiotoxicity. Preventive and management strategies to counteract cancer treatment-related left ventricular dysfunction or heart failure in breast cancer patients should include a comprehensive cardiovascular risk assessment and individual clinical evaluation. This should include both patient and treatment-related factors. Further clinical trials especially on early detection, cardioprevention, and management are urgently needed.

The role of cardiac magnetic resonance imaging in the detection and monitoring of cardiotoxicity in patients with breast cancer after treatment: a comprehensive review

The use of chemotherapy medicines for breast cancer (BC) has been associated with an increased risk of cardiotoxicity. In recent years, there have been growing interests regarding the application of cardiovascular magnetic resonance (CMR) imaging, a safe and noninvasive modality, with the potential to identify subtle morphological and functional changes in the myocardium. In this investigation, we aimed to review the performance of various CMR methods in diagnosing cardiotoxicity in BC, induced by chemotherapy or radiotherapy. For this purpose, we reviewed the literature available in PubMed, MEDLINE, Cochrane, Google Scholar, and Scopus databases. Our literature review showed that CMR is a valuable modality for identifying and predicting subclinical cardiotoxicity induced by chemotherapy. The novel T1, T2, and extracellular volume mapping techniques may provide critical information about cardiotoxicity, in addition to other CMR features such as functional and structural changes. However, further research is needed to verify the exact role of these methods in identifying cardiotoxicity and patient management. Since multiple studies have reported the improvement of left ventricular performance following the termination of chemotherapy regimens, CMR remains an essential imaging tool for the prediction of cardiotoxicity and, consequently, decreases the mortality rate of BC due to heart failure.

Real-time three-dimensional echocardiography predicts cardiotoxicity induced by postoperative chemotherapy in breast cancer patients

BACKGROUND

The anthracycline chemotherapeutic drugs are cardiotoxic. Studies have found some indicators related to cardiotoxicity. However, there is currently no accurate indicator that can predict cardiac toxicity early.

AIM

To explore the diagnostic value of real-time three-dimensional echocardiography (RT3DE) in predicting cardiac toxicity in breast cancer patients undergoing chemotherapy.

METHODS

Female breast cancer patients who underwent radical mastectomy and postoperative chemotherapy at the Affiliated Hanzhou First People’s Hospital, Zhejiang University School of Medicine were recruited. All patients were routinely administered with chemotherapy for four cycles (T1-T4) after surgery. Two-dimensional (2D) echocardiography, RT3DE, and serological examinations were performed after each cycle of chemotherapy. Patients were divided into a toxic group and a non-toxic group based on whether patients had Δ left ventricular ejection fraction > 10% after one year of chemotherapy. Repeated measurement analysis of variance was used to compare the changes in 2D echocardiographic indicators, serological indicators, and RT3DE indicators before and after chemotherapy. Multivariate logistic regression was used to identify independent predictive indicators for cardiac toxicity in postoperative chemotherapy patients. Receiver operating characteristics (ROC) curve analysis was performed to analyze the diagnostic value of potential indicators in the diagnosis of cardiotoxicity.

RESULTS

A total of 107 female breast cancer patients were included in the study. T4 maximum peak velocity in early diastole (E peak)/mitral annulus lateral tissue Doppler (e' peak) (E/e'), serological indicators [T4 cardiac troponin I (cTnI) and T4 pro-brain natriuretic peptide (Pro-BNP)], T3 minimum left atrial volume (LAV), T4 LAVmin, T3 LAV before the start of the P wave (LAVprep), and T4 LAVprep in the toxicity group were significantly higher than those in the non-toxic group. Multivariate logistic regression found that T4 cTnI, T4 Pro-BNP, T3 LAVmin, T4 LAVmin, T3 LAVprep, and T4 LAVprep had potential predictive value for cardiac toxicity (P < 0.05). ROC results showed that T4 LAVmin had the highest accuracy for diagnosing cardiac toxicity [area under the curve (AUC) = 0.947; sensitivity = 78.57%; specificity = 94.62%], followed by T4 LAVprep (AUC = 0.899; sensitivity = 100%; specificity = 66.67%). The accuracies of LAVprep and LAVprep in predicting cardiac toxicity were higher than those of T3 LAVmin and T3 LAVprep.

CONCLUSION

RT3DE of left atrial volume can be used to predict the cardiotoxicity caused by chemotherapy, and it is expected to guide the clinical adjustment of dose and schedule in time.

