1
|
Valiyaveettil D, Joseph D, Malik M. Cardiotoxicity in breast cancer treatment: Causes and mitigation. Cancer Treat Res Commun 2023; 37:100760. [PMID: 37714054 DOI: 10.1016/j.ctarc.2023.100760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 08/25/2023] [Accepted: 09/06/2023] [Indexed: 09/17/2023]
Abstract
Survivorship issues and treatment related toxicities have considerably increased in breast cancer patients following improved therapeutic options. Cardiotoxicity has been a major treatment related side effects in these patients. Despite this being a well-known entity, the real magnitude of the problem remains an enigma. The amount of research in mitigation of cardiotoxicity or its management in breast cancer survivors is limited and there is an urgent need for finding solutions for the problem. In this article, we are reviewing the agents that cause cardiotoxicity and suggesting a proposal for follow up of breast cancer survivors in an attempt to reduce the magnitude of impact on their quality of life.
Collapse
Affiliation(s)
| | - Deepa Joseph
- Department of Radiation Oncology, All India Institute of Medical sciences, Rishikesh, India.
| | - Monica Malik
- Nizam's Institute of Medical sciences, Hyderabad, India
| |
Collapse
|
2
|
Jacobs JEJ, L'Hoyes W, Lauwens L, Yu Y, Brusselmans M, Weltens C, Voigt J, Wildiers H, Neven P, Herrmann J, Thijs L, Staessen JA, Janssens S, Van Aelst LNL. Mortality and Major Adverse Cardiac Events in Patients With Breast Cancer Receiving Radiotherapy: The First Decade. J Am Heart Assoc 2023; 12:e027855. [PMID: 37026536 PMCID: PMC10227262 DOI: 10.1161/jaha.122.027855] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 02/09/2023] [Indexed: 04/08/2023]
Abstract
Background Treatment for breast cancer (BC) frequently involves radiotherapy. Guidelines recommend screening for cardiac adverse events starting 10 years after radiotherapy. The rationale for this interval is unclear. Methods and Results We aimed to study cardiovascular event rates in the first decade following curative radiotherapy for BC. We compared mortality and cardiovascular event rates with an age- and risk factor-matched control population. We included 1095 patients with BC (mean age 56±12 years). Two hundred and eighteen (19.9%) women died. Cancer and cardiovascular mortality caused 107 (49.1%) and 22 (10.1%) deaths, respectively. A total of 904 cases were matched to female FLEMENGHO (Flemish Study on Environment, Genes and Health Outcomes) participants. Coronary artery disease incidence was similar (risk ratio [RR], 0.75 [95% CI, 0.48-1.18]), yet heart failure (RR, 1.97 [95% CI, 1.19-3.25]) and atrial fibrillation/flutter (RR, 1.82 [95% CI, 1.07-3.08]) occurred more often in patients with BC. Age (hazard ratio [HR], 1.033 [95% CI, 1.006-1.061], P=0.016), tumor grade (HR, 1.739 [95% CI, 1.166-2.591], P=0.007), and neoadjuvant treatment setting (HR, 2.782 [95% CI, 1.304-5.936], P=0.008) were risk factors for mortality. Risk factors for major adverse cardiac events were age (HR, 1.053 [95% CI, 1.013-1.093]; P=0.008), mean heart dose (HR, 1.093 [95% CI, 1.025-1.167]; P=0.007), history of cardiovascular disease (HR, 2.386 [95% CI, 1.096-6.197]; P=0.029) and Mayo Clinic Cardiotoxicity Risk Score (HR, 2.664 [95% CI, 1.625-4.367]; P<0.001). Conclusions Ten-year mortality following curative treatment for unilateral BC was mainly cancer related, but heart failure and atrial fibrillation/flutter were already common in the first decade following irradiation. Mean heart dose, pre-existing cardiovascular diseases, and Mayo Clinic Cardiotoxicity Risk Score were risk factors for cardiac adverse events. These results suggest a need for early dedicated cardio-oncological follow-up after radiotherapy.
Collapse
Affiliation(s)
- Johanna E. J. Jacobs
- Department of Cardiovascular DiseasesUniversity Hospitals (UZ) LeuvenLeuvenBelgium
| | - Wouter L'Hoyes
- Department of Cardiovascular DiseasesUniversity Hospitals (UZ) LeuvenLeuvenBelgium
| | - Lieselotte Lauwens
- Department of Radiation OncologyUniversity Hospitals (UZ) LeuvenLeuvenBelgium
| | - Yu‐Ling Yu
- Research Unit Environment and Health, KU Leuven Department of Public Health and Primary CareUniversity of LeuvenLeuvenBelgium
- Non‐Profit Research Association Alliance for the Promotion of Preventive Medicine (APPREMED)MechelenBelgium
| | - Marius Brusselmans
- Leuven Biostatistics and Statistical Bioinformatics Centre (L‐Biostat)LeuvenBelgium
| | - Caroline Weltens
- Department of Radiation OncologyUniversity Hospitals (UZ) LeuvenLeuvenBelgium
| | - Jens‐Uwe Voigt
- Department of Cardiovascular DiseasesUniversity Hospitals (UZ) LeuvenLeuvenBelgium
| | - Hans Wildiers
- Department of Medical OncologyUniversity Hospitals (UZ) LeuvenLeuvenBelgium
| | - Patrick Neven
- Department of GynaecologyUniversity Hospitals (UZ) LeuvenLeuvenBelgium
| | | | - Lutgarde Thijs
- Department of Cardiovascular DiseasesUniversity Hospitals (UZ) LeuvenLeuvenBelgium
| | - Jan A. Staessen
- Non‐Profit Research Association Alliance for the Promotion of Preventive Medicine (APPREMED)MechelenBelgium
- Biomedical Science Group, Faculty of MedicineUniversity of LeuvenLeuvenBelgium
| | - Stefan Janssens
- Department of Cardiovascular DiseasesUniversity Hospitals (UZ) LeuvenLeuvenBelgium
| | | |
Collapse
|
3
|
Cherukuri SP, Chikatimalla R, Dasaradhan T, Koneti J, Gadde S, Kalluru R. Breast Cancer and the Cardiovascular Disease: A Narrative Review. Cureus 2022; 14:e27917. [PMID: 36110451 PMCID: PMC9464354 DOI: 10.7759/cureus.27917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2022] [Indexed: 11/05/2022] Open
Abstract
Breast cancer is the most common malignancy affecting females worldwide and is also among the top causes of all cancer-related deaths. Cardiovascular disease (CVD) is known to have the highest rate of mortality in women. There are several risk factors for both CVD and breast cancer that overlap, such as diet, smoking, and obesity, and also the current breast cancer treatment has a significant detrimental effect on cardiovascular health in general. Patients with exposure to potentially cardiotoxic treatments, including anthracyclines, trastuzumab, and radiation therapy, are more likely to develop CVD than non-cancer controls. Early detection and treatment may reduce the risk of the development of cardiac morbidity and mortality and would increase the number of breast cancer survivors. This article provides a comprehensive overview of breast cancer, identifies shared risk factors among breast cancer and CVD, and the cardiotoxic effects of therapy. It also reviews possible prevention and treatment of CVD in breast cancer patients and reviews literature about chemoprevention of cardiac disease in the setting of breast cancer treatment.
Collapse
|
4
|
Stowe HB, Andruska ND, Reynoso F, Thomas M, Bergom C. Heart Sparing Radiotherapy Techniques in Breast Cancer: A Focus on Deep Inspiration Breath Hold. BREAST CANCER: TARGETS AND THERAPY 2022; 14:175-186. [PMID: 35899145 PMCID: PMC9309321 DOI: 10.2147/bctt.s282799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 06/04/2022] [Indexed: 11/23/2022]
Abstract
Adjuvant radiation therapy is a critical component of breast cancer management. However, when breast cancer patients receive incidental radiation to the heart, there is an increased risk of cardiac disease and mortality. This is most common for patients with left-sided breast cancers and those receiving nodal irradiation as part of treatment. The overall risk of cardiac toxicity increases 4–16% with each Gray increase in mean heart radiation dose, with data suggesting that no lower limit exists which would eliminate cardiac risk entirely. Radiation techniques have improved over time, leading to lower cardiac radiation exposure than in the past. This decline is expected to reduce the incidence of radiation-induced heart dysfunction in patients. Deep inspiration breath hold (DIBH) is one such technique that was developed to reduce the risk of cardiac death and coronary events. DIBH is a non-invasive approach that capitalizes on the natural physiology of the respiratory cycle to increase the distance between the heart and the therapeutic target throughout the course of radiation therapy. DIBH has been shown to decrease the mean incidental radiation doses to the heart and left anterior descending coronary artery by approximately 20–70%. In this review, we summarize different techniques for DIBH and discuss recent data on this technique.
