Cardiotoxicity and cardiovascular disease risk assessment for patients receiving breast cancer treatment

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.

Comorbidities and their management in women with breast cancer-an Australian survey of breast cancer survivors

PURPOSE

Breast cancer survivors experience significant burden from comorbid chronic conditions, but little is known about how well these conditions are managed. We conducted a national survey of Australian breast cancer survivors to examine the burden of chronic conditions, their impact and care alignment with the principles of chronic condition management.

METHODS

A study-specific survey incorporated questions about chronic conditions using the Charlson Comorbidity Index (CCI), functional status using the Vulnerable Elders Survey (VES) and perceived quality of care for cancer and non-cancer conditions using the Patient Assessment of Care for Chronic Conditions Survey (PACIC). Members of Breast Cancer Network Australia (BCNA) were invited via email to complete the survey either online or through direct mail.

RESULTS

The survey was sent to 2198 BCNA members and 177 responses were received (8.1%). Respondents were women aged 32-88 years (median 60.1 years). The majority were married (116; 67.7%) and had private insurance (137; 80.0%) and reported good to excellent health (119; 73.5%). Other health conditions were reported by 157 (88.7%), the most common being chronic pain (27.1%) and fatigue (22.0%). When asked about management of comorbidities or cancer, less than 20% were routinely asked about management goals, helped to set goals or asked about health habits.

CONCLUSIONS

In this population of survivors with good health status and high rates of private insurance, comorbidities were common and their management, as well as management of breast cancer, was poorly aligned with chronic condition management principles.

Modulation of interaction of BRCA1-RAD51 and BRCA1-AURKA protein complexes by natural metabolites using as possible therapeutic intervention toward cardiotoxic effects of cancer drugs: an in-silico approach

Breast cancer type 1 susceptibility protein (BRCA1) plays an important role in maintaining genome stability and is known to interact with several proteins involved in cellular pathways, gene transcription regulation and DNA damage response. More than 40% of inherited breast cancer cases are due to BRCA1 mutation. It is also a prognostic marker in non-small cell lung cancer patients as well as a gatekeeper of cardiac function. Interaction of mutant BRCA1 with other proteins is known to disrupt the tumor suppression mechanism. Two directly interacting proteins with BRCA1 namely, DNA repair protein RAD51 (RAD51) and Aurora kinase A (AURKA), known to regulate homologous recombination (HR) and G/M cell cycle transition, respectively, form protein complex with both wild and mutant BRCA1. To analyze the interactions, protein-protein complexes were generated for each pair of proteins. In order to combat the cardiotoxic effects of cancer drugs, pharmacokinetically screened natural metabolites derived from plant, marine and bacterial sources and along with FDA-approved cancer drugs as control, were subjected to molecular docking. Piperoleine B and dihydrocircumin were the best docked natural metabolites in both RAD51 and AURKA complexes, respectively. Molecular dynamics simulation (MDS) analysis and binding free energy calculations for the best docked natural metabolite and drug for both the mutant BRCA1 complexes suggested better stability for the natural metabolites piperolein B and dihydrocurcumin as compared to drug. Thus, both natural metabolites could be further analyzed for their role against the cardiotoxic effects of cancer drugs through wet lab experiments.Communicated by Ramaswamy H. Sarma.

Incidence of immune checkpoint inhibitor mediated cardiovascular toxicity: A systematic review and meta-analysis

BACKGROUND

Immune checkpoint inhibitors (ICI) are a novel class of anti-cancer therapy becoming increasingly associated with fatal cardiovascular toxicities (CVTs). The aim is to determine the incidence of CVTs in cohorts treated with ICIs as sole anti-cancer therapy.

METHODS

A systematic literature search of scientific and medical databases was performed using PRISMA principles to identify relevant cohorts (PROSPERO registration CRD42021272470). Data for specific CVTs (pericardial disease, myocarditis, heart failure, arrhythmia, myocardial infarction/ischaemia and angina), CVT-related death and CV risk factors were extracted. Presence of CVTs in ICI-monotherapy versus combination-ICI therapy, and programmed death 1/programmed death ligand 1- (PD1/PDL1-) versus cytotoxic T-lymphocyte-associated protein 4- (CTLA4-) inhibitor groups were dichotomised and meta-analysed using random-effect models.

