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Jin H, Xu J, Sui Z, Wang L. Risk factors from Framingham risk score for anthracyclines cardiotoxicity in breast cancer: A systematic review and meta-analysis. Front Cardiovasc Med 2023; 10:1101585. [PMID: 36742068 PMCID: PMC9892715 DOI: 10.3389/fcvm.2023.1101585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 01/05/2023] [Indexed: 01/20/2023] Open
Abstract
Background Framingham risk score (FRS) is an effective tool for evaluating the 10-year risk of cardiovascular diseases. However, the sensitivity of FRS for anthracycline-induced cardiotoxicity is unclear. This meta-analysis aims to evaluate the correlation between risk factors (hypertension, hyperlipidemia, diabetes, smoking, and obesity) in FRS and anthracycline-induced cardiotoxicity in breast cancer. Methods We searched PubMed, EMBASE, and Cochrane Library for studies published from inception to January 2022 which reported cardiotoxicity due to anthracycline. Cardiotoxicity defined as any cardiac events were used as the primary endpoint. A total of 33 studies involving 55,708 breast cancer patients treated with anthracyclines were included in this meta-analysis. Results At least one risk factor was identified at baseline for the 55,708 breast cancer patients treated with anthracycline. Hypertension [I 2 = 45%, Fixed, RR (95% CI) = 1.40 (1.22, 1.60), p < 0.00001], hyperlipidemia [I 2 = 0%, Fixed, RR (95% CI): 1.35 (1.12, 1.62), p = 0.002], diabetes [I 2 = 0%, Fixed, RR (95% CI): 1.29 (1.05, 1.57), p = 0.01], and obesity [I 2 = 0%, Fixed, RR (95% CI): 1.32 (1.05, 1.67), p = 0.02] were associated with increased risks of cardiac events. In addition, smoking was also associated with reduced left ventricular ejection fraction (LVEF) during anthracycline chemotherapy [I 2 = 0%, Fixed, OR (95% CI): 1.91 (1.24, 2.95), p = 0.003] in studies that recorded only the odds ratio (OR). Conclusion Hypertension, hyperlipidemia, diabetes, smoking, and obesity are associated with increased risks of anthracycline-induced cardiotoxicity. Therefore, corresponding measures should be used to manage cardiovascular risk factors in breast cancer during and after anthracycline treatment.
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Affiliation(s)
- Hao Jin
- Department of Cardiology, Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Jianfeng Xu
- Department of Orthopedics, Affiliated Zhongshan Hospital of Dalian University, Dalian, China
| | - Zheng Sui
- Department of Cardiology, Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China,*Correspondence: Zheng Sui,
| | - Lili Wang
- Department of Cardiology, Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China,Lili Wang,
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Value of layer-specific speckle tracking echocardiography for early detection of myocardial injury caused by chemotherapy in breast cancer patients with cardiovascular risk. Int J Cardiovasc Imaging 2021; 38:61-68. [PMID: 34363121 DOI: 10.1007/s10554-021-02367-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 07/27/2021] [Indexed: 10/20/2022]
Abstract
The probability of toxicity-related myocardial injury event with anthracyclines is controversial, which could be related to the underlying cardiac status before chemotherapy. Our study sought to investigate the influence of cardiovascular risk factors on myocardial motion and cardiac function using layer-specific speckle tracking echocardiography (STE) during chemotherapy with epirubicin. Female patients with first-diagnosed breast cancer were prospectively enrolled in our study and received 4 chemotherapeutic cycles with epirubicin in each cycle of 21 days. All patients underwent echocardiography for layer-specific STE analysis before and after all chemotherapy. Clinical data including cardiovascular risk factors were collected. According to the Framingham score, patients with cardiovascular risk factors were divided into groups with low, medium, and high risk. 134 patients existed in the final analysis. The accumulated dose of epirubicin for were 560.0 ± 103.8 mg. 97 (72.4%) patients had cardiovascular risk factors. According to the Framingham score, 57 (42.5%) patients categorized in high risk. Endocardial layer strain after chemotherapy were lower than those at baseline (p < 0.05, all), especially for patients with high risk. The changes of endocardial longitudinal strain during chemotherapy were associated with cardiovascular risks at baseline with correlation coefficient of 0.627. Our study found that layer-specific STE is valuable for early detection of toxicity-related myocardial injury for patients with breast cancer after epirubicin chemotherapy and cardiovascular risk factors have greatly influenced on cardiac function during chemotherapy. The endocardial layer strain is sensitive to evaluate early-stage toxicity-related myocardial injury after epirubicin chemotherapy.
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Joy AA, Vos LJ, Pituskin E, Cook SF, Bies RR, Vlahadamis A, King K, Basi SK, Meza-Junco J, Mackey JR, Stanislaus A, Damaraju VL, Damaraju S, Sawyer MB. Uridine Glucuronosyltransferase 2B7 Polymorphism-Based Pharmacogenetic Dosing of Epirubicin in FEC Chemotherapy for Early-Stage Breast Cancer. Clin Breast Cancer 2021; 21:e584-e593. [PMID: 33832852 DOI: 10.1016/j.clbc.2021.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 02/22/2021] [Accepted: 03/01/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Epirubicin is metabolized by uridine glucuronosyltransferase 2B7 (UGT2B7). Patients homozygous for the minor allele (CC) in the UGT2B7 -161 promoter polymorphism have lower clearance and significantly higher rates of leukopenia compared to wild-type homozygote (TT) or heterozygote (CT) patients. This study was designed to determine if TT and CT genotype patients could tolerate a higher epirubicin dose compared to CC genotype patients. PATIENTS AND METHODS We studied women with histologically confirmed non-metastatic, invasive breast cancer who were scheduled to receive at least three cycles of FE100C in the (neo)adjuvant setting. Patients received standard-dose FE100C during the first 21-day cycle. Based on genotype, the epirubicin dose was escalated in the second and third cycles to 115 and 130 mg/m2 or to 120 and 140 mg/m2 for CT and TT genotype patients, respectively. The main outcome measurements were myelosuppression and dose-limiting toxicity. These were analyzed for relationships with the three genotypes. RESULTS Forty-five patients were enrolled (10 CC, 21 CT, and 14 TT genotypes) and received 100 mg/m2 of epirubicin in the first cycle. Twelve and 10 TT patients were dose escalated at the second and third cycles, respectively; 16 CT patients were dose escalated at the second and third cycles. Leukopenia, but not febrile neutropenia, was genotype and dose dependent and increased in patients with CT and TT genotypes as their dose was increased. However, the third-cycle leukopenia rates were comparable to patients with the CC genotype receiving standard-dose epirubicin. CONCLUSION Pharmacogenetically guided epirubicin dosing is well tolerated and allowed dose escalation without increased toxicity.
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Affiliation(s)
- Anil A Joy
- Division of Medical Oncology, Cross Cancer Institute, Edmonton, AB, Canada; Department of Oncology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Larissa J Vos
- Division of Medical Oncology, Cross Cancer Institute, Edmonton, AB, Canada
| | - Edith Pituskin
- Division of Medical Oncology, Cross Cancer Institute, Edmonton, AB, Canada; Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | - Sarah F Cook
- Department of Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, NY
| | - Robert R Bies
- Department of Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, NY
| | - Ann Vlahadamis
- Division of Medical Oncology, Cross Cancer Institute, Edmonton, AB, Canada
| | - Karen King
- Division of Medical Oncology, Cross Cancer Institute, Edmonton, AB, Canada; Department of Oncology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Sanraj K Basi
- Division of Medical Oncology, Cross Cancer Institute, Edmonton, AB, Canada; Department of Oncology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Judith Meza-Junco
- Division of Medical Oncology, Cross Cancer Institute, Edmonton, AB, Canada; Department of Oncology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - John R Mackey
- Division of Medical Oncology, Cross Cancer Institute, Edmonton, AB, Canada; Department of Oncology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Avalyn Stanislaus
- Department of Oncology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Vijaya L Damaraju
- Department of Oncology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Sambasivarao Damaraju
- Department of Laboratory Medicine and Pathology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Michael B Sawyer
- Division of Medical Oncology, Cross Cancer Institute, Edmonton, AB, Canada; Department of Oncology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.
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Wiggen KE, Saelinger C. ECG of the Month. J Am Vet Med Assoc 2019; 254:350-352. [DOI: 10.2460/javma.254.3.350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Chia PL, Chiang K, Snyder R, Dowling A. The utility of routine pre-chemotherapy screening with cardiac gated blood pool scan for patients at low risk of anthracycline toxicity. J Oncol Pharm Pract 2017; 24:264-271. [PMID: 29284360 DOI: 10.1177/1078155217697487] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Anthracycline-based chemotherapy is used in many malignancies. Current recommendations by several groups suggest cardiac monitoring prior to and during anthracycline therapy. We aim to review the usefulness of baseline cardiac screening for left ventricular ejection fraction to assess if it had any impact on chemotherapy decisions in patients to be treated with anthracycline-based regimens or any beneficial effect upon outcomes. Methods We conducted a retrospective three-year audit of cancer patients who underwent GBPS prior to anthracycline (doxorubicin) chemotherapy. Subjects were identified via records from the Department of Nuclear Medicine. Pharmacy dispensing records identified those who received doxorubicin. Patient demographics, cancer type, cardiac risk factors, GBPS ejection fraction (EF), and cumulative anthracycline dose were collected. Results From 1 August 2009 to 31 July 2012, 179 patients underwent GBPS pre-doxorubicin chemotherapy. The mean age was 59 years (range 21-89 years), with 51% being males. Only two patients (1.1%) had an abnormal EF < 50%, while 33 patients (18%) had an EF 51-59% and 144 patients (80%) had EF ≥ 60%. The two patients with reduced baseline EF still received anthracycline-based chemotherapy. All 135 patients without any known cardiovascular risk factors had normal EFs. The total number of patients who received anthracycline chemotherapy during the same period was 207. Thus 28 patients (13%) commenced anthracycline without a prior GBPS. Conclusion Only 1.1% of the screened patients had EF < 50%. These two patients still received doxorubicin chemotherapy despite a compromised EF, as their treating clinicians believed that the benefits of chemotherapy outweighed the risk of potential cardiac toxicity. Our audit questions the practice of routine cardiac evaluation pre-anthracycline screening with GBPS. We propose that routine screening only be requested if cardiac risk factors are present.