Collapse
Affiliation(s)
- Hayley B Stowe
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Neal D Andruska
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Francisco Reynoso
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Maria Thomas
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Carmen Bergom
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
- Cardio-Oncology Center of Excellence, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
- Alvin J. Siteman Center, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
- Correspondence: Carmen Bergom, Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA, Email
| |
Collapse
|
5
|
Exposure of the heart and cardiac valves in women irradiated for breast cancer 1970-2009. Clin Transl Radiat Oncol 2022; 36:132-139. [PMID: 36034326 PMCID: PMC9399376 DOI: 10.1016/j.ctro.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 07/11/2022] [Accepted: 07/11/2022] [Indexed: 11/22/2022] Open
Abstract
Cardiac exposure decreased substantially 1970–2009. Direct megavoltage IMC beams likely increase the risks of IHD and VHD. Cardiac dosimetry from past regimens is highly heterogeneous. Dosimetry from past decades is key for dose–response relationships for late effects. A wide variation in valve doses may enable a dose–response relationship for VHD.
Purpose To describe cardiac exposure from breast cancer radiotherapy regimens used during 1970–2009 for the development of dose–response relationships and to consider the associated radiation-risks using existing dose–response relationships. Material and methods Radiotherapy charts for 771 women in the Netherlands selected for case control studies of heart disease after breast cancer radiotherapy were used to reconstruct 44 regimens on a typical CT-dataset. Doses were estimated for the whole heart (WH), left ventricle (LV) and cardiac valves. Results For breast/chest wall radiotherapy average WH doses decreased during 1970–2009. For internal mammary chain (IMC) radiotherapy WH doses were highest during the 1980s and 1990s when direct anterior fields were used and reduced in the 2000s when oblique fields were introduced. Average doses varied substantially for IMC regimens (WH 2–33 Gy, LV < 1–23 Gy). For cardiac valves, at least one valve received >30 Gy from most regimens. Conclusions Radiation-risks of IHD from breast/chest wall regimens likely reduced during 1970–2009. Direct anterior IMC regimens likely increased the risks of IHD and VHD over this time period but the use of oblique IMC fields from 2003 may have lowered these risks. These data provide a unique opportunity to develop dose–response relationships.
Collapse
|
6
|
Zhang J, Sum SY, Hsu JG, Chiang MF, Lee TS, Wu SY. Adjuvant postmastectomy radiotherapy might be associated with better survival in women with heart failure receiving total mastectomy. Radiat Oncol 2022; 17:33. [PMID: 35151355 PMCID: PMC8840783 DOI: 10.1186/s13014-022-02000-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 01/28/2022] [Indexed: 11/25/2022] Open
Abstract
Background To date, no data on the effect of adjuvant postmastectomy radiotherapy (PMRT) on oncologic outcomes, such as all-cause death, locoregional recurrence (LRR), and distant metastasis (DM), are available in women with left-side breast invasive ductal carcinoma (IDC) and heart failure with reduced ejection fraction (HFrEF).
Patients and methods We enrolled 646 women with left-breast IDC at clinical stages I–IIIC and HFrEF receiving radical total mastectomy (TM) followed by adjuvant PMRT or non-adjuvant PMRT. We categorized them into two groups based on their adjuvant PMRT status and compared their overall survival (OS), LRR, and DM outcomes. We calculated the propensity score and applied inverse probability of treatment weighting (IPTW) to create a pseudo-study cohort. Furthermore, we performed a multivariate analysis of the propensity score–weighted population to obtain hazard ratios (HRs).
Results In the IPTW-adjusted model, adjuvant PMRT (adjusted HR [aHR]: 0.52; 95% confidence interval [CI]: 0.37–0.74) was a significant independent prognostic factor for all-cause death (P = 0.0003), and the aHR (95% CI) of LRR and DM for adjuvant PMRT was 0.90 (0.79–0.96; P = 0.0356) and 0.89 (0.54–1.50; P = 0.6854), respectively, compared with the nonadjuvant PMRT group. Conclusion Adjuvant PMRT was associated with a decrease in all-cause death, and LRR in women with left IDC and HFrEF compared with nonadjuvant PMRT.
Collapse
|
7
|
Abraham A, Sanghera KP, Gheisari F, Koumna S, Riauka T, Ghosh S, Warkentin H, Gabos Z, Chafe S, Tankel K, Huang F, Sabri S, Paterson DI, Abdulkarim B, Joseph K. Is radiation-induced cardiac toxicity reversible? Prospective evaluation of breast cancer patients enrolled in a phase-III randomized controlled trial. Int J Radiat Oncol Biol Phys 2022; 113:125-134. [DOI: 10.1016/j.ijrobp.2022.01.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/12/2022] [Accepted: 01/15/2022] [Indexed: 12/24/2022]
|
8
|
Zhang J, Sum SY, Hsu JG, Chiang MF, Lee TS, Wu SY. Adjuvant Whole Breast Radiotherapy Improve Survival in Women with Heart Failure with Reduced Ejection Fraction Receiving Breast-Conserving Surgery. J Pers Med 2021; 11:jpm11121358. [PMID: 34945830 PMCID: PMC8703318 DOI: 10.3390/jpm11121358] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 12/05/2021] [Accepted: 12/10/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND to date, no data on the effect of adjuvant whole breast radiotherapy (WBRT) on oncologic outcomes, such as all-cause death, locoregional recurrence (LRR), and distant metastasis (DM), are available in women with left-side breast invasive ductal carcinoma (IDC) and heart failure with reduced ejection fraction (HFrEF). PATIENTS AND METHODS we included 294 women with left-breast IDC at clinical stages IA-IIIC and HFrEF receiving breast-conserving surgery (BCS) followed by adjuvant WBRT or non-adjuvant WBRT. We categorized them into two groups based on their adjuvant WBRT status and compared their overall survival (OS), LRR, and DM outcomes. We calculated the propensity score and applied inverse probability of treatment weighting (IPTW) to create a pseudo-study cohort. Furthermore, we performed a multivariate analysis of the propensity score-weighted population to obtain hazard ratios (HRs). RESULTS in the IPTW-adjusted model, adjuvant WBRT (adjusted HR [aHR]: 0.60; 95% confidence interval [CI]: 0.44-0.94) was a significant independent prognostic factor for all-cause death (p = 0.0424), and the aHR (95% CI) of LRR and DM for adjuvant WBRT was 0.33 (0.24-0.71; p = 0.0017) and 0.37 (0.22-0.63; p = 0.0004), respectively, compared with the non-adjuvant WBRT group. CONCLUSION Adjuvant WBRT was associated with a decrease in all-cause death, LRR, and DM in women with left IDC and HFrEF compared with non-adjuvant WBRT.
Collapse
Affiliation(s)
- Jiaqiang Zhang
- Department of Anesthesiology and Perioperative Medicine, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou 450052, China;
| | - Shao-Yin Sum
- Department of General Surgery, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan 265, Taiwan;
| | - Jeng-Guan Hsu
- Graduate Institute of Business Administration, Fu Jen Catholic University, New Taipei City 242062, Taiwan; (J.-G.H.); (T.-S.L.)
| | - Ming-Feng Chiang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan 265, Taiwan;
| | - Tian-Shyug Lee
- Graduate Institute of Business Administration, Fu Jen Catholic University, New Taipei City 242062, Taiwan; (J.-G.H.); (T.-S.L.)
| | - Szu-Yuan Wu
- Graduate Institute of Business Administration, Fu Jen Catholic University, New Taipei City 242062, Taiwan; (J.-G.H.); (T.-S.L.)
