Clinical Cancer Advances 2005: major research advances in cancer treatment, prevention, and screening--a report from the American Society of Clinical Oncology

Cardiovascular adverse events of antineoplastic monoclonal antibodies among cancer patients: real-world evidence from a tertiary healthcare system

BACKGROUND

Antineoplastic monoclonal antibodies (mAbs), such as trastuzumab, bevacizumab, and pertuzumab have been the mainstay of therapy in cancer patients. Despite proven efficacy of the monoclonal antibodies, cardiovascular-induced adverse events such as heart failure, hypertension, ischemic heart disease, arrhythmias, thromboembolic events, and hemorrhage remain a major complication. The European society of cardiology address that concern with antineoplastic monoclonal antibodies issuing a guideline to manage and monitor chemotherapy-induced cardiotoxicity. There is limited evidence of the real-world prevalence of cardiovascular (CV) events induced by monoclonal antibodies among patients with cancer in Saudi Arabia.

OBJECTIVE

To evaluate the prevalence of cardiovascular adverse events among patients with cancer treated with monoclonal antibodies in Saudi Arabia.

METHODS

This is a retrospective study conducted in a tertiary care hospital, Riyadh, Saudi Arabia. Data were obtained from an electronic medical record of patients with cancer treated with one of the selected monoclonal antibodies, who met the inclusion criteria between January 2005 until June 2015 and have been followed up for at least one year. Patients were stratified into groups according to monoclonal antibodies treatment: trastuzumab, bevacizumab, pertuzumab, and combined mAbs.

RESULTS

A total of 1067 patient were included in the study, within the pre-determined study period. The prevalence of cardiovascular disease among patients with cancer treated with monoclonal antibodies was 16.3%. The prevalence of heart failure was relatively higher in the trastuzumab group (46/626 patients, 7.3%). Among 418 patients treated with bevacizumab, hypertension was the most frequent adverse event, reported in 38 patients (9.1%), followed by thromboembolism reported in 27 patients (6.5%). Treatment discontinuation owing to cardiovascular adverse events was reported in 42/1,067 patients (3.9%).

CONCLUSION AND RELEVANCE

Prevalence of antineoplastic monoclonal antibody induced cardiovascular adverse events among patients with cancer is substantially high in Saudi Arabia. There is an urgent need to streamline the practice for identifying high risk patients and flexible referral system for cardio-oncology care.

Overlap of Thrombotic Microangiopathy and Mesangial Proliferative Glomerulonephritis Caused by Combination Therapy with Atezolizumab and Bevacizumab

Vascular endothelial growth factor inhibitors and checkpoint inhibitors are effective treatments for solid tumors. These new classes of anti-cancer agents frequently cause kidney-related side effects. Although their anti-cancer effects may be enhanced when used in combination, the severity of their kidney-related side effects is unknown. We herein report the first case of thrombotic microangiopathy and mesangial proliferative glomerulonephritis caused by combined treatment with atezolizumab and bevacizumab in a 74-year-old man with hepatocellular carcinoma. The combination therapy was discontinued and replaced with intravenous methylprednisolone followed by oral prednisolone. Subsequently, the urinary protein excretion levels declined.

Cell Culture-Based Assessment of Toxicity and Therapeutics of Phytochemical Antioxidants

Plant-derived natural products are significant resources for drug discovery and development including appreciable potentials in preventing and managing oxidative stress, making them promising candidates in cancer and other disease therapeutics. Their effects have been linked to phytochemicals such as phenolic compounds and their antioxidant activities. The abundance and complexity of these bio-constituents highlight the need for well-defined in vitro characterization and quantification of the plant extracts/preparations that can translate to in vivo effects and hopefully to clinical use. This review article seeks to provide relevant information about the applicability of cell-based assays in assessing anti-cytotoxicity of phytochemicals considering several traditional and current methods.

Detection of Multiple Breast Cancer ESR1 Mutations on an ISFET Based Lab-on-Chip Platform

ESR1 mutations are important biomarkers in metastatic breast cancer. Specifically, p.E380Q and p.Y537S mutations arise in response to hormonal therapies given to patients with hormone receptor positive (HR+) breast cancer (BC). This paper demonstrates the efficacy of an ISFET based CMOS integrated Lab-on-Chip (LoC) system, coupled with variant-specific isothermal amplification chemistries, for detection and discrimination of wild type (WT) from mutant (MT) copies of the ESR1 gene. Hormonal resistant cancers often lead to increased chances of metastatic disease which leads to high mortality rates, especially in low-income regions and areas with low healthcare coverage. Design and optimization of bespoke primers was carried out and tested on a qPCR instrument and then benchmarked versus the LoC platform. Assays for detection of p.Y537S and p.E380Q were developed and tested on the LoC platform, achieving amplification in under 25 minutes and sensitivity of down to 1000 copies of DNA per reaction for both target assays. The LoC system hereby presented, is cheaper and smaller than other standard industry equivalent technologies such as qPCR and sequencing. The LoC platform proposed, has the potential to be used at a breast cancer point-of-care testing setting, offering mutational tracking of circulating tumour DNA in liquid biopsies to assist patient stratification and metastatic monitoring.

Minimally Invasive Anterior Thoracotomy for Routine Lung Cancer Resection

Objectives

A 7-year experience with a minimally invasive approach to routine lung cancer resection is compared with standard lateral open thoracotomy.

Methods

All patients undergoing lung resection with curative intent for primary lung cancer between July 1998 and November 2005 by a single surgical team were registered. Surgical access was obtained through a mini 5- to 6-cm anterior thoracotomy with video assistance; direct visualization was also used extensively.

Results

Patients (n = 167) underwent major pulmonary resection for primary lung cancer. The minimally invasive group (MI), 137 patients, included 12 fully endoscopic or robotic approaches. The open lateral (OL) approach included 30 patients (18%). Both groups included pneumonectomies (8 MI, 3 OL), sleeve resections (3 MI, 2 OL), chest wall resections (2 MI, 5 OL), and pancoasts (3 MI, 0 OL) and had full lymph node resections. The Kaplan-Meier estimated overall mean survival was 64.5 months (95% CL, 58 to 71 months). Mean estimate survivals were stage 1a, 66%; stage 1b, 65%; stage 2a, 61%; stage 2b, 55%; stage 3a, 52%; stage 3b, 45%. Mean survival in the MI group was 64.3 months versus 59.3 with standard open access (OL) (X2 = 0.003 Mantel-Cox; significance, 0.959). In-hospital mortality rate was 2.2%; conversion from a mini to open procedure was 1.5%. Avoidance of rib spreading (soft tissue retractor) and small incisions appeared to have reduced pain and improved early recovery.