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Affiliation(s)
- Puey Ling Chia
- 1 Department of Medical Oncology, St Vincent's Hospital Melbourne, Melbourne, Australia.,2 Department of Medical Oncology, Olivia Newton-John Cancer Research Institute, Austin Health, Melbourne, Australia
| | - K Chiang
- 3 Department of Pharmacy, St Vincent's Hospital Melbourne, Australia
| | - R Snyder
- 1 Department of Medical Oncology, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - A Dowling
- 1 Department of Medical Oncology, St Vincent's Hospital Melbourne, Melbourne, Australia
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Novo G, Cadeddu C, Sucato V, Pagliaro P, Romano S, Tocchetti CG, Zito C, Longobardo L, Nodari S, Penco M. Role of biomarkers in monitoring antiblastic cardiotoxicity. J Cardiovasc Med (Hagerstown) 2017; 17 Suppl 1 Special issue on Cardiotoxicity from Antiblastic Drugs and Cardioprotection:e27-e34. [PMID: 27755240 DOI: 10.2459/jcm.0000000000000379] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Early detection of anticancer drug-induced cardiotoxicity (CTX) has been evaluated by most international scientific cardiology and oncology societies. High expectations have been placed on the use of specific biomarkers. In recent years, conventional biomarkers and molecules of more recent interest have been tested and compared in the context of anticancer drug-related CTX. Encouraging results were obtained from studies on molecules of myocardial damage, such as troponin and markers of myocardial wall stress, including circulating natriuretic peptides, as well as from the assessment of the products of inflammation or circulating levels of free radicals. However, clear guidelines on their sensitivity, specificity, and accuracy are not yet available, and many challenges, such as the optimal time of assessing, optimal schedule for evaluation, optimal cut-off point for positivity with the highest level of specificity, and optimal comparability of different assays for the measurements, remain unresolved. Given the importance of having a reliable and accurate tool for monitoring anticancer drug-induced CTX, this review will focus on the available data on the most effective and widely used biomarkers and the studies that are currently underway that aim to identify the effectiveness of new approaches in this therapeutic setting.
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Affiliation(s)
- Giuseppina Novo
- aDepartment of Internal Medicine and Specialties (DIBIMIS), Chair of Cardiology, University of Palermo, Palermo Italy bDepartment of Medical Sciences 'Mario Aresu', University of Cagliari, Cagliari Italy cDepartment of Clinical and Biological Sciences, University of Turin, Orbassano Italy dDepartment of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy eDepartment of Translational Medical Sciences, University of Napoli Federico II, Naples Italy fDepartment of Clinical and Experimental Medicine. Section of Cardiology, University of Messina, Messina Italy gDepartment of Clinical and Surgical Specialities, Radiological Sciences and Public Health University of Brescia, Brescia, Italy
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Dermitzakis EV, Kimiskidis VK, Lazaridis G, Alexopoulou Z, Timotheadou E, Papanikolaou A, Romanidou O, Georgiadis G, Kalogeras KT, Tsiptsios I, Tarlatzis B, Fountzilas G. The impact of paclitaxel and carboplatin chemotherapy on the autonomous nervous system of patients with ovarian cancer. BMC Neurol 2016; 16:190. [PMID: 27716097 PMCID: PMC5045633 DOI: 10.1186/s12883-016-0710-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 06/10/2016] [Indexed: 11/10/2022] Open
Abstract
Background Paclitaxel-based regimens are frequently associated with the development of peripheral neuropathy. The autonomous nervous system (ANS) effects, however, of this chemotherapeutic agent remain unexplored. Methods We investigated a group of 31 female patients with ovarian cancer receiving treatment with paclitaxel and carboplatin, as well as a group of 16 healthy age- and gender-matched healthy volunteers. All study participants completed a questionnaire and were assessed neurophysiologically at three time points (baseline, 3–4 months and 6–8 months following the onset of chemotherapy). The evaluation of the ANS included assessment of the adrenergic cardiovascular function (orthostatic hypotension-OH), parasympathetic heart innervation (30/15 ratio) and sympathetic skin response (SSR). Results At the 3–4 months ANS assessment, 19.2 % of the patients had systolic OH and the same percentage had diastolic OH, but at the 6–8 months evaluation no patient had systolic OH and only 13.8 % had diastolic OH. The values of the 30/15 ratio were significantly reduced at both time points, whereas the SSR was not affected. Conclusions Combined paclitaxel and carboplatin chemotherapy is associated with significant effects on the parasympathetic heart innervation and occasionally with effects on the adrenergic cardiovascular reaction. The SSR remained unaffected. Physicians should be alert to the possibility of these treatment-emergent side effects, so as to monitor ANS parameters and introduce treatment modifications accordingly. Our findings however, should be validated in larger cohorts. Electronic supplementary material The online version of this article (doi:10.1186/s12883-016-0710-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Emmanouil V Dermitzakis
- Laboratory of Clinical Neurophysiology, Department of Neurology, "Papageorgiou" Hospital, Thessaloniki, 564 03, Greece.
| | - Vasilios K Kimiskidis
- Laboratory of Clinical Neurophysiology, Aristotle University of Thessaloniki, Faculty of Medicine, Thessaloniki, Greece
| | - George Lazaridis
- Department of Medical Oncology, School of Health Sciences, Faculty of Medicine, "Papageorgiou" Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Zoi Alexopoulou
- Department of Biostatistics, Health Data Specialists Ltd, Athens, Greece
| | - Eleni Timotheadou
- Department of Medical Oncology, School of Health Sciences, Faculty of Medicine, "Papageorgiou" Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Alexandros Papanikolaou
- First Department of Obstetrics and Gynecology, School of Health Sciences, Faculty of Medicine, "Papageorgiou" Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ourania Romanidou
- Department of Medical Oncology, School of Health Sciences, Faculty of Medicine, "Papageorgiou" Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Georgiadis
- Neurological Department, "Hippocration" General Hospital, Thessaloniki, Greece
| | - Konstantine T Kalogeras
- Laboratory of Molecular Oncology, Hellenic Foundation for Cancer Research/Aristotle University of Thessaloniki, Thessaloniki, Greece.,Translational Research Section, Hellenic Cooperative Oncology Group, Data Office, Athens, Greece
| | - Iakovos Tsiptsios
- Laboratory of Clinical Neurophysiology, Department of Neurology, "Papageorgiou" Hospital, Thessaloniki, 564 03, Greece
| | - Basil Tarlatzis
- First Department of Obstetrics and Gynecology, School of Health Sciences, Faculty of Medicine, "Papageorgiou" Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Fountzilas
- Laboratory of Molecular Oncology, Hellenic Foundation for Cancer Research/Aristotle University of Thessaloniki, Thessaloniki, Greece
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Oliveira GH, Al-Kindi SG, Caimi PF, Lazarus HM. Maximizing anthracycline tolerability in hematologic malignancies: Treat to each heart's content. Blood Rev 2016; 30:169-78. [DOI: 10.1016/j.blre.2015.11.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 10/20/2015] [Accepted: 11/02/2015] [Indexed: 01/01/2023]
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Valachis A, Nilsson C. Cardiac risk in the treatment of breast cancer: assessment and management. BREAST CANCER-TARGETS AND THERAPY 2015; 7:21-35. [PMID: 25653554 PMCID: PMC4303336 DOI: 10.2147/bctt.s47227] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
As the number of long-term breast cancer survivors has increased, the side effects of adjuvant cancer therapy, such as cardiac toxicity, remain clinically important. Although the cardiac toxicity due to anthracyclines, radiotherapy, or trastuzumab is well-documented, several issues need to be clarified and are the subjects of extensive ongoing clinical research. This review summarizes the incidence of cardiac toxicity due to breast cancer adjuvant therapy and highlights the current trends in early detection and management of cardiac toxicities.
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Affiliation(s)
- Antonis Valachis
- Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden
| | - Cecilia Nilsson
- Center for Clinical Research, Västmanlands County Hospital, Västerås, Sweden
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Stachowiak P, Kornacewicz-Jach Z, Safranow K. Prognostic role of troponin and natriuretic peptides as biomarkers for deterioration of left ventricular ejection fraction after chemotherapy. Arch Med Sci 2014; 10:1007-18. [PMID: 25395954 PMCID: PMC4223124 DOI: 10.5114/aoms.2013.34987] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Revised: 11/12/2012] [Accepted: 12/22/2012] [Indexed: 11/24/2022] Open
Abstract
Cardiotoxicity due to anthracyclines, trastuzumab and other potential cardiotoxic drugs is still a problem of modern chemotherapy. For years researchers have tried to find biological markers that can predict changes in the heart. The most thoroughly tested markers are troponin and natriuretic peptides. Some studies have proven that these markers can indeed be useful. In studies which have shown the predictive role of troponin I the assessment of this marker was performed very frequently. It is not possible to carry out such serial measurements in many centers because of typical 1-day hospital stay times. The predictive role of natriuretic peptides still needs further investigation. This review considers the newest research from recent years.