- Department of Food Nutrition and Health Biotechnology, College of Medical and Health Science, Asia University, Taichung 413, Taiwan
- Big Data, Cancer Center, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan 265, Taiwan
- Division of Radiation Oncology, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan 265, Taiwan
- Department of Healthcare Administration, College of Medical and Health Science, Asia University, Taichung 413, Taiwan
- Centers for Regional Anesthesia and Pain Medicine, Taipei Municipal Wan Fang Hospital, Taipei Medical University, Taipei 110, Taiwan
- Correspondence: or
| |
Collapse
|
9
|
De Sanctis V, Alfò M, Vitiello C, Vullo G, Facondo G, Marinelli L, Burocchi S, Gallo G, Valeriani M, Campanella B, Scalabrino G, Russo I, Salerno G, Cardelli P, Osti M, De Biase L. Markers of Cardiotoxicity in Early Breast Cancer Patients Treated With a Hypofractionated Schedule: A Prospective Study. Clin Breast Cancer 2021; 21:e141-e149. [DOI: 10.1016/j.clbc.2020.09.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 09/01/2020] [Accepted: 09/04/2020] [Indexed: 12/25/2022]
|
10
|
Díaz-Gavela AA, Figueiras-Graillet L, Luis ÁM, Salas Segura J, Ciérvide R, del Cerro Peñalver E, Couñago F, Arenas M, López-Fernández T. Breast Radiotherapy-Related Cardiotoxicity. When, How, Why. Risk Prevention and Control Strategies. Cancers (Basel) 2021; 13:1712. [PMID: 33916644 PMCID: PMC8038596 DOI: 10.3390/cancers13071712] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 03/31/2021] [Accepted: 04/02/2021] [Indexed: 12/24/2022] Open
Abstract
In recent decades, improvements in breast cancer management have increased overall patient survival; however, many cancer therapies have been linked to an important risk of cardiovascular adverse events. Cardio-oncology has been proposed as an emerging specialty to coordinate preventive strategies that improve the cardiovascular health of oncologic patients. It employs the most suitable personalized multidisciplinary management approach for each patient to optimize their cardiovascular health and improve their survival and quality of life. Radiotherapy is an essential part of the therapeutic regimen in breast cancer patients but can also increase the risk of cardiovascular disease. Therefore, minimizing the negative impact of radiation therapy is an important challenge for radiotherapy oncologists and cardiologists specializing in this field. The aim of the present review is to update our knowledge about radiation-induced cardiotoxicity in breast cancer patients by undertaking a critical review of the relevant literature to determine risk prevention and control strategies currently available.
Collapse
Affiliation(s)
- Ana Aurora Díaz-Gavela
- Radiation Oncology, Hospital Universitario Quirónsalud Madrid, 28223 Madrid, Spain;
- Radiation Oncology, Hospital La Luz, 28003 Madrid, Spain
- Clinical Department, Faculty of Biomedicine, Universidad Europea de Madrid, 28670 Madrid, Spain
| | - Lourdes Figueiras-Graillet
- Cardiooncology Clinic, Centro Estatal de Cancerología Miguel Dorantes Mesa, Xalapa-Enríquez 91130, Mexico;
| | - Ángel Montero Luis
- Radiation Oncology Department, Hospital Universitario HM Sanchinarro, 28050 Madrid, Spain; (Á.M.L.); (R.C.)
| | - Juliana Salas Segura
- Cardio-oncology Unit, Hospital San Juan de Dios, San José 10103, Costa Rica;
- Cardiology Department, Hospital Clínica Bíblica. San José 10103, Costa Rica
| | - Raquel Ciérvide
- Radiation Oncology Department, Hospital Universitario HM Sanchinarro, 28050 Madrid, Spain; (Á.M.L.); (R.C.)
| | - Elia del Cerro Peñalver
- Radiation Oncology, Hospital Universitario Quirónsalud Madrid, 28223 Madrid, Spain;
- Radiation Oncology, Hospital La Luz, 28003 Madrid, Spain
- Clinical Department, Faculty of Biomedicine, Universidad Europea de Madrid, 28670 Madrid, Spain
| | - Felipe Couñago
- Radiation Oncology, Hospital Universitario Quirónsalud Madrid, 28223 Madrid, Spain;
- Radiation Oncology, Hospital La Luz, 28003 Madrid, Spain
- Clinical Department, Faculty of Biomedicine, Universidad Europea de Madrid, 28670 Madrid, Spain
| | - Meritxell Arenas
- Radiation Oncology, Hospital Universitari Sant Joan de Reus, 43204 Reus, Spain;
- Universitat Rovira i Virgili. IISPV, 43204 Reus, Spain
| | - Teresa López-Fernández
- Cardio-oncology Unit. Cardiology Department, Hospital Universitario La Paz, 28046 Madrid, Spain;
- Hospital La Paz Institute for Health Research—IdiPAZ, 28046 Madrid, Spain
| |
Collapse
|
11
|
Jimenez RB, Wong SM, Johnson A, Lalani N, Hughes KS. The Association Between Cardiac Mortality and Adjuvant Radiation Therapy Among Older Patients With Stage I Estrogen Positive Breast Cancer: A Surveillance, Epidemiology, and End Results (SEER)-Based Study on Cardiac Mortality and Radiation Therapy. Adv Radiat Oncol 2021; 6:100633. [PMID: 33912735 PMCID: PMC8071719 DOI: 10.1016/j.adro.2020.100633] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/02/2020] [Accepted: 11/09/2020] [Indexed: 11/23/2022] Open
Abstract
PURPOSE We evaluated the risk of cardiac mortality in older patients who receive adjuvant radiation therapy (RT) for stage I breast cancer to determine whether this risk persists in the modern era. METHODS AND MATERIALS Using the 2000 to 2015 Surveillance, Epidemiology, and End Results program data, we performed a population-based cohort study to evaluate the association between adjuvant breast RT, tumor laterality, and cardiac-specific survival (CSS) among patients 60 and older with stage I estrogen receptor positive breast cancer who received breast-conserving surgery and RT. RESULTS At a median follow-up of 6 years (range, 0-15.9 years), patients receiving RT for left-sided breast cancer demonstrated no difference in 5- and 10-year CSS compared with those with right-sided breast cancer (5 year 98.3% vs 98.2%, 10 year 94.3% vs 93.9%; log-rank P = .56). Cox proportional hazards regression analysis confirmed the lack of association of tumor laterality on adjusted 5-year CSS (hazard ratio [HR] = 0.96; 95% confidence interval [CI] = 0.87-1.06), breast-cancer specific survival (HR = 0.96; 95% CI = 0.85-1.09), and overall survival (HR = 0.98; 95% CI = 0.94-1.03). There was also no association of inner versus outer quadrant location on adjusted 5-year CSS for right-sided (HR = 1.06; 95% CI = 0.89-1.12) and left-sided breast cancer (HR = 0.95; 95% CI = 0.79-1.15). CONCLUSIONS With modern radiation therapy techniques, older patients who received left-sided RT for stage I estrogen-receptor positive breast cancer do not demonstrate an increased risk of cardiac mortality compared with patients with right-sided breast cancer. RT can be offered to older patients without concern for inducing cardiac-related death.