RESULTS

Forty-eight studies (11,207 patients) were identified, from which 146 CVTs were observed (incidence 1.30%). ICI-monotherapy led to more CVTs than combination therapy (119/9009; 1.32% vs. 18/2086; 0.86%). Across monotherapies, PD1/PDL1-inhibitors had lower incidence of CVTs compared to CTLA4-inhibitors (62/6950; 0.89% vs. 57/2059; 2.77%). Based on eight studies that were meta-analysed, no significant difference was observed comparing monotherapy versus combination-ICI therapy (RR-0.69, 95% CI -1.47 to 0.09) for all CVTs, or PD1/PDL1- to CTLA4-inhibitors (RR-0.27, 95% CI -2.06 to 1.53), for all CVTs including CVT-death. CV risk factors could not be attributed to an ICI group as data was population based rather than individual based.

CONCLUSION

ICI-mediated CVTs are rare and potentially fatal. The role of CV risk factors in their development remains unclear.

Assessment of Oncology Provider Knowledge and Cardiovascular Screening Practices: A Call for Heightened Screening

Cardiac risk factors are known to compound the development of cardiotoxicities (CTx) in patients exposed to anthracycline (ANT) chemotherapy agents. National oncology and cardiology organizations have published recommendations for cardiovascular risk stratification and screening cancer patients following exposure to ANTs. The frequency with which oncology providers are integrating these principles into practice is unknown. This knowledge-based quality improvement (QI) project was designed to heighten oncology provider competencies such that screening frequency of cancer patients for CTx in the post-ANT setting aligns more closely with national guidelines for care. A web-based educational intervention, cardiac screening tool, and evidence-based literature were shared with 20 oncology providers over the course of 5 months. Retrospective chart reviews and pre- and post-project surveys were performed to assess competencies and practice trends. Qualitative and quantitative data were analyzed to illustrate whether the interventions improved knowledge and changed practice. Findings revealed an increase in the number of provider-perceived percentage of high cardiac risk patients and the number of patients screened, knowledge did not improve, and the frequency by which oncology providers ordered echocardiograms increased minimally. Factors such as organizational system changes, time constraints, and change fatigue limited effective and consistent implementation of the project interventions. The trajectory of cancer survivorship is affected by cardiovascular disease. Cardiac screening of cancer patients is a critical component of cancer care that has the potential to positively impact economic and health outcomes of this susceptible population.

Evaluation of the influence of diet supplementation with conjugated linoleic acid isomers on elemental composition in the cardio-oncological nutritional programming rat' model

BACKGROUND

The 'developmental origin of health and disease' (DOHaD) hypothesis assumes that due to the action of some stimuli during fetal life the long-term physiological changes occurs and may affects the risk of various diseases. The main aim of this study was to assess impact of supplementation of maternal' and early postnatal diet with conjugated linoleic acids (CLA) isomers on selected elements content in hearts of their female offspring with chemically induced breast cancer.

METHODS

Elemental composition was determined by quadrupole mass spectrometer with inductively coupled plasma ionization (ICP-MS).

RESULTS

The effect of maternal' diet on the elements content was more pronounced than the progeny diet modifications. Significant correlations among determined elements, especially macroelements, and lipidomic parameters, in the experimental factors dependent manner were observed. It can be concluded that supplementation of maternal and progeny diets with CLA isomers may significantly influence the contents of both macro- and microelements in cardiac tissue of newborns.

CONCLUSION

Our results also indicate, that dynamic and intricate balance among various elements in body may be affected by the lipid dietary supplements also in the pathological state. Utility of cardio-oncological approach in developmental programming study was confirmed.

Baseline cardiovascular comorbidities, and the influence on cancer treatment decision-making in women with breast cancer

Purpose

To measure the baseline prevalence of cardiovascular disease (CVD), its modifiable and non-modifiable risk factors in breast cancer patients, and determine their association with adjuvant treatment decision-making.

Method

From 2016 to 2017, 2,127 women newly-diagnosed with breast cancer were prospectively recruited. Participants’ cardiovascular biomarkers were measured prior to adjuvant treatment decision-making. Clinical data and medical histories were obtained from hospital records. Adjuvant treatment decisions were collated 6–8 months after recruitment. A priori risk of cardiotoxicity was predicted using the Cardiotoxicity Risk Score.