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Affiliation(s)
- Paweł Stachowiak
- Department of Cardiology, Pomeranian Medical University, Szczecin, Poland
| | | | - Krzysztof Safranow
- Department of Biochemistry and Medical Chemistry, Pomeranian Medical University, Szczecin, Poland
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11
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High-sensitivity cardiac troponin I detection for 2 types of drug-induced cardiotoxicity in patients with breast cancer. Breast Cancer 2014; 22:563-9. [PMID: 24563373 DOI: 10.1007/s12282-014-0520-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Accepted: 02/03/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Breast cancer treatment with trastuzumab, a monoclonal antibody that targets human epidermal growth factor receptor type 2 (HER2), has largely been successful in improving the prognosis of HER2-positive disease. However, a critical issue associated with trastuzumab treatment is its cardiotoxic adverse effects, including cardiac insufficiency. METHODS We measured levels of cardiac troponin I, a marker of myocardial damage, with a highly sensitive method (hs-cTnI) using a fully automated chemiluminescent immunoassay system (ADVIA Centaur(®) XP) in breast cancer patients and examined the relationship between administration of trastuzumab and epirubicin and concentrations of hs-cTnI. RESULTS The coefficient of variation for within-run repeatability was 1.34-5.93 %, using plasma pools and controls of 3 concentrations, and that for between-run reproducibility was 3.99-8.79 %, indicating high precision of the assay. In a dilutional linearity test with highly concentrated specimens, hs-cTnI values could be measured up to 50 ng/mL with linearity. No influence from coexisting substances was observed. The concentration of hs-cTnI was at or above the reference range (0.04 ng/mL) in 9 of 214 total breast cancer cases (4.2 %). The hs-cTnI concentration was at or above the reference range in 4 of 49 cases (8.2 %) that were administered trastuzumab, and in 5 of 165 cases (3.0 %) that were not. Trastuzumab did not cause elevation of hs-cTnI when not administered in combination with epirubicin. CONCLUSIONS These results suggest that epirubicin and trastuzumab cause cardiotoxicity through different mechanisms. Epirubicin can cause myocardial necrosis, while trastuzumab can cause cardiomyopathy without myocardial necrosis.
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12
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Anderson B, Sawyer DB. Predicting and preventing the cardiotoxicity of cancer therapy. Expert Rev Cardiovasc Ther 2014; 6:1023-33. [DOI: 10.1586/14779072.6.7.1023] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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13
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Jones LW. Evidence-based risk assessment and recommendations for physical activity clearance: cancer. Appl Physiol Nutr Metab 2013; 36 Suppl 1:S101-12. [PMID: 21800938 DOI: 10.1139/h11-043] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Physical activity is becoming increasingly acknowledged as an integral component of in the multidisciplinary management of cancer patients. Intensive inquiry in this area is likely to increase further over the next decade; however, cancer-specific, evidence-based risk assessment and recommendations for physical activity are not available. A systematic literature review was performed of all studies conducting an exercise training intervention and (or) any form of objective exercise test among adults diagnosed with cancer. Studies were assessed according to evaluation criteria developed by a panel of experts. A total of 118 studies involving 5529 patients were deemed eligible. Overall, the results suggest that exercise training and maximal and submaximal exercise testing are relatively safe procedures with a total nonlife-threatening adverse event rate of <2%. There was only 1 exercise training-related death. However, the quality of exercise testing methodology and data reporting is less than optimal. Thus, whether the low incidence of events reflects the true safety of exercise training and exercise testing in cancer patients or less than optimal methodology and (or) data reporting remains to be determined. Evidence-based absolute and relative contraindications to physical activity and exercise training and testing are provided as well as probing decision-trees to optimize the adoption and safety of physical activity in persons diagnosed with cancer.
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Affiliation(s)
- Lee W Jones
- Duke Cancer Institute, Durham, NC 27710, USA.
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14
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Preventing Cardiovascular Complications of Breast Cancer Treatment: The Utility of Effective Exercise Prescription. CURRENT CARDIOVASCULAR RISK REPORTS 2013. [DOI: 10.1007/s12170-013-0319-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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15
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Sparano J. Cytotoxic Therapy and Other Nonhormonal Approaches for the Treatment of Metastatic Breast Cancer. Breast Cancer 2013. [DOI: 10.1201/b14039-16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
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Peroukides S, Alexopoulos A, Kalofonos H, Papadaki H. Cardiovascular effects of treatment with taxanes. J Cardiovasc Med (Hagerstown) 2012; 13:319-24. [DOI: 10.2459/jcm.0b013e3283529060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Dev S, Prabhakaran P, Filgueira L, Iyer KS, Raston CL. Microfluidic fabrication of cationic curcumin nanoparticles as an anti-cancer agent. NANOSCALE 2012; 4:2575-2579. [PMID: 22193941 DOI: 10.1039/c2nr11502f] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Curcumin nanoparticles of less than 50 nm in diameter are accessible using a continuous flow microfluidic rotating tube processor (RTP) under scalable conditions, at room temperature. A mixture of DDAB and Pluronic F127 renders higher stability of the curcumin nanoparticles in physiological pH 7.4 for up to eight hours. The nanoparticles have enhanced cytotoxicity in estrogens receptor negative and positive breast cancer cell lines compared with free curcumin.
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Affiliation(s)
- Selvi Dev
- Centre for Strategic Nano-Fabrication, School of Biomedical, Biomolecular and Chemical Sciences, The University of Western Australia, Crawley, WA 6009, Australia
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Valdivieso M, Kujawa AM, Jones T, Baker LH. Cancer survivors in the United States: a review of the literature and a call to action. Int J Med Sci 2012; 9:163-73. [PMID: 22275855 PMCID: PMC3264952 DOI: 10.7150/ijms.3827] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Accepted: 01/11/2012] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND The number of cancer survivors in the U.S. has increased from 3 million in 1971, when the National Cancer Act was enacted, to over 12 million today. Over 70% of children affected by cancer survive more than 10 years, and most are cured. Most cancer survivors are adults, with two-thirds of them 65 years of age or older and two-thirds alive at five years. The most common cancer diagnoses among survivors include breast, prostate and colorectal cancers. This review was conducted to better appreciate the challenges associated with cancer survivors and the opportunities healthcare providers have in making a difference for these patients. METHODS Comprehensive review of literature based on PubMed searches on topics related to cancer survivorship, and associated physical, cognitive, socio-economic, sexual/behavioral and legal issues. RESULTS At least 50% of cancer survivors suffer from late treatment-related side effects, often including physical, psychosocial, cognitive and sexual abnormalities, as well as concerns regarding recurrence and/or the development of new malignancies. Many are chronic in nature and some are severe and even life-threatening. Survivors also face issues involving lack of appropriate health maintenance counseling, increased unemployment rate and workplace discrimination. CONCLUSIONS Advances in the diagnosis and treatment of cancer will lead to more survivors and better quality of life. However, tools to recognize potentially serious long-lasting side effects of cancer therapy earlier in order to treat and/or prevent them must be developed. It is incumbent upon our health care delivery systems to make meeting these patients' needs a priority.
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Affiliation(s)
- Manuel Valdivieso
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48106, USA.
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19
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Shenoy C, Klem I, Crowley AL, Patel MR, Winchester MA, Owusu C, Kimmick GG. Cardiovascular complications of breast cancer therapy in older adults. Oncologist 2011; 16:1138-43. [PMID: 21737575 DOI: 10.1634/theoncologist.2010-0348] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Older adults frequently have pre-existing and cancer-related risk factors for cardiovascular toxicity from cancer treatment. In this review, we discuss the risk factors and strategies for prevention and management of cardiovascular complications in older women with breast cancer.
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Affiliation(s)
- Chetan Shenoy
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina 27710, USA.
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20
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Menna P, Paz OG, Chello M, Covino E, Salvatorelli E, Minotti G. Anthracycline cardiotoxicity. Expert Opin Drug Saf 2011; 11 Suppl 1:S21-36. [PMID: 21635149 DOI: 10.1517/14740338.2011.589834] [Citation(s) in RCA: 142] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Anthracyclines are widely prescribed anticancer agents that cause a dose-related cardiotoxicity, often aggravated by nonanthracycline chemotherapeutics or new generation targeted drugs. Anthracycline cardiotoxicity may occur anytime in the life of cancer survivors. Understanding the molecular mechanisms and clinical correlates of cardiotoxicity is necessary to improve the therapeutic index of anthracyclines or to identify active, but less cardiotoxic analogs. AREAS COVERED The authors review the pharmacokinetic, pharmacodynamic and biochemical mechanisms of anthracycline cardiotoxicity and correlate them to clinical phenotypes of cardiac dysfunction. Attention is paid to bioactivation mechanisms that converted anthracyclines to reactive oxygen species (ROS) or long-lived secondary alcohol metabolites. Preclinical aspects and clinical implications of the "oxidative stress" or "secondary alcohol metabolite" hypotheses are discussed on the basis of literature that cuts across bench and evidence-based medicine. Interactions of anthracyclines with comorbidities or unfavorable lifestyle choices were identified as important cofactors of the lifetime risk of cardiotoxicity and as possible targets of preventative strategies. EXPERT OPINION Anthracycline cardiotoxicity is a multifactorial process that needs to be incorporated in a translational framework, where individual genetic background, comorbidities, lifestyles and other drugs play an equally important role. Fears for cardiotoxicity should not discourage from using anthracyclines in many oncologic settings. Cardioprotective strategies are available and should be used more pragmatically in routine clinical practice.