Collapse
Affiliation(s)
- Rachel B. Jimenez
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Masschusetts
| | - Stephanie M. Wong
- Department of Surgery, McGill University, JGH Segal Cancer Centre, Montreal, Canada
| | - Andrew Johnson
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Masschusetts
| | - Nafisha Lalani
- Department of Radiation Oncology, University of British Columbia, Vancouver, Canada
| | - Kevin S. Hughes
- Department of Surgery, Division of Surgical Oncology, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
12
|
Alatawi Y, Hansen RA, Chou C, Qian J, Suppiramaniam V, Cao G. The impact of cognitive impairment on survival and medication adherence among older women with breast cancer. Breast Cancer 2020; 28:277-288. [PMID: 32909167 DOI: 10.1007/s12282-020-01155-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 08/28/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The purpose of this study was to examine the impact of preexisting cognitive impairments on survival and medication adherence, and whether chronic medication adherence mediates or moderates the association between cognitive impairments and mortality in patients with breast cancer. METHODS This retrospective cohort study of older female patients diagnosed with breast cancer was conducted using the Surveillance, Epidemiology, and End Results Medicare Linked Database. We examined the risk of mortality from cancer and non-cancer causes in patients with and without a history of cognitive impairment. In addition, we examined if chronic medication adherence rates differ between these groups of patients and if medication adherence mediates or moderates the association between cognitive impairments and non-cancer mortality. RESULTS Mortality from cancer-specific (HR 1.13, 95% CI 1.04-1.23) and non-cancer causes (HR 1.16, 95% CI 1.11-1.21) as well as all-cause mortality (HR 1.30, 95% CI 1.23-1.38) was significantly higher in patients with cognitive impairments compared to those without cognitive impairment. Both groups showed low adherence levels to chronic medication before and after the breast cancer diagnosis. Further analysis did not show that medication adherence mediates or moderates the relationship between cognitive impairment and non-cancer mortality (p value > 0.05). CONCLUSION The results of this study indicate that older female patients with cognitive impairments and a breast cancer diagnosis have a heightened risk of cancer-specific and non-cancer mortality. Our findings do not indicate that chronic medication adherence plays a role in the association between a history of cognitive impairment and mortality, it is still necessary to further investigate this issue.
Collapse
Affiliation(s)
- Yasser Alatawi
- Department of Pharmacy Practice, Collage of Pharmacy, University of Tabuk, 7970 King Fahad Rd, Tabuk, 47713-2611, Saudi Arabia. .,Department of Health Outcomes Research and Policy, Harrison School of Pharmacy, Auburn University, Auburn, AL, USA.
| | - Richard A Hansen
- Department of Health Outcomes Research and Policy, Harrison School of Pharmacy, Auburn University, Auburn, AL, USA
| | - Chiahung Chou
- Department of Health Outcomes Research and Policy, Harrison School of Pharmacy, Auburn University, Auburn, AL, USA.,Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
| | - Jingjing Qian
- Department of Health Outcomes Research and Policy, Harrison School of Pharmacy, Auburn University, Auburn, AL, USA
| | - Vishnu Suppiramaniam
- Department of Drug Discovery and Development, Harrison School of Pharmacy, Auburn University, Auburn, AL, USA
| | - Guanqun Cao
- Department of Mathematics and Statistics, Auburn University, Auburn, AL, USA
| |
Collapse
|
13
|
Sung SY, Lee JH, Yang KH, Seo Y, Kang MY. Coronary Event Analysis in Breast Cancer Patients Who Received Breast-Conserving Surgery and Post-Operative Radiotherapy: a Korean Nationwide Cohort Study. J Breast Cancer 2020; 23:291-302. [PMID: 32595991 PMCID: PMC7311360 DOI: 10.4048/jbc.2020.23.e30] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 04/09/2020] [Indexed: 12/15/2022] Open
Abstract
Purpose Adjuvant breast radiotherapy (RT) following breast-conserving surgery (BCS) has been reported to induce cardiac toxicity in breast cancer patients. We investigated the incidence and risk factors of major coronary events after breast RT using Korean nationwide Health Insurance Review and Assessment data. Methods Using data from a nationwide quality assessment of breast cancer treatment, we identified 3,251 patients who received breast RT after BCS in 2013. Data about major coronary events were additionally collected from national claims data. We defined major coronary events according to the International Classification of Diseases, 10th revision (ICD-10) codes I20-25. Results A total of 172 major coronary events (5.3%) occurred among 3,251 breast cancer patients. The 1-year, 2-year, and 3-year coronary event-free survival rates were 98.1%, 96.4% and 95.2%, respectively. Patients with underlying diabetes mellitus (88.6% vs. 95.7%, p < 0.001), high blood pressure (HBP) (89.4% vs. 96.3%, p < 0.001), and cerebrovascular accident (CVA) (84.0% vs. 95.4%, p < 0.001) showed significantly worse 3-year coronary event-free survival rates than those without comorbidities. Multivariate analysis revealed that patient age (p < 0.001), HBP (p < 0.001), CVA (p = 0.025), adjuvant hormonal therapy (p = 0.034), and Herceptin therapy (p < 0.001) were significantly associated with major coronary events in breast cancer patients. Conclusion The incidence of major coronary events after breast RT may be higher in breast-cancer patients with risk factors such as underlying HBP or CVA, or who were in receipt of adjuvant Herceptin therapy. Heart-sparing RT techniques or intensity-modulated RT should be considered for breast-cancer patients with risk factors for heart toxicity.
Collapse
Affiliation(s)
- Soo-Yoon Sung
- Department of Radiation Oncology, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jong Hoon Lee
- Department of Radiation Oncology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ki Hwa Yang
- Review and Assessment Committee, Korean Health Insurance Review & Assessment Service, Wonju, Korea
| | - Yunye Seo
- Review and Assessment Committee, Korean Health Insurance Review & Assessment Service, Wonju, Korea
| | - Mi Yeon Kang
- Review and Assessment Committee, Korean Health Insurance Review & Assessment Service, Wonju, Korea
| |
Collapse
|
14
|
Andersen MM, Ayala-Peacock D, Bowers J, Kooken BW, D'Agostino RB, Jordan JH, Vasu S, Thomas A, Klepin HD, Brown DR, Hundley WG. Effect at One Year of Adjuvant Trastuzumab for HER2+ Breast Cancer Combined with Radiation or an Anthracycline on Left Ventricular Ejection Fraction. Am J Cardiol 2020; 125:1906-1912. [PMID: 32331711 DOI: 10.1016/j.amjcard.2020.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 03/09/2020] [Accepted: 03/10/2020] [Indexed: 11/30/2022]
Abstract
To determine the impact of radiation therapy (XRT) in addition to trastuzumab (TZB) adjuvant chemotherapy for HER2+ breast cancer on left ventricular systolic function, we assessed demographics, oncologic treatment history including XRT exposure, and serial measurements of left ventricular ejection fraction (LVEF) in 135 consecutively identified women receiving TZB for treatment of adjuvant breast cancer. Longitudinal mixed effects models were fit to identify baseline to treatment changes in LVEF among those receiving TZB with or without concomitant anthracycline or XRT. Women averaged 53 ± 3 years in age, 77% were white, 62% patients had 1 or more cardiovascular risk factors at baseline, and mean duration of TZB was 11 ± 5 months. Seventy-seven women were treated with XRT and received between 4000 and 5500 cGy of radiation. The LVEF declined by an average of 3.4% after 1 year for those in the study. Relative to baseline upon completion of adjuvant TZB, LVEF remained reduced for those receiving anthracycline with or without XRT (p=0.002 for both), or XRT alone (p=0.002), but not in those without these therapies. Amongst patients treated only with XRT and TZB, LVEF declined 3.1% on average in those with left-sided disease and 6.9% on average in those with right-sided disease (p= 0.06, p= 0.008 respectively). Among women receiving TZB for adjuvant treatment of HER-2 positive breast cancer, the administration of XRT, anthracycline, or the combination of the 2 is associated with a persistent post-treatment as opposed to a temporary treatment related decline in LVEF.