Conclusions

Kaplan-Meier survival for routine unselected lung cancer resection through a minimal access approach was not significantly different from the open approach and reflects published survival curves.

A narrative synthesis of the quality of cancer care and development of an integrated conceptual framework

The general paradigms that exist to guide measures in quality of care do not sufficiently deal with the changing needs of cancer management. The aim of this study was to review the literature regarding the quality of cancer care and develop a conceptual framework relevant to current practice. A textual narrative review of the literature was conducted by searching electronic databases from the last 10 years. Articles were then screened and included if they were both relevant to the management of cancer and standards in quality of care. Thematic analysis of the included articles was performed. Eighty-three articles were included and 12 domains identified and integrated with current models to develop a conceptual framework. These included: healthcare delivery system; timeliness; access; appropriateness of care; multidisciplinary and coordinated care; patient experience; technical aspects; safety; patient-centred outcomes; disease-specific outcomes; innovation and improvement and value. We propose a conceptual framework for the quality of cancer care based on relevant and current oncology practice. This presents a more practical and comprehensive approach than general models, and can be used by healthcare providers, managers and policy makers to guide and identify the need for metrics for quality improvements.

2D longitudinal LV speckle tracking strain pattern in breast cancer survivors: sports activity vs exercise as prescription model

Prevention strategies are important to optimize and to manage heart care in breast cancer survivors. Regular physical activity at moderate intensity is normally proposed to maintain myocardial performance; however, no data is available about the different impact of different levels of physical exercise. 2D speckle tracking echocardiography (2DSTE) is an accepted method for early detection of myocardial dysfunction. The study aims to monitor the cardiac performances in breast cancer survivors by 2DSTE analysis to manage sports activity vs physical activity. Two groups of previous breast cancer survivors (33 BCS) trained at moderate intensity and 55 athletes practicing dragon boat (DBA) sport were enrolled. They were matched with two healthy subjects groups: 23 competitive female athletes practicing different sports and 20 healthy women trained with exercise as prescription model. All women were studied by a complete echo examination including LV global longitudinal strain (GLS) assessment (XStrain-Esaote). EF and GS are only significantly higher in healthy subjects (-25.4 ± 2.1). Nevertheless, GLS values are within the normal range for all groups. Particularly, GS does not show any significant differences among subjects (-19.93 ± 4) practicing exercise as prescription when compared to the DBA competitive trained group. 2DSTE method is an appropriate method to supervise the intensity of exercise in breast cancer patients. Particularly, GLS can optimize and improve cancer therapy supporting and creating efficiencies within the health system confirming the role of the exercise prescription therapy in maintaining normal heart function.

5-Hydroxyvitamin D concentration in paediatric cancer patients from Scotland: a prospective cohort study

Children with cancer are potentially at a high risk of plasma 25-hydroxyvitamin D (25(OH)D) inadequacy, and despite UK vitamin D supplementation guidelines their implementation remains inconsistent. Thus, we aimed to investigate 25(OH)D concentration and factors contributing to 25(OH)D inadequacy in paediatric cancer patients. A prospective cohort study of Scottish children aged 75 nmol/l). In all, eighty-two patients (median age 3·9, interquartile ranges (IQR) 1·9-8·8; 56 % males) and thirty-five controls (median age 6·2, IQR 4·8-9·1; 49 % males) were recruited. 25(OH)D inadequacy was highly prevalent in the controls (63 %; 22/35) and in the patients (64 %; 42/65) at both baseline and during treatment (33-50 %). Non-supplemented children had the highest prevalence of 25(OH)D inadequacy at every stage with 25(OH)D median ranging from 32·0 (IQR 21·0-46·5) to 45·0 (28·0-64·5) nmol/l. Older age at baseline (R -0·46; P<0·001), overnutrition (BMI≥85th centile) at 3 months (P=0·005; relative risk=3·1) and not being supplemented at 6 months (P=0·04; relative risk=4·3) may have contributed to lower plasma 25(OH)D. Paediatric cancer patients are not at a higher risk of 25(OH)D inadequacy than healthy children at diagnosis; however, prevalence of 25(OH)D inadequacy is still high and non-supplemented children have a higher risk. Appropriate monitoring and therapeutic supplementation should be implemented.

Induction of IL-25 secretion from tumour-associated fibroblasts suppresses mammary tumour metastasis

Tumour-associated fibroblasts (TAFs), as a functionally supportive microenvironment, play an essential role in tumour progression. Here we investigate the role of IL-25, an endogenous anticancer factor secreted from TAFs, in suppression of mouse 4T1 mammary tumour metastasis. We show that a synthetic dihydrobenzofuran lignan (Q2-3), the dimerization product of plant caffeic acid methyl ester, suppresses 4T1 metastasis by increasing fibroblastic IL-25 activity. The secretion of IL-25 from treated human or mouse fibroblasts is enhanced in vitro, and this activity confers a strong suppressive effect on growth activity of test carcinoma cells. Subsequent in vivo experiments showed that the anti-metastatic effects of Q2-3 on 4T1 and human MDA-MD-231 tumour cells are additive when employed in combination with the clinically used drug, docetaxel. Altogether, our findings reveal that the release of IL-25 from TAFs may serve as a check point for control of mammary tumour metastasis and that phytochemical Q2-3 can efficiently promote such anticancer activities.

Interleukin-25 has been reported to have anticancer activity with very little effect on non-malignant cells. Here, the authors show that a synthetic phytochemical can be used to induce the secretion of Interleukin-25 from tumour associated fibroblasts resulting in impaired tumour metastasis.

Disparities by Race, Age, and Sex in the Improvement of Survival for Major Cancers: Results From the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) Program in the United States, 1990 to 2010

IMPORTANCE

Substantial progress has been made in cancer diagnosis and treatment, resulting in a steady improvement in cancer survival. The degree of improvement by age, race, and sex remains unclear.

OBJECTIVE

To quantify the degree of survival improvement over time by age, race, and sex in the United States.