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Affiliation(s)
- Pierantonio Menna
- Campus Bio-Medico University Hospital, CIR and Drug Sciences, Via Alvaro del Portillo, 21, 00128 Rome, Italy
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21
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The efficacy and safety of gemcitabine plus paclitaxel combination first-line therapy for Japanese patients with metastatic breast cancer including triple-negative phenotype. Cancer Chemother Pharmacol 2010; 67:1007-15. [DOI: 10.1007/s00280-010-1390-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2010] [Accepted: 06/20/2010] [Indexed: 12/22/2022]
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22
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Venturini M, Bighin C, Puglisi F, Olmeo N, Aitini E, Colucci G, Garrone O, Paccagnella A, Marini G, Crinò L, Mansutti M, Baconnet B, Barbato A, Del Mastro L. A multicentre Phase II study of non-pegylated liposomal doxorubicin in combination with trastuzumab and docetaxel as first-line therapy in metastatic breast cancer. Breast 2010; 19:333-8. [PMID: 20185313 DOI: 10.1016/j.breast.2010.01.018] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2009] [Revised: 12/23/2009] [Accepted: 01/22/2010] [Indexed: 01/07/2023] Open
Abstract
To evaluate the cardiotoxicity, general toxicity, and activity of non-pegylated liposomal doxorubicin, in combination with docetaxel and trastuzumab, as first-line therapy in metastatic breast cancer. Thirty-one patients with metastatic human epidermal growth factor receptor 2-overexpressing breast cancer, who had not previously received chemotherapy for metastatic disease, received non-pegylated liposomal doxorubicin (50 mg/m(2)), docetaxel (75 mg/m(2)) and trastuzumab (2 mg/kg/week) for up to eight cycles, followed by trastuzumab alone for up to 52 weeks. Cardiotoxicity was defined as a decrease in left ventricular ejection fraction (LVEF) to below 45%, or a decrease in LVEF of at least 20% from baseline. Mean LVEF was maintained at baseline level also in the subset of patients who had received anthracycline previously. Cardiotoxicity developed in three patients during the treatment cycles, and in two further patients after the end of the study. The most common adverse events were haematological toxicity, alopecia, asthenia and fever. The best overall response rate was 65.5%. Median time to progression was 13.0 months. The combination of non-pegylated liposomal doxorubicin, docetaxel and trastuzumab combines acceptable cardiac and general toxicity and promising activity as first-line therapy in metastatic breast cancer.
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Affiliation(s)
- M Venturini
- Oncologia Medica, Ospedale Classificato Sacro Cuore Don Calabria, Via Don A. Sempreboni 5, Negrar, Verona, Italy.
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23
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Barrett-Lee PJ, Dixon JM, Farrell C, Jones A, Leonard R, Murray N, Palmieri C, Plummer CJ, Stanley A, Verrill MW. Expert opinion on the use of anthracyclines in patients with advanced breast cancer at cardiac risk. Ann Oncol 2009; 20:816-27. [PMID: 19153118 DOI: 10.1093/annonc/mdn728] [Citation(s) in RCA: 121] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Anthracyclines are considered to be among the most active agents for the treatment of breast cancer. However, their use is limited by cumulative, dose-related cardiotoxicity. Such cardiotoxicity results in a permanent loss of cardiac myocytes and a progressive reduction in cardiac function following each subsequent dose of anthracycline. Initially, damage to the heart is subclinical; however, increasingly impaired cardiac function can result in cardiovascular symptoms, with serious cardiac injury resulting in chronic heart failure. Since the early detection and treatment of cardiotoxicity can reduce its clinical effects, it is important that oncologists are aware of these adverse effects and manage them appropriately. This review examines the risk factors for anthracycline-associated cardiotoxicity and offers recommendations on strategies to reduce the cardiotoxicity of anthracyclines in the management of patients with advanced breast cancer.
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24
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Salvatorelli E, Menna P, Lusini M, Covino E, Minotti G. Doxorubicinolone Formation and Efflux: A Salvage Pathway against Epirubicin Accumulation in Human Heart. J Pharmacol Exp Ther 2009; 329:175-84. [DOI: 10.1124/jpet.108.149260] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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25
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Magné N, Castadot P, Chargari C, Di Leo A, Philippson C, Van Houtte P. Special focus on cardiac toxicity of different sequences of adjuvant doxorubicin/docetaxel/CMF regimens combined with radiotherapy in breast cancer patients. Radiother Oncol 2009; 90:116-21. [DOI: 10.1016/j.radonc.2008.10.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2008] [Revised: 09/30/2008] [Accepted: 10/08/2008] [Indexed: 10/21/2022]
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26
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Bird BRJH, Swain SM. Cardiac toxicity in breast cancer survivors: review of potential cardiac problems. Clin Cancer Res 2008; 14:14-24. [PMID: 18172247 DOI: 10.1158/1078-0432.ccr-07-1033] [Citation(s) in RCA: 237] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
As breast cancer survival is increased by the diagnosis of earlier-stage disease and treatments improve, the side effects of cancer treatments, such as cardiotoxicity, remain clinically important. Although physicians have known for 30 years that anthracyclines cause acute and chronic cardiotoxicity, the cardiotoxic effects of radiation therapy, hormonal therapy (including tamoxifen and the aromatase inhibitors), and chemotherapy with taxanes and trastuzumab treatment have emerged more recently. This review examines the cardiac toxicity of adjuvant therapy, monitoring for early changes and existing guidelines for monitoring cardiac function in patients with breast cancer.
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Affiliation(s)
- Brian R J Healey Bird
- Breast Cancer Section, Medical Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, MD, USA
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27
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Progress in the Treatment of Early and Advanced Breast Cancer. Breast Cancer 2007. [DOI: 10.1007/978-3-540-36781-9_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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28
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Conte P, Guarneri V, Bengala C. Evolving Nonendocrine Therapeutic Options for Metastatic Breast Cancer: How Adjuvant Chemotherapy Influences Treatment. Clin Breast Cancer 2007; 7:841-9. [DOI: 10.3816/cbc.2007.n.048] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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29
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Gianni L, Salvatorelli E, Minotti G. Anthracycline cardiotoxicity in breast cancer patients: synergism with trastuzumab and taxanes. Cardiovasc Toxicol 2007; 7:67-71. [PMID: 17652806 DOI: 10.1007/s12012-007-0013-5] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/1999] [Revised: 11/30/1999] [Accepted: 11/30/1999] [Indexed: 11/27/2022]
Abstract
Doxorubicin is known to cause cardiomyopathy and congestive heart failure (CHF) upon chronic administration. A major obstacle to doxorubicin-containing multiagent therapies pertains to the possible development of cardiomyopathy and CHF at lower than expected cumulative doses of doxorubicin. For example, the cardiac toxicity of doxorubicin is aggravated by the anti-HER2 antibody Trastuzumab or by the tubulin-active taxane paclitaxel; however, the mechanisms by which Trastuzumab and paclitaxel aggravate doxorubicin-induced cardiotoxicity are mechanistically distinct: Trastuzumab interferes with cardiac-specific survival factors that help the heart to withstand stressor agents like anthracyclines, while paclitaxel acts by stimulating the formation of anthracycline metabolites that play a key role in the mechanism of cardiac failure. Here, we briefly review the molecular mechanisms of the cardiotoxic synergism of Trastuzumab or paclitaxel with doxorubicin, and we attempt to briefly outline how the mechanistic know-how translates into the clinical strategies for improving the safety of anthracycline-based multiagent therapies.
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Affiliation(s)
- Luca Gianni
- Division of Medical Oncology, Fondazione IRCCS Istituto Nazionale Tumori, ViaVenezian 1, Milan 20133, Italy.
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30
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Kouloubinis A, Kaklamanis L, Ziras N, Sofroniadou S, Makaritsis K, Adamopoulos S, Revela I, Athanasiou A, Mavroudis D, Georgoulias V. ProANP and NT-proBNP levels to prospectively assess cardiac function in breast cancer patients treated with cardiotoxic chemotherapy. Int J Cardiol 2007; 122:195-201. [PMID: 17289172 DOI: 10.1016/j.ijcard.2006.11.076] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2006] [Accepted: 11/02/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND Cardiac function impairment is a known side effect of epirubicin-based chemotherapy. Activation of natriuretic peptides is demonstrated in patients with heart failure. AIMS To identify prospectively the cardiotoxic profile of epirubicin-based chemotherapy in breast cancer patients and to evaluate the sensitivity of proANP and NT-proBNP as early biochemical markers of cardiac dysfunction. METHODS Forty cancer patients divided in two nonrandomized groups received either epirubicin and paclitaxel (Group A, n=26) or mitoxantrone and docetaxel (Group B, n=14). Control groups, Group C (n=13) and Group D (n=20), consisted of female patients with heart failure and healthy women respectively. Natriuretic peptides and LVEF were determined in all patients. RESULTS A statistically significant difference was recorded regarding LVEF before and after treatment in Group A patients (p=0.0001). Three patients had a significant LVEF decline between 10% and 18% from baseline values, while three reached an LVEF value below 50%. All of them presented an increase in proANP and NT-proBNP values (mean increase 270.31+/-124 fmol/ml and 303.57+/-108 fmol/ml, respectively). A significant correlation between the increase in plasma proANP (r=0.8, p<0.0001), as well as NT-proBNP (r=0.7, p<0.0001) and the decrease in LVEF was observed. Regarding Group A, levels of proANP increased from 192.25 fmol/ml before treatment to 287.84 fmol/ml after treatment (p=0.0001), whereas NT-proBNP increased from 152.50 to 242 fmol/ml (p<0.0001) respectively. During follow up, two Group A patients developed congestive heart failure twelve and fourteen months after the completion of chemotherapy respectively. A significant LVEF decline was recorded in both patients during the episode. Regarding Group B, no statistically significant differences were demonstrated. CONCLUSION ProANP and NT-proBNP levels might be used as reliable and sensitive markers in the detection of early cardiac impairment caused by epirubicin-based chemotherapy.