Collapse
Affiliation(s)
- Mousumi M Andersen
- Department of Internal Medicine, Section on Cardiovascular Medicine, Wake Forest University Health Sciences, Winston-Salem, NC 27103
| | - Diandra Ayala-Peacock
- Department of Radiation Oncology, Vanderbilt Ingram Cancer Center, Nashville, TN 37232
| | - Jessie Bowers
- Penn State Heart and Vascular Institute, Penn State College of Medicine, Hershey, PA 17033
| | - Banks W Kooken
- Department of Internal Medicine, Radiation Oncology and Radiology, Wake Forest University Health Sciences, Winston-Salem, NC 27103
| | - Ralph B D'Agostino
- Department of Public Health Sciences, Wake Forest University Health Sciences, Winston-Salem, NC 27103
| | - Jennifer H Jordan
- Department of Internal Medicine, Section on Cardiovascular Medicine, Wake Forest University Health Sciences, Winston-Salem, NC 27103; Department of Internal Medicine (Cardiology Division), Pauley Heart Center, VCU Health Sciences, Richmond, VA 23298
| | - Sujethra Vasu
- Department of Internal Medicine, Section on Cardiovascular Medicine, Wake Forest University Health Sciences, Winston-Salem, NC 27103
| | - Alexandra Thomas
- Department of Internal Medicine, Section on Hematology and Oncology Section, Wake Forest University Health Sciences, Winston-Salem, NC 27103
| | - Heidi D Klepin
- Department of Internal Medicine, Section on Hematology and Oncology Section, Wake Forest University Health Sciences, Winston-Salem, NC 27103
| | - Doris R Brown
- Department of Internal Medicine, Radiation Oncology and Radiology, Wake Forest University Health Sciences, Winston-Salem, NC 27103
| | - W Gregory Hundley
- Department of Internal Medicine, Section on Cardiovascular Medicine, Wake Forest University Health Sciences, Winston-Salem, NC 27103; Department of Internal Medicine (Cardiology Division), Pauley Heart Center, VCU Health Sciences, Richmond, VA 23298.
| |
Collapse
|
15
|
Killander F, Wieslander E, Karlsson P, Holmberg E, Lundstedt D, Holmberg L, Werner L, Koul S, Haghanegi M, Kjellen E, Nilsson P, Malmström P. No Increased Cardiac Mortality or Morbidity of Radiation Therapy in Breast Cancer Patients After Breast-Conserving Surgery: 20-Year Follow-up of the Randomized SweBCGRT Trial. Int J Radiat Oncol Biol Phys 2020; 107:701-709. [PMID: 32302682 DOI: 10.1016/j.ijrobp.2020.04.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 04/02/2020] [Accepted: 04/04/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE Radiation therapy (RT) after breast-conserving surgery reduces locoregional recurrences and improves survival but may cause late side effects. The main purpose of this paper was to investigate long-term side effects after whole breast RT in a randomized clinical trial initiated in 1991 and to report dose-volume data based on individual 3-dimensional treatment plans for organs at risk. METHODS AND MATERIALS The trial included 1187 patients with T1-2 N0 breast cancer randomized to postoperative tangential whole breast RT or no further treatment. The prescription dose to the clinical target volume was 48 to 54 Gy. We present 20-year follow-up on survival, cause of death, morbidity, and later malignancies. For a cohort of patients (n = 157) with accessible computed tomography-based 3-dimensional treatment plans in Dicom-RT format, dose-volume descriptors for organs at risk were derived. In addition, these were compared with dose-volume data for a cohort of patients treated with contemporary RT techniques. RESULTS The cumulative incidence of cardiac mortality was 12.4% in the control group and 13.0% in the RT group (P = .8). There was an increase in stroke mortality: 3.4% in the control group versus 6.7% in the RT group (P = .018). Incidences of contralateral breast cancer and lung cancer were similar between groups. The median Dmean (range) heart dose for left-sided treatments was 3.0 Gy (1.1-8.1), and the corresponding value for patients treated in 2017 was 1.5 Gy (0.4-6.0). CONCLUSIONS In this trial, serious late side effects of whole breast RT were limited and less than previously reported in large meta-analyses. We observed no increase in cardiac mortality in irradiated patients. Doses to the heart were a median Dmean of 3.0 Gy for left-sided RT. The observed increase in stroke mortality may partly be secondary to cardiac side effects, complications to anticoagulant treatment, or to chance, rather than a direct side effect of tangential whole breast irradiation.
Collapse
Affiliation(s)
- Fredrika Killander
- Department of Clinical Sciences, Faculty of Medicine, Lund, Lund University, Sweden; Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden.
| | - Elinore Wieslander
- Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Per Karlsson
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Erik Holmberg
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Regional Oncologic Centre West, Gothenburg, Sweden
| | - Dan Lundstedt
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lars Holmberg
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden; Translational Oncology & Urology Research (TOUR), School of Cancer and Pharmaceutical Sciences, Kingś College London, London, United Kingdom
| | - Linda Werner
- Department of Clinical Sciences, Faculty of Medicine, Lund, Lund University, Sweden
| | - Sasha Koul
- Department of Cardiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Mahnaz Haghanegi
- Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Elisabeth Kjellen
- Department of Clinical Sciences, Faculty of Medicine, Lund, Lund University, Sweden; Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Per Nilsson
- Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden; Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Per Malmström
- Department of Clinical Sciences, Faculty of Medicine, Lund, Lund University, Sweden; Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| |
Collapse
|
16
|
Monte IP, Cameli M, Losi V, Privitera F, Citro R. Valvular Damage. J Cardiovasc Echogr 2020; 30:S26-S32. [PMID: 32566463 PMCID: PMC7293871 DOI: 10.4103/jcecho.jcecho_5_19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 02/17/2019] [Accepted: 10/04/2019] [Indexed: 01/05/2023] Open
Abstract
Valvular heart diseases (VHD) may be observed in patients with cancer for several reasons, including preexisting valve lesions, radiotherapy, infective endocarditis, and secondary to the left ventricle dysfunction. The incidence of VHD is especially in younger survivors treated with thoracic radiation therapy for certain malignancies, such as Hodgkin's lymphoma and breast cancer. The mechanism of radiation-induced damage to heart valves is not clear and includes diffuse fibrocalcific thickening of the valve. VHD is commonly diagnosed after a long latent period, in the context of clinical symptoms, or suspected on the basis of a new murmur. The evaluation includes identification of anatomical valve abnormalities, valve dysfunction, and assessing the functional consequences of valve dysfunction on the ventricles. Echocardiography is the optimal imaging technique for diagnostic and therapeutic management. Cardiovascular magnetic resonance and computed tomography (CT) may be used to assess the severity of VHD, but cardiac CT is mainly useful for detecting extensive calcifications of the ascending aorta. Patients exposed to mediastinal radiotherapy and minimal valve dysfunction require follow-up of 2–3 years, with moderate valve disease yearly, with severe, should be assessed for valve surgery.
Collapse
Affiliation(s)
- Ines Paola Monte
- Department of General Surgery and Medical-Surgery Specialities, University of Catania, AOU Policlinico Vittorio Emanuele, Catania, Italy
| | - Matteo Cameli
- Department of Cardiovascular Diseases, University of Siena, Siena, Italy
| | - Valentina Losi
- Department of Scienze Mediche, Chirurgiche e Tecnologie Avanzate, University of Catania, AOU Policlinico, Catania, Italy
| | - Fiorella Privitera
- Department of General Surgery and Medical-Surgery Specialities, University of Catania, AOU Policlinico Vittorio Emanuele, Catania, Italy
| | - Rodolfo Citro
- Department of Heart, University Hospital of Salerno, Salerno, Italy
| |
Collapse
|
17
|
Onal C, Efe E, Guler OC, Yildirim BA. Dosimetric Comparison of Sequential Versus Simultaneous-integrated Boost in Early-stage Breast Cancer Patients Treated With Breast-conserving Surgery. In Vivo 2020; 33:2181-2189. [PMID: 31662554 DOI: 10.21873/invivo.11720] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 08/15/2019] [Accepted: 08/16/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND/AIM To compare simultaneous-integrated boost (SIB) versus sequential-boost (SB) delivered in the context of whole-breast irradiation (WBI) via volumetric-modulated arc therapy (VMAT) and helical-tomotherapy (HT). MATERIALS AND METHODS Planning target-volume (PTV) dosimetric parameters and organs at risk (OAR) were analyzed for SB plan (50 Gy plus 16 Gy boost) and SIB plan (50.4 Gy WBI and 64.4 Gy tumor bed boost) in VMAT and HT techniques. RESULTS Conformity and homogeneity for target-volume doses were better in HT plans compared to VMAT plans. There were no significant differences in ipsilateral lung doses between VMAT and HT plans for SB/SIB techniques, except for a significantly higher lung V5 value with VMAT-SB, and lung V13 value with HT-SIB technique. HT provided a statistically significant decrease in contralateral lung mean V5. CONCLUSION The SIB technique showed better target-volume dose distribution in both HT and VMAT plans, and better sparing heart in HT compared to the SB technique.