Results

Mean age was 54 years. Eighty-five patients had pre-existing cardiac diseases and 30 had prior stroke. Baseline prevalence of hypertension was 47.8%. Close to 20% had diabetes mellitus, or were obese. Dyslipidaemia was present in 65.3%. The proportion of women presenting with ≥2 modifiable CVD risk factors at initial cancer diagnosis was substantial, irrespective of age. Significant ethnic variations were observed. Multivariable analyses showed that pre-existing CVD was consistently associated with lower administration of adjuvant breast cancer therapies (odds ratio for chemotherapy: 0.32, 95% confidence interval: 0.17–0.58). However, presence of multiple risk factors of CVD did not appear to influence adjuvant treatment decision-making. In this study, 63.6% of patients were predicted to have high risks of developing cardiotoxicities attributed to a high baseline burden of CVD risk factors and anthracycline administration.

Conclusion

While recent guidelines recommend routine assessment of cardiovascular comorbidities in cancer patients prior to initiation of anticancer therapies, this study highlights the prevailing gap in knowledge on how such data may be used to optimise cancer treatment decision-making.

Risk Factors for Anthracycline-Induced Cardiotoxicity

Background: Several cardiovascular risk factors have been suggested to be associated with anthracycline-induced cardiotoxicity, but their quantitative effects have not reached a consensus.

Methods: We searched PubMed, EMBASE, and Cochrane Library databases for manuscripts published from inception to February 2021, which reported the results of cardiotoxicity due to anthracycline chemotherapy without trastuzumab. Cardiotoxicity defined by any reduction of left ventricular eject fraction (LVEF) to below 50% or a >10% reduction from baseline was defined as the primary endpoint. Odd ratios (OR) with 95% confidence intervals (CI) were calculated using a random-effects model meta-analysis.

Results: A total of 7,488 patients receiving anthracycline chemotherapy without trastuzumab were included, who had at least one risk factor at baseline. Hypertension (OR: 1.99; 95% CI: 1.43–2.76), diabetes mellitus (OR: 1.74; 95% CI: 1.11–2.74), and obesity (OR: 1.72; 95% CI: 1.13–2.61) were associated with increased risk of cardiotoxicity. In addition, the relative reduction of global longitudinal strain (GLS) from baseline after anthracycline treatment could significantly improve the detection ability of cardiotoxicity (28.5%, 95% CI: 22.1–35.8% vs. 16.4%, 95% CI: 13.4–19.9%) compared with LVEF. The early detection rate of anthracycline-induced cardiotoxicity (3 months after chemotherapy) by GLS was 30.2% (95% CI: 24.9–36.1%), which is similar with the overall result of GLS.

Conclusions: Hypertension, diabetes mellitus, and obesity are associated with increased risk of anthracycline-induced cardiotoxicity, which indicates that corresponding protective strategies should be used during and after anthracycline treatment. The findings of higher detection rate and better early detection ability for cardiotoxicity than LVEF added new proofs for the advantages of GLS in detection of AIC.

Human induced pluripotent stem cell (iPSC)-derived cardiomyocytes as an in vitro model in toxicology: strengths and weaknesses for hazard identification and risk characterization

INTRODUCTION

Human induced pluripotent stem cell (iPSC)-derived cardiomyocytes is one of the most widely used cell-based models that resulted from the discovery of how non-embryonic stem cells can be differentiated into multiple cell types. In just one decade, iPSC-derived cardiomyocytes went from a research lab to widespread use in biomedical research and preclinical safety evaluation for drugs and other chemicals.

AREAS COVERED

This manuscript reviews data on toxicology applications of human iPSC-derived cardiomyocytes. We detail the outcome of a systematic literature search on their use (i) in hazard assessment for cardiotoxicity liabilities, (ii) for risk characterization, (iii) as models for population variability, and (iv) in studies of personalized medicine and disease.

EXPERT OPINION

iPSC-derived cardiomyocytes are useful to increase the accuracy, precision, and efficiency of cardiotoxicity hazard identification for both drugs and non-pharmaceuticals, with recent efforts beginning to demonstrate their utility for risk characterization. Notable limitations include the needs to improve the maturation of cells in culture, to better understand their potential use identifying structural cardiotoxicity, and for additional case studies involving population-wide and disease-specific risk characterization. Ultimately, the greatest future benefits are likely for non-pharmaceutical chemicals, filling a critical gap where no routine testing for cardiotoxicity is currently performed.