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Affiliation(s)
- Alexandros Kouloubinis
- Onassis Cardiac Surgery Center, 2nd Department of Cardiology, 356 Siggrou Avenue, 17674, Athens, Greece
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31
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Nisticò C, Bria E, Cuppone F, Carpino A, Ferretti G, Vitelli G, Sperduti I, Calabretta F, Toglia G, Tomao S, Cognetti F, Terzoli E. Troponin-T and myoglobin plus echocardiographic evaluation for monitoring early cardiotoxicity of weekly epirubicin–paclitaxel in metastatic breast cancer patients. Anticancer Drugs 2007; 18:227-32. [PMID: 17159609 DOI: 10.1097/cad.0b013e328011335e] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Increased serum level of troponin-T and myoglobin has been recently reported to be related to cumulative anthracycline exposure. Left ventricular ejection fraction seems accurate in monitoring systolic function according to the latest version of Toxicity Criteria by chemotherapeutics 3.0. From January 2002, 20 patients with untreated advanced breast cancer received epirubicin (25 mg/m/week) and paclitaxel (80 mg/m/week) for 24 weeks. Troponin-T, myoglobin and biochemical serum enzymes circulating levels were measured immediately before and 4 h after epirubicin administration every week. Patients underwent electrocardiography and echocardiography at weeks 0, 8, 16 and 24. The number of courses administered was 352 (median 18, range 4-24). Epirubicin median dose administered was 600 mg/m and paclitaxel median dose administered was 1760 mg/m. Troponin-T never overcame the upper normal limit; one patient experienced troponin-T elevation without any clinical or instrumental sign of cardiac failure. Myoglobin never significantly increased with the exception of a patient who underwent several abdominal fluid drainages. Creatine kinase MB and C-reactive protein never moved outside the upper normal limit. No symptomatic cardiac event was recorded. In 55 performed echocardiograms at weeks 0, 8, 16 and 24, neither left ventricular ejection fraction nor early peak flow/atrial flow velocity registered any significant decrease. No troponin-T or myoglobin serum elevations and Left ventricular ejection fraction/early peak flow/atrial flow velocity changes were registered in our series of nonsymptomatic women during epirubicin/paclitaxel weekly chemotherapy in the absence of clinical cardiac toxicity. Longer follow-up is needed, however, to understand whether the troponin-T or myoglobin circulating level measurement is able to detect subclinical, early-stage doxorubicin-induced cardiotoxicity.
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Affiliation(s)
- Cecilia Nisticò
- Department of Medical Oncology, Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144 Rome, Italy
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Menna P, Salvatorelli E, Gianni L, Minotti G. Anthracycline Cardiotoxicity. Top Curr Chem (Cham) 2007; 283:21-44. [DOI: 10.1007/128_2007_11] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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33
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Jones RL, Ewer MS. Cardiac and cardiovascular toxicity of nonanthracycline anticancer drugs. Expert Rev Anticancer Ther 2006; 6:1249-69. [PMID: 17020459 DOI: 10.1586/14737140.6.9.1249] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Anthracyclines are a well-known cause of cardiotoxicity, but a number of other drugs used to treat cancer can also result in cardiac and cardiovascular adverse effects. Cardiotoxicity can result in the alteration of cardiac rhythm, changes in blood pressure and ischemia, and can also alter the ability of the heart to contract and/or relax. The clinical spectrum of these toxicities can range from subclinical abnormalities to catastrophic life-threatening, and sometimes fatal, sequelae. These events may occur acutely or may only become apparent months or years following completion of oncological treatment. Ischemia and rhythm abnormalities are treated symptomatically in most cases. Knowledge of these toxicities can aid clinicians to choose the optimal and least toxic regimen suitable for an individual patient.
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Affiliation(s)
- Robin L Jones
- Royal Marsden Hospital, Department of Medicine, Fulham Road, London SW3 6JJ, UK.
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Salvatorelli E, Menna P, Gianni L, Minotti G. Defective Taxane Stimulation of Epirubicinol Formation in the Human Heart: Insight into the Cardiac Tolerability of Epirubicin-Taxane Chemotherapies. J Pharmacol Exp Ther 2006; 320:790-800. [PMID: 17135345 DOI: 10.1124/jpet.106.116160] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The antitumor anthracycline doxorubicin induces a dose-related cardiotoxicity that correlates with the myocardial levels of its secondary alcohol metabolite doxorubicinol. Combining doxorubicin with taxanes such as paclitaxel or docetaxel may aggravate cardiotoxicity, presumably because the taxanes cause an allosteric-like stimulation of cytoplasmic aldehyde reductases that convert doxorubicin to doxorubicinol in the heart. A less severe aggravation of cardiotoxicity was observed on combining taxanes with epirubicin, a closely related analog of doxorubicin; therefore, we characterized whether the cardiac tolerability of epirubicin-taxane therapies could be due to a defective taxane stimulation of the conversion of epirubicin to its secondary alcohol metabolite epirubicinol. Comparisons between doxorubicin and epirubicin in isolated human heart cytosol showed that epirubicin exhibited a lower V(max)/K(m) value for reaction with aldehyde reductases and a defective stimulation of epirubicinol formation by paclitaxel or docetaxel. A similar pattern occurred in the soluble fraction of human myocardial strips incubated in plasma with anthracyclines and paclitaxel or docetaxel, formulated in their clinical vehicles Cremophor EL or polysorbate 80. Doxorubicin, but not epirubicin, was also able to generate reactive oxygen species in the membrane fraction of myocardial strips; however, the levels of doxorubicin-derived reactive oxygen species were not further augmented by paclitaxel. These results support the notion that taxanes might aggravate the cardiotoxicity of doxorubicin through a specific stimulation of doxorubicinol formation. The failure of paclitaxel or docetaxel to stimulate epirubicinol formation therefore uncovers an important determinant of the improved cardiac tolerability of epirubicin-taxane combinations.
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Affiliation(s)
- Emanuela Salvatorelli
- Department of Drug Sciences and Center of Excellence on Aging, G. d'Annunzio University School of Medicine, Via dei Vestini, 66013 Chieti, Italy
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Bengala C, Zamagni C, Pedrazzoli P, Matteucci P, Ballestrero A, Da Prada G, Martino M, Rosti G, Danova M, Bregni M, Jovic G, Guarneri V, Maur M, Conte PF. Cardiac toxicity of trastuzumab in metastatic breast cancer patients previously treated with high-dose chemotherapy: a retrospective study. Br J Cancer 2006; 94:1016-20. [PMID: 16570045 PMCID: PMC2361220 DOI: 10.1038/sj.bjc.6603060] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
HER-2 overexpression is associated to a poor prognosis in high-risk and metastatic breast cancer (MBC) patients treated with high-dose chemotherapy (HDC). HER-2 status is also a predictive factor and when trastuzumab is administered in combination with or sequentially to chemotherapy, a significant disease-free and/or overall survival improvement has been observed in HER-2+ early and MBC. Unfortunately, in both settings, trastuzumab is associated with an increased risk of cardiac dysfunction (CD). We have reviewed the clinical charts of HER-2-overexpressing MBC patients treated with trastuzumab after HDC. Age, baseline left ventricular ejection fraction (LVEF), radiation therapy on cardiac area, exposure to anthracycline, single or multiple transplant, high-dose agents, trastuzumab treatment duration were recorded as potential risk factors. In total, 53 patients have been included in the analysis. Median LVEF at baseline was 60.5%; at the end of trastuzumab (data available for 28 patients only), it was 55% (P = 0.01). Five out of the 28 (17.9%) patients experienced CD. Two out of 53 (3.8%) patients developed a congestive heart failure. Age > or = 50 years and multiple transplant procedure were potential risk factors for CD. The overall incidence of CD observed in this population of HER-2+ MBC patients treated with trastuzumab after HDC is not superior to that reported with concomitant trastuzumab and anthracyclines. However, patients with age > or = 50 years or receiving multiple course of HDC should be considered at risk for CD.
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Affiliation(s)
- C Bengala
- Division of Medical Oncology, University Hospital, Via del Pozzo, 71-41100 Modena, Italy.
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36
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Conte P, Bengala C. Current State of the Treatment in Metastatic Breast Cancer. J Breast Cancer 2006. [DOI: 10.4048/jbc.2006.9.1.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- PierFranco Conte
- Division of Medical Oncology, Department of Oncology and Hematology, University Hospital, University of Modena and Reggio Emilia Via del Pozzo, 71 41100 Modena, Italy
| | - Carmelo Bengala
- Division of Medical Oncology, Department of Oncology and Hematology, University Hospital, University of Modena and Reggio Emilia Via del Pozzo, 71 41100 Modena, Italy
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Abstract
Topoisomerase II inhibitors represent a broad class of antineoplastic agents with a wide spectrum of activity against malignancies. Topoisomerase II inhibitors include the anthracyclines, mitoxantrone and epipodophyllotoxins. Short-term toxicity includes myelosuppression and gastrointestinal toxicity. Long-term survivors are at risk of cardiac toxicity and secondary leukaemia. This article discusses these toxicities in detail, including administration of these agents to patients with hepatic and/or renal insufficiency, and the need for dose adjustments in selected patient populations.