DESIGN, SETTING, AND PARTICIPANTS

Longitudinal analyses of cancer follow-up data from 1990 to 2010, from 1.02 million patients who had been diagnosed as having cancer of the colon or rectum, breast, prostate, lung, liver, pancreas, or ovary from 1990 to 2009 and who were included in 1 of 9 population-based registries of the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) program.

MAIN OUTCOMES AND MEASURES

Hazard ratios (HRs) and 95% CIs for cancer-specific death were estimated for patients diagnosed as having any of these cancers during 1995 to 1999, 2000 to 2004, and 2005 to 2009, compared with those diagnosed in 1990 to 1994.

RESULTS

Significant improvements in survival were found for cancers of the colon or rectum, breast, prostate, lung, and liver. Improvements were more pronounced for younger patients. For patients aged 50 to 64 years and diagnosed from 2005 to 2009, adjusted HRs (95% CIs) were 0.57 (95% CI, 0.55-0.60), 0.48 (95% CI, 0.45-0.51), 0.61 (95% CI, 0.57-0.69), and 0.32 (95% CI, 0.30-0.36), for cancer of the colon or rectum, breast, liver, and prostate, respectively, compared with the same age groups of patients diagnosed during 1990 to 1994. However, the corresponding HRs (95% CIs) for elderly patients (those 75-85 years old) were only 0.88 (95% CI, 0.84-0.92), 0.88 (95% CI, 0.82-0.95), 0.76 (95% CI, 0.69-0.84), and 0.65 (95% CI, 0.61-0.70), for the same 4 cancer sites, respectively. A similar, although weaker, age-related period effect was observed for lung and pancreatic cancers. The adjusted HRs (95% CIs) for lung cancer were 0.75 (95% CI, 0.73-0.77) and 0.84 (95% CI, 0.81-0.86), respectively, for patients aged 50 to 64 years and 75 to 85 years diagnosed between 2005 and 2009, compared with the same age groups of patients diagnosed between 1990 and 1994 (0.73 [95% CI, 0.69-0.77] and 0.90 [95% CI, 0.85-0.95], respectively. Compared with whites or Asians, African Americans experienced greater improvement in prostate cancer survival. From 1990 to 2009, ovarian cancer survival declined among African Americans but improved among whites. No apparent sex difference in the degree of improvement for any non-sex-specific cancer was noted.

CONCLUSIONS AND RELEVANCE

Younger patients experienced greater benefit from recent oncology advances than elderly patients. African Americans experienced poorer survival than whites for all cancers, and the racial difference decreased for prostate cancer but increased for ovarian cancer. Identifying factors associated with varied improvement in cancer survival can inform future improvements in cancer care for all.

Systematic review and meta-analysis: Prevalence and possible causes of vitamin D deficiency and insufficiency in pediatric cancer patients

BACKGROUND AND AIMS

Vitamin D inadequacy is now an internationally recognized health problem and pediatric cancer patients may be at even higher risk than healthy children. We aimed to evaluate primary research to establish the prevalence of vitamin D inadequacy and to explore its possible causes in pediatric cancer patients.

METHODS

Electronic databases were searched (no restriction-Aug 2013) with no language restrictions and keywords related to cancer and vitamin D. We included studies of patients aged <18 years, diagnosed with and treated for cancer and reporting plasma vitamin D status. Evidence was critically appraised employing the CASP tool. Meta-analysis was performed when appropriate.

RESULTS

We included 19 studies, which were mainly of moderate-quality and heterogeneous in the definitions of vitamin D deficiency and insufficiency. The median (range) prevalence of vitamin D deficiency was 14% (0-61.5%) and insufficiency 23% (0-83%). Finally, a significant effect of younger age with vitamin D inadequacy was shown (effect size: -0.132; 95%CI -0.203, -0.060).

CONCLUSION

There is a possibility of a high prevalence of vitamin D inadequacy in pediatric cancer patients, especially older children, urging the need for high-quality population-based longitudinal studies using standard definitions.

Nanoparticle-Mediated Target Delivery of TRAIL as Gene Therapy for Glioblastoma

Human tumor necrosis factor α-related apoptosis-inducing ligand (TRAIL) is an attractive cancer therapeutic because of its ability to induce apoptosis in tumor cells while having a negligible effect on normal cells. However, the short serum half-life of TRAIL and lack of efficient in vivo administration approaches have largely hindered its clinical use. Using nanoparticles (NPs) as carriers in gene therapy is considered as an alternative approach to increase TRAIL delivery to tumors as transfected cells would be induced to secrete TRAIL into the tumor microenvironment. To enable effective delivery of plasmid DNA encoding TRAIL into glioblastoma (GBM), we developed a targeted iron oxide NP coated with chitosan-polyethylene glycol-polyethyleneimine copolymer and chlorotoxin (CTX) and evaluated its effect in delivering TRAIL in vitro and in vivo. NP-TRAIL successfully delivers TRAIL into human T98G GBM cells and induces secretion of 40 pg mL(-1) of TRAIL in vitro. Transfected cells show threefold increased apoptosis as compared to the control DNA bound NPs. Systemic administration of NP-TRAIL-CTX to mice bearing T98G-derived flank xenografts results in near-zero tumor growth and induces apoptosis in tumor tissue. Our results suggest that NP-TRAIL-CTX can potentially serve as a targeted anticancer therapeutic for more efficient TRAIL delivery to GBM.

Subclinical ventricular dysfunction detected by speckle tracking two years after use of anthracycline

Background

Heart failure is a severe complication associated with doxorubicin (DOX) use. Strain, assessed by two-dimensional speckle tracking (2D-STE), has been shown to be useful in identifying subclinical ventricular dysfunction.

Objectives

a) To investigate the role of strain in the identification of subclinical ventricular dysfunction in patients who used DOX; b) to investigate determinants of strain response in these patients.

Methods

Cross-sectional study with 81 participants: 40 patients who used DOX ±2 years before the study and 41 controls. All participants had left ventricular ejection fraction (LVEF) ≥55%. Total dose of DOX was 396mg (242mg/ms²). The systolic function of the LV was evaluated by LVEF (Simpson), as well as by longitudinal (ε_LL), circumferential (ε_CC), and radial (ε_RR) strains. Multivariate linear regression (MLR) analysis was performed using ε_LL (model 1) and ε_CC (model 2) as dependent variables.