Two novel anticancer compounds with minimum cardiotoxic property

BACKGROUND

Although two novel synthesized compounds with tri-aryl structures; 3-(4-chlorophenyl)-5-(4-fluorophenyl)-4-phenyl-4,5-dihydro-1,2,4-oxadiazole (A) and 3,5-bis-(4-chlorophenyl)-4-phenyl-4,5-dihydro-1,2,4-oxadiazole (B) have been previously demonstrated to possess remarkable anti-breast cancer activity, their cardiotoxicity remains a major concern due to their mechanism of action. To address this concern, we assessed the ability of these compounds to cause toxicity towards H9c2 cardiomyocytes as an in vitro model of cardiotoxicity.

METHODS

Cytotoxic activity of both compounds was explored in vitro on H9c2 cells using MTT assay. Annexin V/PI method, intracellular ROS determination and mitochondrial membrane potential assay were applied to elucidate the mechanism of action of the cell death.

RESULTS

MTT assay revealed a concentration- and time-dependent cardiotoxicity. Findings of apoptosis by double staining with annexin V and propidium iodide divulged no cell death including apoptosis and necrosis at the concentration that were effective to inhibit cancer cells proliferation (10 μM) at 24 and 48 h. Furthermore, flow cytometric measurement of membrane potential and ROS determination using DCFH-DA verified the safe concentration of the compounds against H9c2 cells with no cardiotoxic effect. However, the higher concentration of the compounds could induce cell death through ROS-mediated mitochondrial dysfunction.

CONCLUSIONS

Altogether, the results represented two novel chemical molecules possessing anti-breast cancer activity with minimum cardiac side effect.

Maternal and Early Postnatal Diet Supplemented with Conjugated Linoleic Acid Isomers Affect Lipid Profile in Hearts of Offspring Rats with Mammary Tumors

Linking the early life environment with later health status is known as "developmental programming". This study aimed to assess whether the introduction of conjugated linoleic acids (CLAs) into the maternal diet affects the content fatty acids (FAs), conjugated FAs (CFAs), cholesterol, oxysterols, malondialdehyde (MDA) and tocopherols in the hearts of their female offspring treated with 7,12-dimethylbenz[a]anthracene and if offspring supplementation enhanced the effect of maternal supplementation. FA, cholesterol and oxysterol contents were determined by gas chromatography-mass spectrometry, while contents of CFAs and MDA were determined by high-performance liquid chromatography (HPLC) with photodiode detection. The supplementation of mothers with CLAs significantly decreased the amount of atherogenic saturated FAs and enhanced the level of eicosapentaenoic FA in the hearts of offspring. Continuous progeny supplementation decreased the content of arachidonic acid in hearts. Supplementation of the maternal diet with CLAs and its continuation during the postnatal period increased the ratio of hypo to hypercholesterolemic FAs. Significantly fewer oxysterols were detected in the hearts of progeny of dams fed with CLAs as compared to the offspring of mothers receiving safflower oil. Both fetal and postnatal CLA intake significantly reduced 7β-hydroxycholesterol accumulation. It can be concluded that CLA supplementation during the fetal and postnatal period may be an effective method of maintaining the cardiac health status of newborns.

Cardiotoxicity after cancer treatment: a process map of the patient treatment journey

BACKGROUND/AIM

Cardiotoxicity is a potential complication of anticancer therapy. While guidelines have been developed to assist practitioners, an effective, evidence based clinical pathway for the treatment of cardiotoxicity has not yet been developed. The aim of this study was to describe the journey of patients who developed cardiotoxicity through the healthcare system in order to establish baseline data to inform the development and implementation of a patient-centred, evidence-based clinical pathway.

METHODS

Mixed-methods design with quantitative and qualitative components using process mapping at 3 large medical centres in 2 states between 2010 and 2015.