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Affiliation(s)
- Karen Seiter
- New York Medical College, Room 250 Munger Pavilion, Valhalla, New York 10595, USA.
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38
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Gennari A, Conte P, Rosso R, Orlandini C, Bruzzi P. Survival of metastatic breast carcinoma patients over a 20-year period. Cancer 2005; 104:1742-50. [PMID: 16149088 DOI: 10.1002/cncr.21359] [Citation(s) in RCA: 201] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The expectation of improvement in patient survival with administration of new chemotherapy agents for metastatic breast carcinoma (MBC) is not consistently supported by data from clinical trials, which are often underpowered and have not detected moderate survival advantage. The aim of this study was to evaluate the impact of new agents on prognosis of MBC patients enrolled in clinical trials of first-line chemotherapy. METHODS Between 1983 and 2001, 640 MBC patients were entered into 6 consecutive trials; the present analysis was limited to patients. The date of diagnosis of metastatic breast disease was used to define 5 arbitrarily chosen 3-year time cohorts, 1983-1986, 1987-1989, 1992-1994, 1995-1997, and 1998-2001. Multivariate proportion of hazard (PH) models were used to evaluate changes in overall survival (OS) and progression-free survival (PFS) over time and to detect changes associated with the use of taxanes, while adjusting for differences in baseline factors among 5 cohorts. RESULTS Patient characteristics were evenly distributed across the 5 cohorts. Median OS was 18 months, 17.2 months, 19.2 months, 26.1 months, and 23.6 months, respectively, in cohorts 1983-1986, 1987-1989, 1992-1994, 1995-1997, 1998-2001 (P < 0.0001). Age, performance status, relapse-free survival, type of adjuvant treatment, metastatic site, and taxane first-line chemotherapy were all associated with survival. These data failed to provide an indication of temporal trend and suggested a reduction in hazard of death in two cohorts (1995-1997 and 1998-2001) where taxane was added to first-line chemotherapy. CONCLUSIONS The analysis provided evidence of improvement in prognosis of MBC patients that was associated with use of modern chemotherapeutic agents independent of time.
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Affiliation(s)
- Alessandra Gennari
- Department of Oncology, Division of Medical Oncology, Santa Chiara University Hospital, Pisa, Italy.
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Stöhr W, Paulides M, Brecht I, Kremers A, Treuner J, Langer T, Beck JD. Comparison of epirubicin and doxorubicin cardiotoxicity in children and adolescents treated within the German Cooperative Soft Tissue Sarcoma Study (CWS). J Cancer Res Clin Oncol 2005; 132:35-40. [PMID: 16205946 DOI: 10.1007/s00432-005-0041-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2005] [Accepted: 09/05/2005] [Indexed: 11/29/2022]
Abstract
PURPOSE Up to now, cardiotoxicity of epirubicin has been studied almost exclusively in adult cancer patients. The aim of this study was to investigate epirubicin in children and adolescents, in comparison with doxorubicin. METHODS About 172 soft tissue sarcoma patients (mean age at diagnosis: 8.3 years), treated with epirubicin (median cumulative dose: 450 mg/m2) or doxorubicin (median cumulative dose: 240 mg/m2) within the high-risk group of the CWS-96 study, were examined in a prospective multicentre study. Heart function was analysed by echocardiography, measuring left-ventricular fractional shortening (FS). The median follow up was 27.7 months. RESULTS Incidence of clinically manifest cardiomyopathy was 0% (0/60; 95% CI: 0-6.0%) in patients treated with epirubicin, and 0.9% (1/108; 95% CI: 0-5.1%) in patients treated with doxorubicin. A further three patients showed subclinical cardiomyopathy. There was no difference in FS between the two treatment arms. CONCLUSIONS Cardiotoxicity was low in our study. For the short term, cardiotoxicity seems to be only a minor problem in patients treated with epirubicin as applied in this cohort.
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Affiliation(s)
- W Stöhr
- Department of Pediatric Oncology, LESS Center, University Hospital for Children and Adolescents, Loschgestrasse 15, 91054, Erlangen, Germany
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Erman M, Baltali E, Karaoglu A, Abali H, Engin H, Ozisik Y, Guler N, Altundag K, Tekuzman G, Atahan IL, Onat D, Sayek I. A phase II study on the safety and efficacy of 5-fluorouracil, epirubicin, cyclophosphamide (FEC) followed by paclitaxel in the adjuvant treatment of breast cancer. Cancer Invest 2005; 23:215-21. [PMID: 15945507 DOI: 10.1081/cnv-200055956] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The incorporation of a taxane into an anthracycline-containing regimen in the adjuvant treatment of breast cancer is a promising approach. In this study, we aimed to evaluate the safety and efficacy of four cycles of FEC (fluorouracil 500 mg/m2, epirubicin 70 mg/m2, cyclophosphamide 500 mg/m2, every 3 weeks) followed by four cycles of paclitaxel (175 mg/m2 every 3 weeks) in the adjuvant treatment of node-positive and other high-risk breast cancer patients. A total of 88 female patients were enrolled. Mean age (+/- SD) of the patients was 47 +/- 10 (min: 24; max: 71). The patients were followed for a median of 48 months (min: 20; max: 64). The most common side effects were nausea-vomiting (grade I-II: 91%; grade III: 2%), as well as hematological toxicity (grade I-II: 70%; grade III: 3%). Although all patients experienced some degree of toxicity, it was severe enough to be classified as grade III or IV in only 10 (11%) of the cases. Of note, six (8%) patients had grade I and only one (1%) had grade II cardiotoxicity. No grade III or IV cardiotoxicity was observed. The full eight cycles of study treatment could be administered to 75 patients (85%). Side effects necessitated the reduction of the doses of FEC and paclitaxel in one (1%) and three patients (3%), respectively. Median overall (OS) and disease-free survival (DFS) have not yet been reached. Five-year OS and DFS have been estimated to be 78% and 61%, respectively. We conclude that FEC followed by paclitaxel is a well-tolerated and feasible regimen in the adjuvant treatment of early breast cancer. Its efficacity is comparable with other commonly used regimens and merits evaluation in a phase III study.
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MESH Headings
- Adult
- Aged
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Breast Neoplasms/drug therapy
- Breast Neoplasms/pathology
- Breast Neoplasms/surgery
- Chemotherapy, Adjuvant
- Cyclophosphamide/administration & dosage
- Disease-Free Survival
- Epirubicin/administration & dosage
- Female
- Fluorouracil/administration & dosage
- Humans
- Lymphatic Metastasis
- Middle Aged
- Neoplasms, Ductal, Lobular, and Medullary/drug therapy
- Neoplasms, Ductal, Lobular, and Medullary/pathology
- Neoplasms, Ductal, Lobular, and Medullary/surgery
- Paclitaxel/administration & dosage
- Safety
- Survival Rate
- Treatment Outcome
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Affiliation(s)
- Mustafa Erman
- Department of Internal Medicine, Section of Medical Oncology, Hacettepe University Faculty of Medicine, Ankara, Turkey.
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Magné N, Largillier R, Marcy PY, Magné J, Namer M. Cardiac toxicity assessment in locally advanced breast cancer treated neoadjuvantly with doxorubicin/paclitaxel regimen. Support Care Cancer 2005; 13:819-25. [PMID: 15798914 DOI: 10.1007/s00520-005-0804-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2004] [Accepted: 03/01/2005] [Indexed: 12/01/2022]
Abstract
BACKGROUND The psychological difficulty of accepting a mastectomy for locally advanced breast cancer (LABC) justifies the use of chemotherapy as neoadjuvant primary treatment. The aim of this prospective study was to assess the efficacy of the doxorubicin/paclitaxel (AT) schedule neoadjuvantly administered in terms of response rates and survival in patients with LABC, with a special focus on cardiac toxicity. PATIENTS AND METHOD All patients were treated by doxorubicin (60 mg/m2 i.v.) bolus followed by paclitaxel (200 mg/m2) as a 3-h infusion. Treatment was repeated every 3 weeks for four or six courses and followed by surgery, radiotherapy, and hormonotherapy for patients with positive hormonal receptors. Patients with significant cardiovascular history or ECG abnormalities were not eligible for the study. Measurements of left ventricular ejection fraction (LVEF) were performed at baseline and at the end of chemotherapy. RESULTS From 1998 to 2001, 34 consecutive patients followed up in our institution were entered into this study. Median age was 49 years (range, 32-68 years). Seventeen patients had stage IIB, 5 patients stage IIIA, and 12 patients stage IIIB disease. Twenty-one patients underwent conservative surgery, 7 radical surgery, and 6 patients no surgery due to metastatic disease occurring during treatment. An objective clinical response was noted in 22 (65%) of 34 patients (6 patients with histological complete response, 10 patients with rare malignant cells, and 6 patients with a partial response), 6 patients presented a progressive disease, and 8 patients a stable disease. Twenty-four patients have kept normal cardiac function, 7 patients had a cardiac toxicity as defined by the institution [4 (24%) of 17 patients received 360 mg/m2 of doxorubicin (A), 2 of 4 presented congestive heart failure (CHF), and 3 (21%) of 14 patients received 240 mg/m(2) of A without CHF]. Three patients did not receive four or six cycles as initially planned due to the progressive disease during the chemotherapy courses. These patients were excluded from the final analysis, particularly cardiac toxicity analysis. At time of median follow-up (42 months), 28 of 34 patients were alive (one death due to CHF, five others due to progressive disease). CONCLUSION The AT regimen in neoadjuvant treatment for LABC remains efficient, but cardiac toxicity reported in this study underlies the necessity to optimize the schedule of AT combination.