Results

Systolic and diastolic blood pressure values were higher in the control group (p < 0.05). ε_LL was lower in the DOX group (-12.4 ±2.6%) versus controls (-13.4 ± 1.7%; p = 0.044). The same occurred with ε_CC: -12.1 ± 2.7% (DOX) versus -16.7 ± 3.6% (controls; p < 0.001). The S’ wave was shorter in the DOX group (p = 0.035). On MLR, DOX was an independent predictor of reduced ε_CC (B = -4.429, p < 0.001). DOX (B = -1.289, p = 0.012) and age (B = -0.057, p = 0.029) were independent markers of reduced ε_LL.

Conclusion

a) ε_LL, ε_CC and the S’ wave are reduced in patients who used DOX ±2 years prior to the study despite normal LVEF, suggesting the presence of subclinical ventricular dysfunction; b) DOX was an independent predictor of reduced ε_CC; c) prior use of DOX and age were independent markers of reduced ε_LL.

Effects of pediatric cancer and its treatment on nutritional status: a systematic review

CONTEXT

Malnutrition in pediatric cancer is common worldwide, yet its prevalence and effects on clinical outcomes remain unclear.

OBJECTIVE

The aim of this review was to evaluate primary research reporting the prevalence of malnutrition in pediatric cancer patients and to assess the effects of pediatric cancer and its treatment on nutritional status.

DATA SOURCES

Electronic databases of MEDLINE, CINHAL, and PubMed were searched (January 1990-February 2013).

STUDY SELECTION

Studies of patients aged <18 years who were diagnosed with and treated for cancer and for whom measurements of anthropometry were reported and included. The primary outcome was the prevalence of malnutrition (undernutrition and overnutrition), expressed as body mass index (BMI), in children diagnosed with and treated for cancer.

DATA EXTRACTION

Evidence was appraised critically by employing the Critical Appraisal Skills Program tool, and data was extracted from original articles.

DATA SYNTHESIS

A total of 46 studies were included, most of which were considered to be of low quality on the basis of heterogeneity in both the criteria and the measurements used to define malnutrition. Undernutrition was identified by measuring BMI, weight loss, mid-upper arm circumference, and triceps skinfold thickness, while overnutrition was assessed using BMI. Overall, the prevalence of undernutrition ranged from 0% to 65% and overnutrition from 8% to 78%. Finally, undernutrition in pediatric cancer at diagnosis was associated with poor clinical outcomes in 6 of 9 studies.

CONCLUSION

The possibility of a high prevalence of malnutrition in childhood cancer, indicated by the studies reviewed, highlights the need for high-quality, population-based, longitudinal studies using standard criteria to identify malnutrition.

Targeted therapies for soft-tissue sarcomas

The past several decades have revealed certain challenges that are inherent to soft-tissue sarcomas with regards to devising, testing and setting treatment paradigms for such a rare and heterogeneous malignancy. Despite this, significant advances have been made through the efforts of scientists, clinicians and patients alike. We are now entering a molecular era of cancer and current biotechnology is beginning to unravel the pathogenic enigma of these often devastating tumors. As our understanding of these malignancies improves, so does our list of potential treatment options. The impetus now lies with the medical/scientific community to direct translational research and subsequently the development and clinical testing of novel compounds in a fashion that best serves this unique patient population. To do so, we must continue to integrate the lessons of the past with the resources and promise of the future. This review will outline current areas of therapeutic interest in soft-tissue sarcomas with regard to agents that have reached clinical testing.

Combination of sunitinib with anti-tumor vaccination inhibits T cell priming and requires careful scheduling to achieve productive immunotherapy

Sunitinib, a protein tyrosine kinase inhibitor is the frontline therapy for renal and gastrointestinal cancers. We hypothesized that by virtue of its well documented tumor apoptosis and immune adjuvant properties, combination of Sunitinib with anti-tumor immunotherapeutics will provide synergistic inhibition of tumor growth. Our study was designed to evaluate the impact of Sunitinib on immunotherapy mediated anti-tumor immune responses and evaluate its efficacy as a combinatorial therapy with tumor targeted immunotherapeutic vaccination. Mice immunized with recombinant α-lactalbumin, a lactation protein expressed on majority of breast tumors were treated with 1 mg of Sunitinib for seven consecutive days beginning (1) concurrently, on the day of α-lactalbumin immunization or (2) sequentially, on day 9 after immunization. Ten-day lymph nodes or 21 day spleens were tested by ELISPOT assays and flow cytometry to evaluate responsiveness to α-lactalbumin immunization in presence of Sunitinib and distribution of cells involved in T cell antigen priming and proliferation in different lymphoid compartments. In addition, therapeutic efficacy of the α-lactalbumin/ Sunitinib combination was evaluated by monitoring tumor growth in the 4T1 transplanted tumor model. Our studies reveal that concurrent administration of Sunitinib with active vaccination against a targeted tumor antigen inhibits priming to the immunogen due to a drastic decrease in CD11b+CD11c+ antigen presenting cells, leading to failure of vaccination. However, sequential delivery of Sunitinib timed to avoid the priming phase of vaccination results in the desired vaccination mediated boost in immune responses.

Cancer patients' and professional caregivers' needs, preferences and factors associated with receiving and providing fertility-related information: a mixed-methods systematic review

OBJECTIVES

Cancer treatment can impair fertility. The aim of this review was to investigate (1) fertility information needs, receipt and provision, (2) fertility information preferences, and (3) factors associated with receiving/providing fertility information. Cancer patients' and professional caregivers' perspectives were considered.

DESIGN

Mixed-methods systematic review.

DATA SOURCES

Six electronic databases (PubMed, Web of Science, CINAHL, CRD, Embase) were systematically screened to retrieve articles published between January 2001 and March 2012. Reference lists and conference abstracts were checked for additional publications.

REVIEW METHODS

The principles outlined in the Cochrane Handbook for Systematic Reviews of Intervention were applied. Publications were included if they explored fertility-related information/communication in cancer patients/survivors of reproductive age or professional caregivers. The Critical Appraisal Skills Programme for Qualitative Studies and the Quality Assessment Tool for Quantitative Studies were used to assess the methodological quality. A standardised form based on the Cochrane guidelines for systematic reviews was used to extract the data. Two independent reviewers performed all methodological steps.