Breast Cancer Survivorship, Quality of Life, and Late Toxicities

Breast cancer is the most frequent cancer in women: in 2018, almost two million cases have been diagnosed all over the world and it represents the principal cause of death from a neoplastic disease in women. In the past years, breast cancer prognosis has significantly improved over time: currently 5-year survival rates are in the range of 90%, and 10-year survival is about 80%. This improvement has been mostly observed in western countries, due to high coverage and compliance with screening programs, leading to early diagnosis, i.e., when the disease is at a subclinical level, and to an improvement in tumor molecular characterization and innovative systemic treatments. Yet the identification of different biological breast cancer subtypes prompted the development of innovative targeted agents and improved treatment personalization. On the other hand, longer survival rates and increasing proportions of cured patients require dedicated strategies to manage long-term sequelae of breast cancer treatments, with particular attention to quality of life. This review analyzes the most important issues, potentially occurring with cancer treatments, concerning long-term sequelae and quality of life, to define a global approach to breast cancer survivorship.

Impact of preexisting type 2 diabetes mellitus and antidiabetic drugs on all-cause and cause-specific mortality among Medicaid-insured women diagnosed with breast cancer

BACKGROUND

We investigated the influence preexisting type 2 diabetes mellitus (T2DM) and antidiabetic drugs have on all-cause and cause-specific mortality among Medicaid-insured women diagnosed with breast cancer.

METHODS

9221 women aged <64 years diagnosed with breast cancer and reported to the New York State (NYS) Cancer Registry from 2004 to 2016 were linked with Medicaid claims. Preexisting T2DM was determined by three diagnosis claims for T2DM with at least one claim prior to breast cancer diagnosis and a prescription claim for an antidiabetic drug within three months following breast cancer diagnosis. Estimated menopausal status was determined by age (premenopausal age <50; postmenopausal age ≥50). Hazard ratios (HR) and 95 % confidence intervals (95 %CI) were calculated with Cox proportional hazards regression, adjusting for confounders.

RESULTS

Women with preexisting T2DM had greater all-cause (HR = 1.40; 95 %CI 1.21, 1.63), cancer-specific (HR = 1.24; 95 %CI 1.04, 1.47), and cardiovascular-specific (HR = 2.46; 95 %CI 1.54, 3.90) mortality hazard compared to nondiabetic women. In subgroup analyses, the association between T2DM and all-cause mortality was found among non-Hispanic White (HR 1.78 95 %CI 1.38, 2.30) and postmenopausal (HR = 1.47; 95 %CI 1.23, 1.77) women, but not among other race/ethnicity groups or premenopausal women. Additionally, compared to women prescribed metformin, all-cause mortality hazard was elevated among women prescribed sulfonylurea (HR = 1.44; 95 %CI 1.06, 1.94) or insulin (HR = 1.54; 95 %CI 1.12, 2.11).

CONCLUSION

Among Medicaid-insured women with breast cancer, those with preexisting T2DM have an increased mortality hazard, especially when prescribed sulfonylurea or insulin. Further research is warranted to determine the role antidiabetic drugs have on survival among women with breast cancer.

Six Months vs. 12 Months of Adjuvant Trastuzumab Among Women With HER2-Positive Early-Stage Breast Cancer: A Meta-Analysis of Randomized Controlled Trials

Purpose: Both 12 and 6 months of trastuzumab in combination with chemotherapy are effective for HER2+ early-stage breast cancer. This meta-analysis was performed to assess the effectiveness and the toxicity of the two durations. Methods and Materials: We acquired relevant randomized controlled trials (RCTs) from PubMed, the Cochrane Library, ScienceDirect, EMBASE, Ovid MEDLINE, Web of Science, Scopus, and Google Scholar. Our endpoints included disease-free survival (DFS), overall survival (OS), number of recurrences, mortality and early stopping of trastuzumab, and adverse events (AEs). Results: We included five good-quality studies. Both durations of trastuzumab were effective among women with HER2+ early-stage breast cancer, but 12 months of trastuzumab appeared to have better DFS [hazard ratio (HR) = 1.10, 95% confidence interval (CI): 0.99-1.23, P = 0.09] and better OS than 6 months of trastuzumab (HR = 1.14, 95% CI: 0.99-1.32, P = 0.07). However, the 12 month group had more AEs, especially cardiac events [risk ratio (RR) = 0.66, 95% CI: 0.56-0.77, P < 0.00001]. In our sub-analyses, the 12 months duration had better DFS among patients using trastuzumab concurrently than the 6 months duration (HR = 1.23, 95% CI: 1.06-1.44, P = 0.006). Additionally, the 12 months duration had superior OS in women with ER-negative breast cancer (HR = 1.51, 95% CI: 1.10-2.08, P = 0.01) and patients treated with trastuzumab concurrently than the 6 months duration (HR = 1.61, 95% CI: 1.13-2.29, P = 0.008). Conclusions: Twelve months was the standard duration of adjuvant trastuzumab among patients with HER2+ early-stage breast cancer, with a tendency toward superior survival. However, patients in the 12 month group had more significant cardiac toxicity than those in the 6 month group.