Collapse
Affiliation(s)
- Cem Onal
- Department of Radiation Oncology, Baskent University Faculty of Medicine, Adana, Turkey
| | - Esma Efe
- Department of Radiation Oncology, Baskent University Faculty of Medicine, Adana, Turkey
| | - Ozan C Guler
- Department of Radiation Oncology, Baskent University Faculty of Medicine, Adana, Turkey
| | - Berna A Yildirim
- Department of Radiation Oncology, Baskent University Faculty of Medicine, Adana, Turkey
| |
Collapse
|
18
|
Boekel NB, Duane FK, Jacobse JN, Hauptmann M, Schaapveld M, Sonke GS, Gietema JA, Hooning MJ, Seynaeve CM, Maas AH, Darby SC, Aleman BM, Taylor CW, van Leeuwen FE. Heart failure after treatment for breast cancer. Eur J Heart Fail 2020; 22:366-374. [PMID: 31721395 PMCID: PMC7137787 DOI: 10.1002/ejhf.1620] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 05/10/2019] [Accepted: 08/23/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND We aimed to develop dose-response relationships for heart failure (HF) following radiation and anthracyclines in breast cancer treatment, and to assess HF associations with trastuzumab and endocrine therapies. METHODS AND RESULTS A case-control study was performed within a cohort of breast cancer survivors treated during 1980-2009. Cases (n = 102) had HF as first cardiovascular diagnosis and were matched 1:3 on age and date of diagnosis. Individual cardiac radiation doses were estimated, and anthracycline doses and use of trastuzumab and endocrine therapy were abstracted from oncology notes. For HF cases who received radiotherapy, the estimated median mean heart dose (MHD) was 6.8 Gy [interquartile range (IQR) 0.9-13.7]. MHD was not associated with HF risk overall [excess rate ratio (ERR) = 1%/Gy, 95% confidence interval (CI) -2 to 10]. In patients treated with anthracyclines, exposure of ≥20% of the heart to ≥20 Gy was associated with a rate ratio of 5.7 (95% CI 1.7-21.7) compared to <10% exposed to ≥20 Gy. For cases who received radiotherapy, median cumulative anthracycline dose was 247 mg/m2 (IQR 240-319). A dose-dependent increase was observed after anthracycline without trastuzumab (ERR = 1.5% per mg/m2 , 95% CI 0.5-4.1). After anthracycline and trastuzumab, the rate ratio was 34.9 (95% CI 11.1-110.1) compared to no chemotherapy. CONCLUSIONS In absence of anthracyclines, breast cancer radiotherapy was not associated with increased HF risk. Strongly elevated HF risks were observed after treatment with anthracyclines and also after treatment with trastuzumab. The benefits of these systemic treatments usually exceed the risks of HF, but our results emphasize the need to support ongoing efforts to evaluate preventative strategies.
Collapse
Affiliation(s)
- Naomi B. Boekel
- EpidemiologyNetherlands Cancer InstituteAmsterdamThe Netherlands
| | - Fran K. Duane
- Medical Research Council Population Health Research UnitUniversity of OxfordOxfordUK
- Nuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - Judy N. Jacobse
- EpidemiologyNetherlands Cancer InstituteAmsterdamThe Netherlands
| | | | | | - Gabe S. Sonke
- Medical OncologyNetherlands Cancer InstituteAmsterdamThe Netherlands
| | - Jourik A. Gietema
- Medical OncologyUniversity Medical Center GroningenGroningenThe Netherlands
| | | | | | - Angela H.E.M. Maas
- Department of CardiologyRadboud University Medical CentreNijmegenThe Netherlands
| | - Sarah C. Darby
- Nuffield Department of Population HealthUniversity of OxfordOxfordUK
| | | | - Carolyn W. Taylor
- Nuffield Department of Population HealthUniversity of OxfordOxfordUK
| | | |
Collapse
|
19
|
Radiobiological models in prediction of radiation cardiotoxicity. Rep Pract Oncol Radiother 2019; 25:46-49. [PMID: 31889920 DOI: 10.1016/j.rpor.2019.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 12/04/2019] [Indexed: 12/16/2022] Open
Abstract
Coronary disease induced by previous radiotherapy is the most common cause of death among patients treated with radiotherapy for cancer. Risk factors that may affect the frequency and intensity of radiotherapy's cardiac toxicity are primarily the radiation dose and the volume of the heart exposed to radiation. The prolonged survival time of patients after radiotherapy, but also the intensive development of modern radiotherapy techniques results in the necessity of precise estimation of both tumor control probability, and the risk of normal tissue damage, thus the models describing the probability of complications in normal tissues have also been developed. The response from the cardiovascular system to high-dose radiation is known and associated with a pro-inflammatory response. However, the effect of low doses may be completely different because it induces an anti-inflammatory response. Also, there is no unambiguous answer to the question of whether RICD is a deterministic effect. Moreover, there is a lack of literature data on the use of known radiobiological models to assess the risk of cardiovascular complications. The models described are general and concerns any healthy tissue. Therefore, when planning treatment for patients, particular attention should be paid to the dose and area of the heart to be irradiated.
Collapse
|
20
|
Mahdavi H. Radiation oncologists' perspectives on reducing radiation-induced heart disease in early breast cancer. Curr Probl Cancer 2019; 44:100509. [PMID: 31748146 DOI: 10.1016/j.currproblcancer.2019.100509] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 09/30/2019] [Accepted: 10/10/2019] [Indexed: 12/27/2022]
Abstract
Radiotherapy (RT) as an adjuvant treatment for breast cancer (BC), has caused a reduction of recurrences and BC-related deaths. But it has also induced cardiovascular mortality. Oxidative stress is the principle mediator of RT-induced heart disease, similar to many conventional cardiovascular risk factors. The aggregate effect of cardiovascular conditions, RT of heart substructures, implied techniques, and population cardiac mortality rates is not well understood. Due to uncertainties in this field, this article aims to briefly review the recommended strategies for risk assessment, plan optimization, and screening for prevention of RT-induced heart disease in BC patients.
Collapse
Affiliation(s)
- Hoda Mahdavi
- Department of Radiation Oncology, Iran University of Medical Sciences, Tehran, Iran.
| |
Collapse
|
21
|
Desai MY, Jellis CL, Kotecha R, Johnston DR, Griffin BP. Radiation-Associated Cardiac Disease: A Practical Approach to Diagnosis and Management. JACC Cardiovasc Imaging 2019; 11:1132-1149. [PMID: 30092970 DOI: 10.1016/j.jcmg.2018.04.028] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 04/12/2018] [Accepted: 04/13/2018] [Indexed: 01/14/2023]
Abstract
Radiation-associated cardiac disease (RACD) results in complex clinical presentations, unique management issues, and increased morbidity and mortality. Patients typically present years or even decades after radiation exposure, with delayed-onset cardiac damage sustained from high cumulative doses. Multimodality imaging is crucial to determine the manifestations and severity of disease because symptoms are often nonspecific. Comprehensive screening using a coordinated approach may enable early detection. However, timing of intervention should be carefully considered in these patients because surgery is often complex and high-risk second surgeries should be minimized in the long-term. This review aims to provide treating physicians with a comprehensive and clinically focused overview of RACD, including clinical/imaging manifestations, multi-modality screening recommendations, and management options.