RESULTS

Of the 1872 papers found, 27 were included in this review. The majority (66-100%) of the cancer patients wanted information about the impact of cancer therapy on fertility. The need and importance were higher in younger and childless patients, and in patients having childbearing plans. The number of patients receiving this information ranged from 0% to 85%. Several factors were associated with the lack of information receipt, including female gender and age 35 years or older. Patients preferred information via an individual consultation. In the diagnostic phase patients needed information about the impact of the treatment on fertility and preservation options. At the end or after the treatment, information needs shifted towards long term effects. Professional caregivers experienced several barriers in providing fertility information, including caregiver-, patient- and institutional-related factors. Nurses in particular, perceived difficulty in providing fertility-related information due to additional barriers associated with limited responsibility and opportunity in fertility information provision.

CONCLUSION

Professional caregivers experienced multiple barriers that hinder information provision. Further exploration of the role of Advanced Nurse Practitioners/Midwifes and the development of an evidence based intervention to overcome caregiver-related barriers are recommended to improve information provision.

Using cardiac biomarkers and treating cardiotoxicity in cancer

Cardiotoxicity is a frequent and serious adverse effect of both conventional and novel anticancer treatments, affecting patient survival and quality of life. The current standard for cardiac monitoring during cancer therapy, mainly based on left ventricular ejection fraction assessment, detects myocardial damage only when a functional impairment has already occurred, not allowing for early preventive strategies. Measurement of cardiospecific biomarkers has proven to have higher prognostic value than imaging modalities. In particular, cardiac troponin elevation during chemotherapy allows the identification of patients who are more prone to develop myocardial dysfunction and cardiac events during follow-up. In these patients, the use of an angiotensin-converting enzyme inhibitor such as enalapril has shown to be effective in improving clinical outcome, giving the chance for a cardioprotective strategy in a selected population. Once left ventricular dysfunction occurs, heart failure therapies currently used for other forms of left ventricular dysfunction, particularly angiotensin-converting enzyme inhibitors and β-blockers, seem to be effective. However, their use in cancer patients is still undervalued.

Economic evaluation of bevacizumab in the treatment of non-small cell lung cancer (NSCLC)

Background

Delivering affordable cancer care is becoming increasingly important. Bevacizumab (BEV) is a costly molecular targeted agent effective for a variety of cancer including lung cancer. The objective of this review is to assess published economic evaluation of BEV in the treatment of non-small cell lung cancer (NSCLC).

Methods

A literature search in PubMed, Cochrane, and the Health Technology Assessment reports for English-language publications before February 2012 was performed. Studies were independently screened by two reviewers, and eight publications were included in the review. The results of these eight articles were tabulated and all cost estimates were reported in 2011 US dollars.

Results

Among the eight articles, three were cost studies and five were cost-effectiveness/utility analysis. For first-line treatment, BEV-containing regimen was reported to be the most costly regimen in one study but cost saving when compared with pemetrexed/cisplatin in another study. When compared with other regimens, BEV-containing regimen was reported to be cost effective in two cost-effectiveness studies (incremental cost-effectiveness ratio [ICER] in the range of US$30,318–US$54,317 per life year) but not cost effective in the other three studies (ICER over US$300,000 per life year).

Conclusion

In this review of economic evaluation of BEV in the treatment of NSCLC, it was found that the literature was not conclusive on the economic benefit of BEV. The role of BEV in other treatment settings for NSCLC was unknown. Further studies, such as clinical trials with adequate power to compare the efficacy between low dose and high dose BEV, potential impact of predictive biomarkers for BEV, and comprehensive economic evaluation will strengthen the current state of knowledge on the economic value of BEV in NSCLC.

Nanobiopolymer for direct targeting and inhibition of EGFR expression in triple negative breast cancer

Treatment options for triple negative breast cancer (TNBC) are generally limited to cytotoxic chemotherapy. Recently, anti-epidermal growth factor receptor (EGFR) therapy has been introduced for TNBC patients. We engineered a novel nanobioconjugate based on a poly(β-L-malic acid) (PMLA) nanoplatform for TNBC treatment. The nanobioconjugate carries anti-tumor nucleosome-specific monoclonal antibody (mAb) 2C5 to target breast cancer cells, anti-mouse transferrin receptor (TfR) antibody for drug delivery through the host endothelial system, and Morpholino antisense oligonucleotide (AON) to inhibit EGFR synthesis. The nanobioconjugates variants were: (1) P (BioPolymer) with AON, 2C5 and anti-TfR for tumor endothelial and cancer cell targeting, and EGFR suppression (P/AON/2C5/TfR), and (2) P with AON and 2C5 (P/AON/2C5). Controls included (3) P with 2C5 but without AON (P/2C5), (4) PBS, and (5) P with PEG and leucine ester (LOEt) for endosomal escape (P/mPEG/LOEt). Drugs were injected intravenously to MDA-MB-468 TNBC bearing mice. Tissue accumulation of injected nanobioconjugates labeled with Alexa Fluor 680 was examined by Xenogen IVIS 200 (live imaging) and confocal microscopy of tissue sections. Levels of EGFR, phosphorylated and total Akt in tumor samples were detected by western blotting. In vitro western blot showed that the leading nanobioconjugate P/AON/2C5/TfR inhibited EGFR synthesis significantly better than naked AON. In vivo imaging revealed that 2C5 increased drug-tumor accumulation. Significant tumor growth inhibition was observed in mice treated with the lead nanobioconjugate (1) [P = 0.03 vs. controls; P<0.05 vs. nanobioconjugate variant (2)]. Lead nanobioconjugate (1) also showed stronger inhibition of EGFR expression and Akt phosphorylation than other treatments. Treatment of TNBC with the new nanobioconjugate results in tumor growth arrest by inhibiting EGFR and its downstream signaling intermediate, phosphorylated Akt. The nanobioconjugate represents a new generation of nanodrugs for treatment of TNBC.