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Affiliation(s)
- Nicolas Magné
- Department of Medical Oncology, Centre Antoine Lacassagne, 06189 Nice, France.
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Tiersten A, Wo J, Jacobson C, Weitzman A, Horwich T, Hesdorffer C, Savage D, Troxel A. Cardiac toxicity observed in association with high-dose cyclophosphamide-based chemotherapy for metastatic breast cancer. Breast 2004; 13:341-6. [PMID: 15325671 DOI: 10.1016/j.breast.2004.02.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2004] [Indexed: 10/26/2022] Open
Abstract
INTRODUCTION Cyclophosphamide is an alkylating agent given frequently as a component of many conditioning regimens. In high doses, its nonhematological dose-limiting toxicity is cardiomyopathy. STUDY DESIGN We combined paclitaxel, melphalan and high-dose cyclophosphamide, thiotepa, and carboplatin in a triple sequential high-dose regimen for patients with metastatic breast cancer. Analysis was performed on 61 women with chemotherapy-responsive metastatic breast cancer receiving 96-h infusional cyclophosphamide as part of a triple sequential high-dose regimen to assess association between presence of peritransplant congestive heart failure (CHF) and the following pretreatment characteristics: presence of electrocardiogram (EKG) abnormalities, age, hypertension, prior cardiac history, smoking, diabetes mellitus, prior use of anthracyclines, and left-sided chest irradiation. RESULTS Six of 61 women (10%) developed clinically reversible grade 3 CHF following infusional cyclophosphamide with a median percent decline in ejection fraction of 31%. Incidence of transient cyclophosphamide-related cardiac toxicity (10%) is comparable to previous recorded literature. Older age was significantly correlated with the CHF development; with median ages for the entire group and for patients developing CHF of 45 and 59, respectively. No association was found with other pretreatment characteristics. CONCLUSIONS As a result of these findings, oncologists should carefully monitor fluid balance in older patients. Routine EKG monitoring during infusional cyclophosphamide did not predict CHF development.
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Affiliation(s)
- Amy Tiersten
- Department of Medical Oncology, NYU Medical Center, 160 East 32nd Street, Second Floor, New York, NY 10016, USA.
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Abstract
Drug interactions are an ongoing concern in treatment of cancer, especially when cytotoxic drugs are being used. However, the clinical relevance of these interactions is not always investigated. Drug interactions can be pharmaceutical, pharmacokinetic, or pharmacodynamic. They can also be wanted (eg, use of ciclosporin to enhance the oral bioavailability of paclitaxel); unwanted (eg, combination of the antiviral agent sorivudine and oral fluorouracil analogues can lead to fatal complications); between cytotoxic drugs, cytotoxic drugs and non-cytotoxic drugs; or with pharmaceutical vehicles. Potential interactions between anticancer drugs and over-the-counter or alternative medicines and herbs should not be underestimated. More attention should be given to the recognition of potential drug interactions in the preclinical and early clinical development phase of a new anticancer drug. Here, we provide a comprehensive overview of drug interactions, with selected examples.
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Affiliation(s)
- Jos H Beijnen
- Department of Pharmacy and Pharmacology, Slotervaart Hospital, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
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Minotti G, Menna P, Salvatorelli E, Cairo G, Gianni L. Anthracyclines: Molecular Advances and Pharmacologic Developments in Antitumor Activity and Cardiotoxicity. Pharmacol Rev 2004; 56:185-229. [PMID: 15169927 DOI: 10.1124/pr.56.2.6] [Citation(s) in RCA: 2566] [Impact Index Per Article: 128.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The clinical use of anthracyclines like doxorubicin and daunorubicin can be viewed as a sort of double-edged sword. On the one hand, anthracyclines play an undisputed key role in the treatment of many neoplastic diseases; on the other hand, chronic administration of anthracyclines induces cardiomyopathy and congestive heart failure usually refractory to common medications. Second-generation analogs like epirubicin or idarubicin exhibit improvements in their therapeutic index, but the risk of inducing cardiomyopathy is not abated. It is because of their janus behavior (activity in tumors vis-à-vis toxicity in cardiomyocytes) that anthracyclines continue to attract the interest of preclinical and clinical investigations despite their longer-than-40-year record of longevity. Here we review recent progresses that may serve as a framework for reappraising the activity and toxicity of anthracyclines on basic and clinical pharmacology grounds. We review 1) new aspects of anthracycline-induced DNA damage in cancer cells; 2) the role of iron and free radicals as causative factors of apoptosis or other forms of cardiac damage; 3) molecular mechanisms of cardiotoxic synergism between anthracyclines and other anticancer agents; 4) the pharmacologic rationale and clinical recommendations for using cardioprotectants while not interfering with tumor response; 5) the development of tumor-targeted anthracycline formulations; and 6) the designing of third-generation analogs and their assessment in preclinical or clinical settings. An overview of these issues confirms that anthracyclines remain "evergreen" drugs with broad clinical indications but have still an improvable therapeutic index.
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Affiliation(s)
- Giorgio Minotti
- G. d'Annunzio University School of Medicine, Centro Studi sull'Invecchiamento, Room 412, Via dei Vestini, 66013 Chieti, Italy.
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Gennari A, Bruzzi P, Orlandini C, Salvadori B, Donati S, Landucci E, Guarneri V, Rondini M, Ricci S, Conte P. Activity of first-line epirubicin and paclitaxel in metastatic breast cancer is independent of type of adjuvant therapy. Br J Cancer 2004; 90:962-7. [PMID: 14997190 PMCID: PMC2410217 DOI: 10.1038/sj.bjc.6601634] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
To evaluate the impact of prior adjuvant chemotherapy on response rate (RR), progression-free (PFS) and overall survival (OS) of metastatic breast cancer patients treated with epirubicin/paclitaxel (ET) regimens. In all, 291 patients enrolled in five studies in metastatic breast cancer were analysed: 101 (35%) were chemonaive, 109 (37%) had received adjuvant CMF and 81 (28%) adjuvant anthracyclines. Response rate to ET was 66%. Response rate was 63% for cyclophosphamide plus methotrexate plus 5-fluorouracil (CMF), 67% for prior anthracyclines and 68% in chemonaive patients (P=0.5). By multivariate analysis, adjusted odds ratio for response was 0.81 (95% CI: 0.37-1.79) for CMF and 0.92 (95% CI 0.43-2.01) for anthracyclines (P=0.86). The CR rates were 14% for both CMF and anthracyclines and 22% for chemonaive patients (P=0.2). By multivariate analysis, the relative odds of CR for CMF or anthracyclines were 0.40 and 0.39 as compared to chemonaive patients (P=0.036). The median PFS was 11.0 months for prior CMF, 10.2 months for anthracyclines and 12.5 months in chemonaive patients (P=0.33). In multivariate Cox's model, a nonsignificant increase in the risk of progression was seen in patients treated with adjuvant CMF or anthracyclines. The median OS was 23.8 months for CMF, 20.2 months for anthracyclines and 27.5 months in chemonaive patients (P=0.61). The same, nonsignificant, association was seen in multivariate analysis. The ET regimens provide satisfactory results in metastatic breast cancer, regardless of previous adjuvant chemotherapy.
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Affiliation(s)
- A Gennari
- Department of Oncology, Division of Medical Oncology, Santa Chiara University Hospital, Via Roma 5756126, Pisa, Italy.