DIBI, a novel 3-hydroxypyridin-4-one chelator iron-binding polymer, inhibits breast cancer cell growth and functions as a chemosensitizer by promoting S-phase DNA damage

Breast cancer is a leading cause of cancer-related death in women; however, chemotherapy of breast cancer is often hindered by dose-limiting toxicities, demonstrating the need for less toxic approaches to treatment. Since the rapid growth and metabolism of breast cancer cells results in an increased requirement for iron, withdrawal of bioavailable iron using highly selective iron chelators has been suggested to represent a new approach to breast cancer treatment. Here we show that the recently developed iron-binding polymer DIBI inhibited the growth of five different breast cancer cell lines (SK-BR3, MDA-MB-468, MDA-MB-231, MCF-7, and T47D). In cultures of MDA-MB-468 breast cancer cells, which were most sensitive to DIBI-mediated growth inhibition, iron withdrawal was associated with increased expression of transferrin receptor 1 and ferritin H mRNA but decreased expression of ferroportin mRNA. MDA-MB-468 cells that were exposed to DIBI experienced double-strand DNA breaks during the S phase of the cell cycle. DNA damage was not mediated by reactive oxygen species (ROS) since DIBI-treated MDA-MB-468 cells exhibited a reduction in intracellular ROS. DIBI-treated MDA-MB-468 cells also showed increased sensitivity to growth inhibition by the chemotherapeutic drugs cisplatin, doxorubicin, and 4-hydroperoxy cyclophosphamide (active metabolite of cyclophosphamide). Combination treatment of MDA-MB-468 cells with DIBI and cisplatin caused greater DNA damage than either treatment alone, which was also associated with an increase in apoptotic cell death. Taken together, these findings suggest that DIBI-mediated iron withdrawal may enhance the effect of chemotherapeutic agents used in breast cancer treatment.

Adherence to quality breast cancer survivorship care in four Canadian provinces: a CanIMPACT retrospective cohort study

BACKGROUND

In order to maximize later health, there are established components and guidelines for quality follow-up care of breast cancer survivors. However, adherence to quality follow-up in Canada may not be optimal, and may vary by province. We determined and compared the proportion of patients in each province who received adherent and non-adherent surveillance for recurrence, new cancers and late effects, recommended preventive care, and recommended physician visits for comorbidities.

METHODS

Cohorts consisted of all adult women diagnosed with incident invasive breast cancer between 2007 and 2010/2012 in four Canadian provinces (British Columbia (BC) N = 9338; Manitoba N = 2688; Ontario N = 23,700; Nova Scotia (NS) N = 2735), identified from provincial cancer registries, alive and cancer-free at 30 months post-diagnosis. Their healthcare utilization was determined from one to 5 years post-treatment, using linked administrative databases. Adherence, underuse, and overuse of recommended services were evaluated yearly and compared using descriptive statistics.

RESULTS

In all provinces and follow-up years, the majority of survivors had more than the recommended number of visits to either an oncologist or primary care physician (range 53.8% NS Year 3; 85.8% Ontario Year 4). The proportion of patients with the guideline-recommended number of oncologist visits varied by province (range 29.8% BC Year 5; 74.8% Ontario Year 5), and the proportion of patients with less than the recommended number of specified breast cancer-related visits with either an oncologist or primary care physician ranged from 32.6% (Ontario Year 2) to 84.4% (NS Year 3). Underuse of surveillance breast imaging was identified in NS and BC. The proportion of patients receiving imaging for metastatic disease (not recommended in the guidelines) in BC, Manitoba, and Ontario (not reported in NS) ranged from 20.3% (BC Year 5) to 53.3% (Ontario Year 2). Compliance with recommended physician visits for patients with several chronic conditions was high in Ontario and NS. Preventive care was less than optimal in all provinces with available data.

CONCLUSIONS

Quality of breast cancer survivor follow-up care varies among provinces. Results point to exploration of factors affecting differences, province-specific opportunities for care improvement, and the value of administrative datasets for health system assessment.