WEE1 inhibition sensitizes basal breast cancer cells to TRAIL-induced apoptosis

TRAIL is a member of the TNF super family and has been shown to induce apoptosis in many cancer cell lines but not in normal cells. Breast cancers can be divided into different subgroups on the basis of the expression of estrogen and progesterone receptors, HER-2 amplification, or the lack of these three markers (known as triple-negative or basal-type breast cancer). Our group and others have shown previously that triple-negative breast cancer cell lines are sensitive to TRAIL whereas others are relatively resistant. In an earlier study, we reported that inhibition of WEE1, a cell-cycle checkpoint regulator, causes increased cell death in breast cancer cell lines. In this study, we tested the effects of WEE1 inhibition on TRAIL-mediated apoptosis in breast cancer cell lines. Pretreatment with WEE1 inhibitor or knockdown of WEE1 increased the toxicity of TRAIL in the basal/triple-negative breast cancer cell lines compared with WEE1 inhibitor or TRAIL treatment alone. The enhanced cell death is attributed to increased surface expression of death receptors, increased caspase activation which could be blocked by the pan-caspase inhibitor, Z-VAD-FMK, thereby rescuing cells from caspase-mediated apoptosis. The cell death was initiated primarily by caspase-8 because knockdown of caspase-8 and not of any other initiator caspases (i.e., caspase-2, -9, or -10) rescued cells from WEE1 inhibitor-sensitized TRAIL-induced cell death. Taken together, the data suggest that the combination of WEE1 inhibitor and TRAIL could provide a novel combination for the treatment of basal/triple-negative breast cancer.

Epidermal growth factor receptor and K-Ras in non-small cell lung cancer-molecular pathways involved and targeted therapies

Lung cancer is currently the leading cause of cancer death in Western nations. Non-small cell lung cancer (NSCLC) represents 80% of all lung cancers, and adenocarcinoma is the predominant histological type. Despite the intensive research carried out on this field and therapeutic advances, the overall prognosis of these patients remains unsatisfactory, with a 5-year overall survival rate of less than 15%. Nowadays, pharmacogenetics and pharmacogenomics represent the key to successful treatment. Recent studies suggest the existence of two distinct molecular pathways in the carcinogenesis of lung adenocarcinoma: one associated with smoking and activation of the K-Ras oncogene and the other not associated with smoking and activation of the epidermal growth factor receptor (EGFR). The K-ras mutation is mainly responsible for primary resistance to new molecules which inhibit tyrosine kinase EGFR (erlotinib and gefitinib) and most of the EGFR mutations are responsible for increased tumor sensitivity to these drugs. This article aims to conduct a systematic review of the literature regarding the molecular pathways involving the EGFR, K-Ras and EGFR targeted therapies in NSCLC tumor behavior.

Combined modality therapy with TRAIL or agonistic death receptor antibodies

Molecularly targeted therapies, such as antibodies and small molecule inhibitors have emerged as an important breakthrough in the treatment of many human cancers. One targeted therapy under development is tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) due to its ability to induce apoptosis in a variety of human cancer cell lines and xenografts, while lacking toxicity in most normal cells. TRAIL and apoptosis-inducing agonistic antibodies to the TRAIL death receptors have been the subject of many preclinical and clinical studies in the past decade. However, the sensitivity of individual cancer cell lines of a particular tumor type to these agents varies from highly sensitive to resistant. Various chemotherapy agents have been shown to enhance the apoptosis-inducing capacity of TRAIL receptor-targeted therapies and induce sensitization of TRAIL-resistant cells. This review provides an overview of the mechanisms associated with chemotherapy enhancement of TRAIL receptor-targeted therapies including modulation of the apoptotic (death receptor expression, FLIP, and Bcl-2 or inhibitors of apoptosis (IAP) families) as well as cell signaling (NFκB, Akt, p53) pathways. These mechanisms will be important in establishing effective combinations to pursue clinically and in determining relevant targets for future cancer therapies.

Potent antitumoral activity of TRAIL through generation of tumor-targeted single-chain fusion proteins

In an attempt to improve TRAIL's (tumor necrosis factor-related apoptosis-inducing ligand) tumor selective activity a variant was designed, in which the three TRAIL protomers are expressed as a single polypeptide chain (scTRAIL). By genetic fusion with a single-chain antibody fragment (scFv) recognizing the extracellular domain of ErbB2, we further equipped scTRAIL with tumor-targeting properties. We studied tumor targeting and apoptosis induction of scFv–scTRAIL in comparison with non-targeted scTRAIL. Importantly, the tumor antigen-targeted scTRAIL fusion protein showed higher apoptotic activity in vitro, with a predominant action by TRAIL-R2 signaling. Pharmacokinetic studies revealed increased plasma half-life of the targeted scTRAIL fusion protein compared with scTRAIL. In vivo studies in a mouse tumor model with xenotransplanted Colo205 cells confirmed greater response to the ErbB2-specific scTRAIL fusion protein compared with non-targeted scTRAIL both under local and systemic application regimen. Together, in vitro and in vivo data give proof of concept of higher therapeutic activity of tumor-targeted scFv–scTRAIL molecules. Further, we envisage that through targeting of scTRAIL, potential side effects should be minimized. We propose that scFv-mediated tumor targeting of single-chain TRAIL represents a promising strategy to improve TRAIL's antitumoral action and to minimize potential unwanted actions on normal tissues.

Diagnostic and therapeutic delays among a multiethnic sample of breast and cervical cancer survivors

BACKGROUND

Several publications reporting on health disparities document that ethnic minorities disproportionately experience delays in healthcare access, delivery, and treatment. However, few studies examine factors underlying access and receipt of healthcare among cancer survivors from the patient perspective. This study explores diagnostic and therapeutic care delays among a multiethnic sample of breast and cervical cancer survivors and examines contextual factors influencing diagnostic and therapeutic care delays.

METHODS

Population-based sampling and a cross-sectional design were used to recruit 1377 survivors (breast cancer, n = 698; cervical cancer, n = 679). This multiethnic sample included 449 European American, 185 African American, 468 Latina American, and 275 Asian American survivors.

RESULTS

Latina Americans were more likely to report diagnostic delays (P = .003), whereas African Americans were more likely to report therapeutic delays (P = .007). In terms of cancer type, cervical cancer survivors were more likely to report diagnostic (P = .004) and therapeutic delays (P = .000) compared with breast cancer survivors. "Fear of finding cancer" was the most frequently cited reason for diagnostic delays, and "medical reasons" were most frequently cited for therapeutic delays.

CONCLUSIONS

Due in part to a higher proportion of diagnostic and therapeutic delays, ethnic minorities endure greater cancer burden, including poorer survival and survivorship outcomes. The medical community must recognize the impact of existing psychological and cultural dimensions on diagnostic care, as well as the personal and healthcare system level barriers that contribute to therapeutic delays.