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Guarneri V, Conte PF. The curability of breast cancer and the treatment of advanced disease. Eur J Nucl Med Mol Imaging 2004; 31 Suppl 1:S149-61. [PMID: 15107948 DOI: 10.1007/s00259-004-1538-5] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Breast cancer represents a major health problem, with more than 1,000,000 new cases and 370,000 deaths yearly worldwide. In the last decade, in spite of an increasing incidence, breast cancer mortality has been declining in the majority of developed countries. This is the combined result of better education, widespread screening programmes and more efficacious adjuvant treatments. Better knowledge of breast cancer biology now allows the cosmetic, physical and psychological consequences of radical mastectomy to be spared in the majority of breast cancer patients. Use of the sentinel node technique is rapidly expanding and this will further reduce the extent and the consequences of surgery. Several clinico-pathological factors are used to discriminate between patients at low (<10%), average (10-40%) and high risk of relapse. Nodal status, tumour size, tumour grade and age are accepted universally as important factors to define risk categories. Newer factors such as uPA/PAI-1, HERer2-neu, proliferative indices and gene expression profile are promising and will allow better discrimination between patients at different risk. Endocrine manipulation with tamoxifen, ovarian ablation or both is the preferred option in the case of endocrine-responsive tumours. Tamoxifen administered for 5 years is the standard treatment for postmenopausal patients; tamoxifen plus ovarian ablation is more effective than tamoxifen alone for premenopausal women. Recent data demonstrate that, for postmenopausal patients, the aromatase inhibitors are superior to tamoxifen, with a different safety profile. At present, anastrozole can be used in the adjuvant setting in cases of tamoxifen intolerance or toxicity. Chemotherapy is the treatment of choice for steroid receptor-negative tumours. Polychemotherapy is superior to single agents and anthracycline-containing regimens are superior to CMF. Six courses of FEC or FAC or the sequential administration of four doses of anthracycline followed by four of CMF are the recommended regimens. New regimens including the taxanes have produced a further improvement in risk reduction and are reasonable therapeutic options. The taxanes have been approved for adjuvant therapy in the USA, while European approval is pending. Combined endocrine-chemotherapy is the standard adjuvant treatment in high-risk patients with endocrine-responsive tumours. Endocrine manipulation is usually administered after completion of the chemotherapy programme. For HER2-neu overexpressing tumours, several rapidly accruing trials are exploring the potential additive effect of trastuzumab, a monoclonal antibody directed against the extramembrane portion of the HER2 receptor. Primary chemotherapy is increasingly used in the treatment of locally advanced and operable breast cancer, with increased rates of breast-conserving surgery. A proportion of patients achieve a pathological complete response and these patients have significantly better long-term outcomes. Twenty-five to forty percent of breast cancer patients develop distant metastases. At this stage the disease is incurable; however, treatments can assure a significant prolongation of survival, symptomatic control and maintenance of quality of life. In the case of hormone receptor positivity and in the absence of visceral, life-threatening disease, endocrine manipulation is the treatment of choice. Active treatments include tamoxifen, ovarian ablation, aromatase inhibitors, pure anti-oestrogens and progestins. Aromatase inhibitors are the most active agents, but the choice and the sequence of endocrine therapies are also dictated by prior adjuvant treatment. Chemotherapy has to be preferred in cases of receptor-negative tumours, acquired resistance to hormones and aggressive visceral disease. Combination regimens are usually associated with higher response rates and sometimes survival prolongation, and this approach should be recommended in young patients with good performance status and visceral disease. On the other hand, single agents have a better tolerability profile and should be tand should be the treatment of choice when a careful balance between activity and tolerability is needed. For HER2-neu positive tumours, the combination of trastuzumab and chemotherapy is significantly superior to chemotherapy alone in terms of both response rates and survival. Other useful palliative treatments include bisphosphonates for the control of metastatic bone disease and radiotherapy for painful bone lesions or local relapses.
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Affiliation(s)
- Valentina Guarneri
- Department of Oncology and Hematology, University of Modena and Reggio Emilia, Modena, Italy
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Kristensen GB, Vergote I, Stuart G, Del Campo JM, Kaern J, Lopez AB, Eisenhauer E, Aavall-Lundquist E, Ridderheim M, Havsteen H, Mirza MR, Scheistroen M, Vrdoljak E. First-line treatment of ovarian cancer FIGO stages IIb-IV with paclitaxel/epirubicin/carboplatin versus paclitaxel/carboplatin. Int J Gynecol Cancer 2004; 13 Suppl 2:172-7. [PMID: 14656276 DOI: 10.1111/j.1525-1438.2003.13363.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The objective of this study was to compare the safety and efficacy of carboplatin plus epirubicin and paclitaxel (TEC) to carboplatin and paclitaxel (TC), in the treatment of epithelial ovarian, peritoneal, or tubal carcinoma. Between March 1999 and August 2001, 887 patients were randomized to receive six to nine cycles of paclitaxel (175 mg/m2, 3 h intravenously) followed by carboplatin (AUC 5, Calvert formula) with or without epirubicin (75 mg/m2 intravenously prior to paclitaxel), on a 3-weekly schedule. The primary endpoint was progression-free survival. Demographic information: Residual disease <1 cm was reported on 41% of patients. At the end of treatment, 65% in the TEC and 55% in the TC arm had achieved a clinical complete response, and 18 and 25% a clinical partial response resulting in an overall response rate of 83% in the TEC and 80% in the TC arm, whereas 7 and 9% had progressive disease, respectively. The three-drug combination produced a markedly higher myelotoxicity, resulting in a higher frequency of febrile neutropenia (12.5% of the TEC and 1.5% of the TC patients) and a higher number of dose reductions and treatment delays. Cycle prolongation above seven days was seen in 7 and 5% of cycles in the TEC and TC arm, respectively. Stomatitis > or = grade 3 was also higher with TEC (4% TEC and 0.5% TC). Reductions in left ventricular ejection fraction of more than 15% after six courses were slightly more common with the TEC regimen (3% versus 1.5%), but the difference was not statistically significant (P = 0.2). In conclusion, treatment with the TEC combination produced a higher rate of complete responses than treatment with the TC combination. Toxicity was manageable. Long-term survival data are awaited.
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Affiliation(s)
- G B Kristensen
- Department of Gynecologic Oncology, The Norwegian Radium Hospital, Oslo, Norway.
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Abstract
Cardiotoxicity is a well-known side effect of several cytotoxic drugs, especially of the anthracyclines and can lead to long term morbidity. The mechanism of anthracycline induced cardiotoxicity seems to involve the formation of free radicals leading to oxidative stress. This may cause apoptosis of cardiac cells or immunologic reactions. However, alternative mechanisms may play a role in anthracycline induced cardiotoxicity. Cardiac protection can be achieved by limitation of the cumulative dose. Furthermore, addition of the antioxidant and iron chelator dexrazoxane to anthracycline therapy has shown to be effective in lowering the incidence of anthracycline induced cardiotoxicity. Other cytotoxic drugs such as 5-fluorouracil, cyclophosphamide and the taxoids are associated with cardiotoxicity as well, although little is known about the possible mechanisms. Recently, it appeared that some novel cytotoxic drugs such as trastuzumab and cyclopentenyl cytosine also show cardiotoxic side effects.
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Affiliation(s)
- Kirsten J M Schimmel
- Department of Clinical Pharmacy, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Netherlands
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Conte PF, Guarneri V, Bruzzi P, Prochilo T, Salvadori B, Bolognesi A, Aldrighetti D, Venturini M, Rosso R, Mammoliti S, Carnino F, Giannessi P, Costantini M, Moyano A, Baldini E. Concomitant versus sequential administration of epirubicin and paclitaxel as first-line therapy in metastatic breast carcinoma. Cancer 2004; 101:704-12. [PMID: 15305399 DOI: 10.1002/cncr.20400] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND The authors performed a randomized trial comprising patients with metastatic breast carcinoma (MBC). They used a noninferiority design to evaluate whether the results of sequential administration of epirubicin and paclitaxel were not markedly worse than the concomitant administration in terms of objective response rates (ORRs). Toxicity profile, quality of life (QOL), and pharmacoeconomic evaluations were evaluated as well. METHODS In the current study, 202 patients with MBC were randomized to receive either the combination of epirubicin at a dose of 90 mg/m2 plus paclitaxel at a dose of 200 mg/m2 for 8 cycles (concomitant arm, n = 108) or epirubicin at a dose of 120 mg/m2 for 4 cycles followed by paclitaxel at a dose of 250 mg/m2 over 3 hours for 4 cycles every 21 days (sequential arm, n = 94). RESULTS The authors rejected the null hypothesis that the sequential treatment is less active than the standard concomitant regimen (ORRs: concomitant = 58.5%, sequential = 57.6%). The median progression-free and overall survival periods were 11.0 months (95% confidence interval [95% CI], 9.7-12.3) and 20.0 months (95% CI, 17.2-22.6), respectively, in the concomitant arm and 10.8 months (95% CI, 7.9-13.6) and 26 months (95% CI, 18.1-33.8), respectively, in the sequential arm (P = not significant). Patients who received the sequential regimen experienced a higher incidence of Grade 3/4 (according to the World Health Organization grading system) neutropenia (62.2% of courses vs. 50.62%; P = 0.003) and Grade > or = 2 neuropathy (45.5% vs. 30.4% of patients; P = 0.03), whereas 6 patients who received the concomitant regimen developed Grade II cardiotoxicity according to New York Heart Association criteria. QOL analyses failed to provide clear differences. CONCLUSIONS The sequential administration of epirubicin and paclitaxel at full doses was found to be as active as their association. Therefore, both the sequential and the combined administration were acceptable options.
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Affiliation(s)
- Pier Franco Conte
- Division of Medical Oncology, St. Chiara University Hospital, Pisa, Italy.
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Recht A. Integration of systemic therapy and radiation therapy for patients with early-stage breast cancer treated with conservative surgery. Clin Breast Cancer 2003; 4:104-13. [PMID: 12864938 DOI: 10.3816/cbc.2003.n.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
There is no consensus on the optimal combination of systemic therapy and radiation therapy for patients with early-stage breast cancer treated with conservative surgery. This article reviews prospective and retrospective studies that shed light on this topic. Patients with positive, close, or unknown microscopic margins appear to benefit from relatively early initiation of radiation therapy, whereas those with wider tumor-free margin widths do not. For patients at high risk of distant failure (such as those with = 4 positive axillary nodes), chemotherapy may be more effective when it begins before radiation therapy rather than after. Regimens of concurrent radiation therapy and chemotherapy tend to have higher acute and subacute complication rates than sequential regimens, but the actual rates vary substantially with the exact details of the overall treatment program. There are no data on the impact of the timing of tamoxifen administration on the effectiveness of radiation therapy. Tamoxifen does not appear to increase complication rates relative to the use of radiation therapy alone. Thus, the best way of giving combined-modality therapy is uncertain. Further retrospective and prospective studies to investigate the issues discussed herein should be performed.
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Affiliation(s)
- Abram Recht
- Department of Radiation Oncology, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, MA,USA.
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