Suspected Adverse Drug Reactions Related to Breast Cancer Chemotherapy: Disproportionality Analysis of the Brazilian Spontaneous Reporting System

Spontaneous reporting systems may generate a large volume of information in real world conditions with a relatively low cost. Disproportionality measures are useful to indicate and quantify unexpected safety issues associated with a given drug-event pair (signals of disproportionality), based upon differences compared to the background reporting frequency. This cross-sectional study (2008 to 2013) aimed to analyse the feasibility of detecting such signals in the Brazilian Pharmacovigilance Database comprising suspected adverse drug reactions related to the use of doxorubicin, cyclophosphamide, carboplatin, trastuzumab, docetaxel, and paclitaxel for breast cancer chemotherapy. We first accessed overall database features (patient information and suspected adverse drug reactions) and further conducted a disproportionality analysis based on Reporting Odds Ratios with a confidence interval of 95% in order to identify possible signals of disproportionate reporting, only among serious suspected adverse drug reactions. Of all data reports of adverse reactions (n = 2603), 83% were classified as serious, with the highest prevalence with docetaxel (78.1%). The final analysis was performed using 1,309 reports with 3,139 drug-reaction pairs. The following signals of disproportionate reporting, some rare or not mentioned on labels, were observed: tachypnea with docetaxel; bronchospasm, syncope, cyanosis, and anaphylactic reaction with paclitaxel; and anaphylactic shock with trastuzumab. Structured management of spontaneous adverse drug reaction reporting is essential for monitoring the safe use of drugs and detecting early safety signals. Disproportionality signal analysis represents a viable and applicable strategy for oncology signal screening in the Brazilian Pharmacovigilance Database.

Curing breast cancer and killing the heart: A novel model to explain elevated cardiovascular disease and mortality risk among women with early stage breast cancer

Due to advances in prevention, early detection and treatment, early breast cancer mortality has decreased by nearly 40% during the last four decades. Yet, the risk of cardiovascular disease (CVD) mortality is significantly elevated following a breast cancer diagnosis, and it is a leading cause of death in this population. This review will discuss the most recent evidence for risks, pathology, mechanisms, and prevention of CVD morbidity and mortality in women with breast cancer. This evidence will be synthesized into a new model 'the compounding risk and protection model.' This model proposes that the balance between risk factors (i.e., older age, pre-existing traditional CVD risk factors and shared biologic pathways for CVD and cancer such as inflammation, as well as treatment-related and lifestyle toxicity) and potential protection factors (i.e., lifelong non-smoking, regular physical activity, a healthy diet rich in fruits and vegetables, and management of body weight and stress, heart failure therapy) determine the individual risk of CVD morbidity and mortality after diagnosis of early breast cancer.

Effect of individualised physical rehabilitation programmes on the functional state of the cardiovascular system in women with post-mastectomy syndrome

Background/Aims

The purpose of this study was to determine the effectiveness of individualised physical rehabilitation programmes aimed at improving cardiovascular function in women with post-mastectomy syndrome.

Methods

The following methods were applied: theoretical analysis of scientific and methodologic literature data, impedance cardiography, and mathematical statistical methods. A total of 115 women with late symptoms of post-mastectomy syndrome who completed the interventions were included in this study. The participants were randomly enrolled into three groups for the first individualised programme (Group 1, n=45), for the second individualised programme (Group 2, n=40) and for the third individualised programme (Group 3, n=30). The first programme included aqua aerobics (aqua jogging, aqua building, aqua stretching), conditional swimming and recreational aerobics; the second programme included conditional swimming and Pilates exercises; the third programme included yoga-based exercises and stretching. The study was conducted during the ambulatory rehabilitation stage and lasted for 12 months.

Results

It was found that most of the investigated hemodynamic parameters in all groups steadily improved during the year of rehabilitation. The average values of stroke volume, cardiac output, left ventricular work, left ventricular power after 12 months of rehabilitation were statistically better (P<0.05) in the first main group compared with the second and third main groups.

Conclusions

Individualised programmes of physical rehabilitation were effective in improvement of cardiovascular function of all studied patients with post-mastectomy syndrome.

Effect of Rosuvastatin in Preventing Chemotherapy-Induced Cardiotoxicity in Women With Breast Cancer: A Randomized, Single-Blind, Placebo-Controlled Trial

OBJECTIVE

Chemotherapy-induced cardiotoxicity is a major and leading cause of death in breast cancer survivors. It can present decades after chemotherapy and can manifest in different ways; some chemotherapeutic agents have a powerful dose-dependent relationship with cardiotoxicity. The aim of this study was to investigate the effect of rosuvastatin on preventing chemotherapy-induced cardiotoxicity in patients with breast cancer.