Recombinant human PDCD5 sensitizes chondrosarcomas to cisplatin chemotherapy in vitro and in vivo

Clinical management of chondrosarcoma remains a challenging problem, largely due to the toxicity and resistance of this tumor to conventional chemotherapy. Programmed Cell Death 5 (PDCD5) is a protein that accelerates apoptosis in different cell types in response to various stimuli, and has been shown to be down-regulated in many cancer tissues. In this study, mRNA and protein levels of PDCD5 were found to be up-regulated in cisplatin-treated SW1353 chondrosarcoma cells compared with untreated cells. Recombinant human PDCD5 (rhPDCD5) was also shown to sensitize chondrosarcoma cells to cisplatin-based chemotherapy, with inhibition of cell growth and apoptosis detected both in vitro and in vivo. Increased expression of Bax and decreased expression of Bcl-2 were also observed, along with release of cytochrome c from mitochondria into the cytosol. Additionally, cleavage of caspase-9 and caspase-3, as well as the cleavage of poly (ADP-ribose) polymerase (PARP), were detected, suggesting that sensitization of chondrosarcoma cells involves the intrinsic mitochondrial apoptosis pathway. In vivo, the treatment of a xenograft model of chondrosarcoma with rhPDCD5 and cisplatin significantly inhibited tumor cell proliferation and induced apoptosis compared to treatment with cisplatin alone. Overall, these data provide a theoretical basis for the administration of rhPDCD5 and cisplatin for the treatment of patients with chondrosarcoma.

Targeted therapies in cancer

Recent advances in understanding the biologic mechanisms underlying cancer development have driven the design of new therapeutic approaches, termed 'targeted therapies', that selectively interfere with molecules or pathways involved in tumor growth and progression. Inactivation of growth factors and their receptors on tumor cells as well as the inhibition of oncogenic tyrosine kinase pathways and the inhibition of molecules that control specific functions in cancer cells constitute the main rational bases of new cancer treatments tailored for individual patients. Small-molecule inhibitors and monoclonal antibodies are major components of these targeted approaches for a number of human malignancies. As the studies of the bio-molecular features of cancer progress, new exciting strategies have arisen, such as targeting cancer stem cells that drive tumor relapses or the selective induction of apoptosis in malignant cells. This article primarily focuses on the biologic bases of the new cancer drugs and summarizes their mechanisms of action, the clinical evidence of their anti-cancer effectiveness as well as the rationale for their use in clinical practice.

Phase 1b study of dulanermin (recombinant human Apo2L/TRAIL) in combination with paclitaxel, carboplatin, and bevacizumab in patients with advanced non-squamous non-small-cell lung cancer

PURPOSE

To determine the safety, pharmacokinetics (PK), and maximum-tolerated dose (MTD) up to a prespecified target dose of dulanermin in combination with paclitaxel, carboplatin, and bevacizumab (PCB) in patients with previously untreated, nonsquamous, stage IIIb (with pleural effusion)/IV or recurrent non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

In this phase 1b study, patients (n = 24) received PCB on day 1 of each 21-day cycle then dulanermin at 4 or 8 mg/kg/d for 5 consecutive days or 15 or 20 mg/kg/d for 2 consecutive days per assigned treatment cohort. Incidence of dose-limiting toxicities (DLTs), adverse events, and antidulanermin antibodies were assessed. PK parameters were recorded for each agent. Tumor response was measured by modified Response Evaluation Criteria in Solid Tumors.

RESULTS

Twenty-four patients received at least one dose of dulanermin plus PCB, six in each treatment cohort. There were no DLTs. An MTD was not reached, and the drug combination was well tolerated. Treatment-emergent adverse events were generally as expected for the PCB regimen. Adverse events attributed to dulanermin were grade 1/2; no significant hepatotoxicity occurred. There was minimal impact of PCB on the PK of dulanermin. There was one confirmed complete response and 13 confirmed partial responses. The overall response rate was 58% (95% CI, 37 to 78). Median progression-free survival was 7.2 months (95% CI, 4.7 to 10.3).

CONCLUSION

Dulanermin plus PCB was well tolerated with no occurrence of DLTs and demonstrated antitumor activity in this patient population. Dulanermin at 8 mg/kg/d for 5 days and 20 mg/kg/d for 2 days every 3 weeks in combination with PCB is being studied in a phase II trial.

A framework for the organization and delivery of systemic treatment

Background

Increasing systemic treatment and shortages of oncology professionals in Canada require innovative approaches to the safe and effective delivery of intravenous (IV) cancer treatment. We conducted a systematic review of the clinical and scientific literature, and an environmental scan of models in Canada, the United Kingdom, Australia, and New Zealand. We then developed a framework for the organization and delivery of IV systemic treatment.

Methods

The systematic review covered the medline, embase, cinahl, and HealthStar databases. The environmental scan retrieved published and unpublished sources, coupled with a free key word search using the Google search engine. The Systemic Treatment Working Group reviewed the evidence and developed a draft framework using evidence-based analysis, existing recommendations from various jurisdictions, and expert opinion based on experience and consensus. The draft was assessed by Ontario stakeholders and reviewed and approved by Cancer Care Ontario.

Results

The poor quantity and quality of the evidence necessitated a consensus-derived model. That model comprises four levels of care determined by a regional systemic treatment program and three integrated structures (integrated cancer programs, affiliate institutions, and satellite institutions), each with a defined scope of practice and a specific organizational framework.

Interpretation

New models of care are urgently required beyond large centres, particularly in geographically remote or rural areas. Despite limited applicable evidence, the development and successful implementation of this framework is intended to create sustainable, accessible, quality care and to measurably improve patient outcomes.

Psychogenic carcinogenesis: carcinogenesis is without exogenic carcinogens

The history of researches of a problem of cancer has cleared a number of key cellular-molecular-genetic mechanisms of carcinogenesis, however process of carcinogenesis, is still out of control and a world forecast is unfavorable despite the advanced pathogenetically focused medication and excellent results of cancer treatment in vivo. Numerous researches have shown that chronic psycho-emotional stress by means of stressful hormones and endogenous mutagens (reactive oxygen and nitrogen species) are capable to damage cells DNA and to compromise immune system. Actually, chronic psycho-emotional stress is capable to activate the key mechanisms of carcinogenesis. It specifies an opportunity of existence psychogenic carcinogenesis--"carcinogenesis is without carcinogens" which can function as independent and in a combination with physical, chemical and biological carcinogens, strengthening their carcinogenic effect. At cancer patients with psychogenically induced carcinogenesis use only the somatically focused therapy of a cancer (surgery, radiotherapy, chemotherapy, immunotherapy), apparently, is not enough for achievement of steady remission. At psychogenically induced carcinogenesis creation of effective anticarcinogenic medicines is also apparently problematic. The presented hypothesis allows to hope for search in the future of diagnostic criteria of revealing of persons with psychogenic also and development of new strategy of the second prophylactic, treatments and rehabilitations such cancer patients. The hypothesis psychogenic carcinogenesis expands existing representations about pathogenesis of malignant tumors and forms holistic approach to the decision of problems of a cancer at the person.