Collapse
Affiliation(s)
- Milind Y Desai
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
| | | | - Rupesh Kotecha
- Department of Radiation Oncology, Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Brian P Griffin
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
22
|
Finazzi T, Nguyen VT, Zimmermann F, Papachristofilou A. Impact of patient and treatment characteristics on heart and lung dose in adjuvant radiotherapy for left-sided breast cancer. Radiat Oncol 2019; 14:153. [PMID: 31462267 PMCID: PMC6714299 DOI: 10.1186/s13014-019-1364-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 08/21/2019] [Indexed: 12/25/2022] Open
Abstract
PURPOSE The heart and lungs are routinely exposed to incidental irradiation during adjuvant radiotherapy (RT) of breast cancer. We analyzed the impact of patient and treatment characteristics on heart and lung dose in left-sided breast RT. METHODS We analyzed 332 female patients treated with left-sided breast RT between 2013 and 2018. Mean heart dose (MHD), left mean lung dose (MLD) and heart / lung V20Gy were collected from treatment plans. Patients were stratified by RT technique (3D-conformal RT, 3DCRT; intensity-modulated RT, IMRT; volumetric modulated arc therapy, VMAT) and target volumes, including lymph node RT (LN-RT). Patient characteristics (body mass index (BMI), heart and lung volume) were assessed using correlation analyses. RESULTS LN-RT was performed in 111 patients with increased MHD (median 4.6 vs. 3.3 Gy; p < .01), left MLD (14.8 vs. 7.7 Gy; p < .01) and left lung V20Gy (30.0% vs. 14.4%; p < .01) compared to treatment without LN-RT. Internal mammary LN-RT further increased organ doses compared to RT involving only supraclavicular +/- axillary LN (p < .01 for all values; MHD 6.9 vs. 4.2 Gy). In 221 patients treated without LN-RT, IMRT/VMAT was associated with higher left lung doses (MLD 9.1 vs. 7.4 Gy, p < .01; V20Gy 18.8% vs. 14.0%, p < .01) compared to 3DCRT. A negative correlation between total lung volume and both MHD (r = - 0.38; p < .01) and heart V20Gy (r = - 0.37; p < .01), as well as a weak positive correlation of BMI and MHD (r = 0.27; p < .01) were observed. CONCLUSIONS In adjuvant RT for left-sided breast cancer, LN-RT is associated with a marked increase in heart and lung doses, particularly with internal mammary LN-RT. Potential advantages of IMRT/VMAT for breast or chest wall RT need to be weighed against a moderately increased lung dose.
Collapse
Affiliation(s)
- Tobias Finazzi
- Clinic of Radiotherapy and Radiation Oncology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Van-Trinh Nguyen
- Clinic of Radiotherapy and Radiation Oncology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Frank Zimmermann
- Clinic of Radiotherapy and Radiation Oncology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Alexandros Papachristofilou
- Clinic of Radiotherapy and Radiation Oncology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| |
Collapse
|
23
|
Cardiovascular outcome of breast cancer patients with concomitant radiotherapy and chemotherapy: A 10-year multicenter cohort study. J Cardiol 2019; 74:175-181. [DOI: 10.1016/j.jjcc.2019.02.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 01/03/2019] [Accepted: 02/13/2019] [Indexed: 12/25/2022]
|
24
|
Duane FK, McGale P, Brønnum D, Cutter DJ, Darby SC, Ewertz M, Hackett S, Hall P, Lorenzen EL, Rahimi K, Wang Z, Warren S, Taylor CW. Cardiac Structure Doses in Women Irradiated for Breast Cancer in the Past and Their Use in Epidemiological Studies. Pract Radiat Oncol 2019; 9:158-171. [PMID: 30690085 PMCID: PMC6493043 DOI: 10.1016/j.prro.2019.01.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 12/09/2018] [Accepted: 01/04/2019] [Indexed: 12/25/2022]
Abstract
PURPOSE Incidental cardiac exposure during radiation therapy may cause heart disease. Dose-response relationships for cardiac structures (segments) may show which ones are most sensitive to radiation. Radiation-related cardiac injury can take years to develop; thus, studies need to involve women treated using 2-dimensional planning, with segment doses estimated using a typical computed tomography (CT) scan. We assessed whether such segment doses are accurate enough to use in dose-response relationships using the radiation therapy charts of women with known segment injury. We estimated interregimen and interpatient segment dose variability and segment dose correlations. METHODS AND MATERIALS The radiation therapy charts of 470 women with cardiac segment injury after breast cancer radiation therapy were examined, and 41 regimens were identified. Regimens were reconstructed on a typical CT scan. Doses were estimated for 5 left ventricle (LV) and 10 coronary artery segments. Correlations between cardiac segments were estimated. Interpatient dose variation was assessed in 10 randomly selected CT scans for left regimens and in 5 for right regimens. RESULTS For the typical CT scan, interregimen segment dose variation was substantial (range, LV segments <1-39 Gy; coronary artery segments <1-48 Gy). In 10 CT scans, interpatient segment dose variation was higher for segments near field borders (range, 3-47 Gy) than other segments (range, <2 Gy). Doses to different left-anterior descending coronary artery (LADCA) segments were highly correlated with each other, as were doses to different LV segments. Also, LADCA segment doses were highly correlated with doses to LV segments usually supplied by the LADCA. For individual regimens there was consistency in hotspot location and segment ranking of higher-versus-lower dose. CONCLUSIONS The scope for developing quantitative cardiac segment dose-response relationships in patients who had 2-dimensional planning is limited because different segment doses are often highly correlated, and segment-specific dose uncertainties are not independent of each other. However, segment-specific doses may be reliably used to rank segments according to higher-versus-lower doses.
Collapse
Affiliation(s)
- Frances K Duane
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, United Kingdom.
| | - Paul McGale
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, United Kingdom
| | - Dorthe Brønnum
- Centre for Clinical Research, North Denmark Regional Hospital/Department of Clinical Medicine, Aalborg University, Hjørring, Denmark
| | - David J Cutter
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, United Kingdom
| | - Sarah C Darby
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, United Kingdom
| | - Marianne Ewertz
- Department of Oncology, Odense University Hospital, Institute of Clinical Research, University of Southern Denmark, Denmark
| | - Sara Hackett
- CRUK/MRC Oxford Institute for Radiation Oncology, Gray Laboratories, University of Oxford, United Kingdom
| | - Per Hall
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden; Department of Oncology, South General Hospital, Stockholm, Sweden
| | - Ebbe L Lorenzen
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark
| | - Kazem Rahimi
- George Institute for Global Health, University of Oxford, Oxford, United Kingdom
| | - Zhe Wang
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, United Kingdom
| | - Samantha Warren
- University of Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Carolyn W Taylor
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, United Kingdom
| |
Collapse
|
25
|
Risk of cardiovascular disease after radiotherapy in survivors of breast cancer: A case-cohort study. J Cardiol 2019; 73:280-291. [DOI: 10.1016/j.jjcc.2018.10.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 09/27/2018] [Accepted: 10/13/2018] [Indexed: 12/27/2022]
|
26
|
Risk of cardiotoxicity induced by adjuvant anthracycline-based chemotherapy and radiotherapy in young and old Asian women with breast cancer. Strahlenther Onkol 2019; 195:629-639. [PMID: 30690687 DOI: 10.1007/s00066-019-01428-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 12/24/2018] [Indexed: 12/13/2022]
Abstract
PURPOSE The risk of cardiotoxicity induced by adjuvant anthracycline-based chemotherapy (CT) and radiotherapy (RT) is yet to be investigated in a large-scale randomized controlled trial with an adequate sample size of young and old women with breast cancer. PATIENTS AND METHODS To compare the occurrence of major heart events (heart failure and coronary artery disease) in patients with breast cancer, 3489 women who underwent surgical resection of the breast tumor were retrospectively selected from the Taiwan National Health Insurance Research Database. The patients were categorized into the following groups based on their treatment modalities: group 1 (n = 1113), no treatment; group 2 (n = 646), adjuvant RT alone; group 3 (n = 705), adjuvant anthracycline-based CT alone; and group 4 (n = 1025), combined adjuvant RT and anthracycline-based CT. RESULTS The mean patient age was 50.35 years. Subsequent coronary artery disease and heart failure were identified in 244 (7.0%) and 206 (5.9%) patients, respectively. All three adjuvant therapies were significant independent prognostic factors of major heart events (adjusted hazard ratio [95% confidence interval]: 1.47 [1.24-1.73]; 1.48 [1.25-1.75], and 1.92 [1.65-2.23] in groups 2, 3, and 4, respectively). In patients aged ≥50 years with breast cancer who underwent surgery, the log-rank p values of groups 2 and 3 after adjustment were 0.537 and 0.001, respectively. CONCLUSION Adjuvant RT can increase cardiotoxicity in patients with breast cancer, particularly when used in combination with anthracycline-based CT. Therefore, it should be offered with optimal heart-sparing techniques, particularly in younger patients with good prognosis and long life expectancy.