RESULTS

Fifty (50) confirmed cases of cardiotoxicity were reviewed (39 medical record reviews, 7 medical record review and interviews and 4 internview only). The mean age at cancer diagnosis of this group was 53.3 years (range 6-89 years); 50% female; 30% breast cancer, 23% non-Hodgkin's lymphoma; mean chemotherapy cycles 5.2 (median 6; range 1-18); 49 (89%) presented to chemotherapy with pre-existing cardiovascular risk factors; 39 (85%) had at least one modifiable risk factor and 11 (24%) had more than 4; 44 (96%) were diagnosed by echocardiogram and 27 (57%) were referred to a cardiologist (only 7 (15%) before chemotherapy). Post chemotherapy, 22 (48%) patients were referred to a multidisciplinary heart failure clinic; 8 (17%) to cardiac rehabilitation; 1 (2%) to cancer survivorship clinic and 10 (22%) to a palliative care service. There were 16 (34%) deaths during the timeframe of the study; 4 (25%) cardiac-related, 6 (38%) cancer-related, 4 (25%) due to sepsis and 2 (12%) other causes not recorded. The main concerns participants raised during the interviews were cancer professionals not discussing the potential for cardiotoxicity with them prior to treatment, nor risk modification strategies; a need for health education, particularly regarding risks for developing heart failure related to cancer treatment; and a lack of collaboration between oncologists and cardiologists.

CONCLUSIONS

Our results demonstrate that the clinical management of cancer patients with cardiotoxicity was variable and fragmented and not patient centered. This audit establishes practice gaps that can be addressed through the design of an evidence-based clinical pathway for cancer patients with, or at risk, of cardiotoxicity.

Discovering Innovative Drugs Targeting Both Cancer and Cardiovascular Disease by Shared Protein-Protein Interaction Network Analyses

Cancer and cardiovascular disease (CVD) have a common co-occurrence. Both diseases display overlapping pathophysiology and risk factors, suggesting shared biological mechanisms. Conditions such as obesity, diabetes, hypertension, smoking, poor diet, and inadequate physical activity can cause both heart disease and cancer. The burgeoning field of onco-cardiology aims to develop diagnostics and innovative therapeutics for both diseases through targeting shared mechanisms and molecular targets. In this overarching context, this expert review presents an analysis of the protein-protein interaction (PPI) networks for onco-cardiology drug discovery. Several PPI complexes such as MDM2-TP53 and CDK4-pRB have been studied for their tumor-suppressive functions. In addition, XIAP-SMAC, RAC1-GEF, Sur-2ESX, and TP53-BRCA1 are other PPI complexes that offer potential breakthrough for onco-cardiology therapeutics innovation. As both cancer and CVD share biological mechanisms to a certain degree, the PPI network analyses for onco-cardiology drug discovery are promising for addressing comorbid diseases in the spirit of systems medicine. We discuss the emerging architecture of PPI networks in cancer and CVD and prospects and challenges for their exploitation toward therapeutics applications. Finally, we emphasize that PPIs that were once thought to be undruggable have become potential new class of innovative drug targets.

Therapy-induced cardiotoxicity in breast cancer patients: a well-known yet unresolved problem

Breast cancer is the second most commonly diagnosed cancer, being one of the main health issues that needs to be addressed worldwide. New therapies have led to a remarkable increase in survival rates, which is unfortunately overshadowed by their negative impact on cardiac structure and function in disease-free patients. Since anthracyclines and trastuzumab cause the most undesired outcome in breast cancer patients - cardiac-related mortality, they have been widely studied. However, other therapies (such as hormonal therapy, tyrosine kinase inhibitors, anti-VEGF drugs etc.) can also affect the cardiovascular system and lead to ischemia, hypertension or vascular thromboembolism. Even though excessive research has been conducted in thepast decades, there are still no guidelines regarding the most adequate methods neither to detect and prevent severe cardiotoxicity that can finally lead to heart failure and ultimately death nor for the further management of patients after cardiotoxicity is detected. Biomarkers of ischemia (troponins T and I) and of overload (BNP and NT-proBNP) in association with periodic echocardiographies (assessment of the global longitudinal strain) are two of the most important means used by physicians in the evaluation of cardiac disease in this group of patients. Given that no internationally accepted guidelines for screening and surveillance of different populations exist, the cardio-oncology team is crucial in the management of these patients, their collaboration resulting in individualized treatment regimens. After careful evaluation of different variables (treatment effects, malignancy status, and the patient's pre-existing conditions), a decision is made to either reduce the dosage or rate of administration, change the medication or interrupt the treatment and initiate the cardioprotective therapeutic associations. Consequently, it is an absolute necessity the development of customized treatment guidelines and the conduction of multiple clinical studies in order to demonstrate their effect on long-term survival.