METHODS

Our study was a randomized, single-blind, placebo-controlled trial that involved 89 women with newly diagnosed breast cancer who were scheduled to receive chemotherapy. Patients were randomly assigned to receive rosuvastatin or a placebo in a 1:1 ratio for 6 months. Echocardiography, using 2-dimensional (2D) Doppler, tissue Doppler, and speckle-tracking methods, was used to determine the absolute changes in the left ventricular systolic ejection fraction (LVEF), left ventricular end-diastolic volume (LVEDV), left ventricular end-systolic volume (LVESV), left atrial (LA) diameter, transmitral Doppler early diastolic velocity (E wave), tissue Doppler early diastolic (e') and peak systolic (s') mitral annular velocities, E/e' ratio, and global longitudinal systolic strain.

RESULTS

The LVEF was significantly reduced in the placebo group at the end of the study when compared with the baseline value. However, there was no significant difference in the LVEF in the intervention group (intergroup P = .012). Furthermore, compared with the intervention group at the end of the study, there was a significant increase in the 4- and 2-chamber LVESV, LA diameter, and E/e' ratio in the placebo group (intergroup P = .019, P = .024, P < .001, and P = .021, respectively) and a significant decrease in the e' and s' velocities in the placebo group (intergroup P < .001 and P < .006, respectively).

CONCLUSIONS

The present study showed that the prophylactic use of rosuvastatin may prevent the development of chemotherapy-induced cardiotoxicity.

Normal tissue sparing potential of scanned proton beams with and without respiratory gating for the treatment of internal mammary nodes in breast cancer radiotherapy

Proton therapy has shown potential for reducing doses to normal tissues in breast cancer radiotherapy. However data on the impact of protons when including internal mammary nodes (IMN) in the target for breast radiotherapy is comparatively scarce. This study aimed to evaluate normal tissue doses when including the IMN in regional RT with scanned proton beams, with and without respiratory gating. The study cohort was composed of ten left-sided breast patients CT-scanned during enhanced inspiration gating (EIG) and free-breathing (FB). Proton plans were designed for the target including or excluding the IMN. Targets and organs-at-risk were delineated according to RTOG guidelines. Comparison was performed between dosimetric parameters characterizing target coverage and OAR radiation burden. Statistical significance of differences was tested using a paired, two-tailed Student's t-test. Inclusion of the IMN in the target volume led to a small increase of the cardiopulmonary burden. The largest differences were seen for the ipsilateral lung where the mean dose increased from 6.1 to 6.6 Gy (RBE) (P < 0.0001) in FB plans and from 6.9 to 7.4 Gy (RBE) (P = 0.003) in EIG plans. Target coverage parameters were very little affected by the inclusion of IMN into the treatment target. Radiotherapy with scanned proton beams has the potential of maintaining low cardiovascular burden when including the IMN into the target, irrespective of whether respiratory gating is used or not.

Ongoing unmet needs in treating estrogen receptor-positive/HER2-negative metastatic breast cancer

Estrogen receptor-positive (ER+)/human epidermal growth factor receptor 2 negative (HER2-) advanced or metastatic breast cancer (MBC) is the most common MBC subtype and currently remains incurable, with a median overall survival of 24.8 months (95% confidence interval, 21.3-30.3). Common sites of metastases are bone, viscera, and brain, causing significant symptoms that negatively affect patient functioning, quality of life (QoL), and work productivity. Guidelines state that endocrine therapy (ET) is preferable to chemotherapy as first-line treatment for patients with ER+ MBC, regardless of limited visceral metastases, unless rapid tumor response is required or ET resistance is suspected. Although response rates up to 40% have been reported for first-line MBC treatment, the majority of initial responders eventually develop ET resistance. Notwithstanding the steep decline in efficacy between first and later lines of ET, some patients may receive chemotherapy earlier than necessary. Although new treatments have been approved for patients with ER+/HER2- advanced or MBC in the past decade, neither survival nor QoL appear to have improved significantly. Thus, there remain significant unmet needs for this patient population, including improved survival, maintaining or improving patient QoL, and emphasizing the importance of treatment selection to assist healthcare practitioners managing patient care. In this review, we identify current challenges and unmet needs in this patient population, review cutting-edge treatments, and provide clinically relevant suggestions for treatment selection that can optimize outcomes and patients' health-related QoL.