Utilization of genomic signatures to identify phenotype-specific drugs

Genetic and genomic studies highlight the substantial complexity and heterogeneity of human cancers and emphasize the general lack of therapeutics that can match this complexity. With the goal of expanding opportunities for drug discovery, we describe an approach that makes use of a phenotype-based screen combined with the use of multiple cancer cell lines. In particular, we have used the NCI-60 cancer cell line panel that includes drug sensitivity measures for over 40,000 compounds assayed on 59 independent cells lines. Targets are cancer-relevant phenotypes represented as gene expression signatures that are used to identify cells within the NCI-60 panel reflecting the signature phenotype and then connect to compounds that are selectively active against those cells. As a proof-of-concept, we show that this strategy effectively identifies compounds with selectivity to the RAS or PI3K pathways. We have then extended this strategy to identify compounds that have activity towards cells exhibiting the basal phenotype of breast cancer, a clinically-important breast cancer characterized as ER-, PR-, and Her2- that lacks viable therapeutic options. One of these compounds, Simvastatin, has previously been shown to inhibit breast cancer cell growth in vitro and importantly, has been associated with a reduction in ER-, PR- breast cancer in a clinical study. We suggest that this approach provides a novel strategy towards identification of therapeutic agents based on clinically relevant phenotypes that can augment the conventional strategies of target-based screens.

Follow-up care for cancer survivors: the views of clinicians

Background:

Evidence for the efficacy of late effects surveillance in adult cancer survivors is lacking and there is little agreement among clinicians on appropriate follow-up care.

Methods:

We report the views of both cancer experts and general practitioners (GPs) on long-term follow-up provision for cancer survivors, focussing on the 18–45 years age group. A total of 421 cancer experts (36% haematologists, 33% oncologists, 18% surgeons, 10% nurses, 2% other) and 54 GPs responded to a structured online survey. Reasons for follow-up care (clinical or supportive); advantages and disadvantages of follow-up in primary care; current practice; and resources required for a quality follow-up service were assessed.

Results:

Clinicians valued clinical reasons for follow-up more highly than supportive reasons (P<0.001). Learning more about late effects and checking for cancer recurrence were rated as the most important reasons for follow-up by cancer experts and GPs. A total of 85% of cancer specialists hold follow-up consultations alongside patients on active treatment. Cancer experts agreed that primary care follow-up would increase their availability for acute oncological care, but reduce information on late effects. The most important resource to provide a quality follow-up service was specialist nursing support (91%).

Conclusions:

Follow-up guidelines that include late effects surveillance are needed. Where and who should deliver this care requires further debate.

Is TRAIL the holy grail of cancer therapy?

Inducing apoptosis has become an important approach in the development of new anti-cancer treatments. Tumour necrosis factor apoptosis inducing ligand (TRAIL) based therapies have emerged as one of the most promising examples of this as they selectively induce apoptosis in tumour cells. However, many primary tumours are inherently resistant to TRAIL-mediated apoptosis and require additional sensitisation. Here we review apoptotic and non-apoptotic TRAIL-signalling, and the therapeutic effects of TRAIL-based treatments both as monotherapy and in combination with sensitising agents.

Targeting death-receptors in radiation therapy

The development of apoptosis resistance is a crucial step during the pathogenesis of malignant tumors. Thus, any treatment approach overcoming apoptosis resistance may be a valuable tool in oncology. Although a variety of treatments induce apoptosis, only very few specifically trigger programmed cell death. In this regard, the class of apoptosis inducing ligands may turn out to have a considerable potential in oncology. TNF-alpha-related apoptosis-inducing ligand (TRAIL/Apo2L) is the most promising candidate, either alone or in combination with established cancer therapies, since it induces apoptosis in a wide range of malignant cells while sparing most normal tissues. Since death-receptor induced apoptosis is mainly mediated via nonmitochondrial death pathways, it is possible to induce apoptosis in cancer cell systems which mainly harbor defects within the mitochondrial death cascades. Even more so it has been shown that conventional DNA damaging approaches reduced the killing threshold for receptor induced apoptosis, making TRAIL an ideal candidate for combined approaches. Thus, combined treatments might offer the chance to enhance therapeutic efficiency and overcome resistance. In combination, additive or synergistic apoptotic responses and substantially enhanced clonogenic cell kill has been documented. Furthermore, in several settings it has been shown that combined modality teatments were effective in malignant cells, which are highly resistant to either treatment, alone. Ionizing radiation is one of the most effective modalities in oncology. Thus, it is reasonable to test, how far combinations of TRAIL with ionizing radiation may increase the efficacy. Indeed, the combination of TRAIL with ionizing radiation in several in vitro settings as well as xenograft models resulted in highly increased rates of cell kill and long-term tumor control. No increase in the rate and severity of side effects has been documented, indicating that the combination really increases the therapeutic ratio. It is important to note that TRAIL and TRAIL receptor agonistic antibodies, either as single

Cardio-oncology: a new medical issue

Due to the increasing number of long-term cancer survivors, the ageing of the population, as well as the increased incidence and prevalence of oncologic and cardiovascular diseases, the number of patients presenting oncologic and cardiologic co-morbidities are increasing. Accordingly, there is a rapidly growing need for a comprehensive and proficient management of patients in whom the two co-morbidities exist, and for cancer patients whose clinical history and oncologic treatment put them at higher risk for developing cardiovascular problems, in order to provide the optimal treatment in every situation, and to avoid the possibility that the development of the second disease does not lead to a reduction of therapeutic opportunities for the patient. A new discipline, cardio-oncology, has been created to deal with this need. Its aim is to investigate new strategies, collect new evidence-based indications and develop interdisciplinary expertise in order to manage this growing category of patients. Cardio-oncology deals with the following main clinical and research areas: early diagnosis of cardiotoxicity, risk stratification and preventions, treatment and monitoring of cardiotoxicity.