Collapse
|
27
|
Lawrenson R, Lao C, Ali A, Campbell I. Impact of radiotherapy on cardiovascular health of women with breast cancer. J Med Imaging Radiat Oncol 2018; 63:250-256. [PMID: 30556371 DOI: 10.1111/1754-9485.12838] [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: 03/08/2018] [Accepted: 10/24/2018] [Indexed: 11/28/2022]
Abstract
INTRODUCTION This study aims to examine the impact of radiotherapy on the cardiovascular health of women diagnosed with breast cancer in the Waikato region in New Zealand. METHODS Women diagnosed with stage 0-III breast cancer and recorded in the Waikato Breast Cancer Registry were divided into two groups: a radiotherapy group and a no-radiotherapy group. Baseline characteristics and treatments were compared in the two groups. Kaplan-Meier survival analysis was performed to compare cardiovascular morbidity and mortality. Cox Proportional Hazard regression analysis was used to estimate the hazard ratio of radiotherapy on the risk of cardiovascular morbidity and mortality while adjusting for other factors. RESULTS A total of 3528 women were included in this study, with 2303 in the radiotherapy group and 1225 in the no-radiotherapy group. At 10-year follow-up, 11.7% of women in the radiotherapy group and 19.4% in the no-radiotherapy group experienced cardiovascular events. Only 2.3% of patients who received radiotherapy died of cardiovascular disease by 10 years compared to 7.0% in the no-radiotherapy group. After adjusting for clinically significant factors, there was unexplained reduced risk of developing cardiovascular disease in the radiotherapy group compared to the no-radiotherapy group (HR 0.73, 95% CI: 0.59-0.92). No significant difference was found in cardiovascular mortality between the two groups. CONCLUSIONS Radiotherapy appears less likely to be offered to patients at higher risk of cardiovascular disease. No evidence of increased risk of a cardiovascular event was found in the group of women with breast cancer treated with radiotherapy and current regimens appear safe. Traditional cardiovascular risk factors remain the main culprits in this setting. Clinicians should work with patients in managing these risk factors for optimal results.
Collapse
Affiliation(s)
- Ross Lawrenson
- Waikato Medical Research Centre, The University of Waikato, Hamilton, New Zealand
| | - Chunhuan Lao
- Waikato Medical Research Centre, The University of Waikato, Hamilton, New Zealand
| | - Ahmed Ali
- Waikato District Health Board, Hamilton, New Zealand
| | - Ian Campbell
- School of Medicine, The University of Auckland, Auckland, New Zealand
| |
Collapse
|
28
|
Li WH, Zhang ZG, Huang ZR, Zhang W, Li ZB, Qi ZQ. No association between tumor laterality and cardiac-related mortality in breast cancer patients after radiotherapy: a population-based study. Cancer Manag Res 2018; 10:3649-3656. [PMID: 30271213 PMCID: PMC6152604 DOI: 10.2147/cmar.s172595] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction To assess the effect of tumor laterality to cardiac-related deaths of breast cancer in the current radiation practices using a large modern population-based study. Methods Women diagnosed with breast cancer from 2000 to 2008 were included using the current Surveillance, Epidemiology, and End Results database. The primary outcome of this study was the cardiac-related mortality. Multivariate analysis was performed using the Cox proportional hazards model to analyze the cardiac-related mortality including demographic, clinicopathologic, and treatment factors. Results We identified 168,761 breast cancer patients, including 85,006 (50.4%) patients with left-sided tumors and 83,755 (49.6%) patients with right-sided tumors. The median follow-up period was 8.8 years. The 10-year cardiac-related mortality was 2.3% and 2.3% in left- and right-sided tumors, respectively (P=0.685). The results indicated that patients with older age, non-Hispanic Black, receipt of mastectomy, and married status were the independent adverse factors for cardiac-related mortality. However, left-sided tumors were not associated to a higher risk of cardiac-related mortality than right-sided tumors following postoperative radiotherapy (right vs left, hazard ratios 1.025, 95% CI 0.856–1.099, P=0.484). The risk of cardiac-related mortality in the entire cohort was increased with the extension of follow-up time. However, there was still not significantly different between left- and right-sided tumors. Subgroup analysis also found no association between tumor laterality and cardiac-related mortality after postoperative radiotherapy based on various demographics and treatment factors. Conclusion With a median follow-up of 8.8 years, no significant differences were found in cardiac-related mortality between left- and right-sided tumors under current radiation practices of breast cancer patients.
Collapse
Affiliation(s)
- Wei-Hua Li
- Xiamen Institute of Cardiovascular Diseases, The First Affiliated Hospital of Xiamen University, Xiamen 361003, People's Republic of China
| | - Zi-Guan Zhang
- Xiamen Institute of Cardiovascular Diseases, The First Affiliated Hospital of Xiamen University, Xiamen 361003, People's Republic of China
| | - Zheng-Rong Huang
- Xiamen Institute of Cardiovascular Diseases, The First Affiliated Hospital of Xiamen University, Xiamen 361003, People's Republic of China
| | - Wei Zhang
- Xiamen Institute of Cardiovascular Diseases, The First Affiliated Hospital of Xiamen University, Xiamen 361003, People's Republic of China
| | - Zhi-Bin Li
- Epidemiology Research Unit, The First Affiliated Hospital of Xiamen University, Xiamen 361003, People's Republic of China,
| | - Zhong-Quan Qi
- Organ Transplantation Institute, Medical College, Xiamen University, Xiamen 361005, People's Republic of China,
| |
Collapse
|
29
|
Dosimetric evaluation of right coronary artery in radiotherapy for breast cancer. Med Dosim 2018; 44:205-209. [PMID: 30170990 DOI: 10.1016/j.meddos.2018.06.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 06/09/2018] [Accepted: 06/22/2018] [Indexed: 01/15/2023]
Abstract
Comparison with control groups of untreated patients suggests that right-breast-cancer patients who receive radiotherapy have a higher rate of heart disease. Dose constraint for heart has been established to minimize radiotherapy-induced cardiotoxicity during left breast cancer treatment. Additionally, it is suggested to minimize the dosage on left anterior descending (LAD) artery. Right coronary artery (RCA), is the second largest artery, after left main coronary artery, supplying the heart. A dose evaluation study is not present for RCA; the proximal part of which is included in the irradiation field during breast cancer treatment of right breast. To investigate the presence of a correlation, doses resulting from right and left breast radiotherapy on proximal RCA (pRCA), LAD, and heart are evaluated in this study. Forty breast cancer patients who went under breast-conserving surgery are the subject of this study. Four groups were established; right breast, right breast and internal mammary (IM), left breast and left breast, and IM. pRCA, LAD, and heart volumes were contoured for each group on the planning tomographies. Resultant doses of tangential fields planning on these volumes were compared using dose-volume histograms. Mean and maximum doses of pRCA were statistically compared between groups. The highest mean and maximum point doses (192 to 284 cGy) were found in the right breast + IM group (p < 0.05). The mean and maximum doses only in the right breast and left breast + IM group did not differ statistically. However, the mean and maximum pRCA doses in these 2 groups were higher than only the left breast group (p < 0.05). pRCA receives high doses during radiotherapy of right and left breast especially if IM is included. This may predispose to coronary artery disease.
Collapse
|
30
|
Żyromska A, Małkowski B, Wiśniewski T, Majewska K, Reszke J, Makarewicz R. 15O-H 2O PET/CT as a tool for the quantitative assessment of early post-radiotherapy changes of heart perfusion in breast carcinoma patients. Br J Radiol 2018; 91:20170653. [PMID: 29470136 DOI: 10.1259/bjr.20170653] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE Studies examining radiation-induced heart toxicity in breast cancer patients are inconclusive. The aim of this study was to prospectively and quantitatively asses myocardial blood flow (MBF) with, for the first time, 15O-H2O PET/CT as a marker of heart damage in irradiated breast cancer patients. METHODS 15 breast cancer patients receiving intact breast or chest wall irradiation were included in the analysis (six with right-sided and nine with left-sided breast cancer). They underwent 15O-H2O PET/CT before radiotherapy (RT) and 2 and 8 months after RT. MBF was quantitatively assessed at rest and under stress conditions in 17 heart segments distinguished according to the American Ultrasound Association classification. Regional MBF values were derived in each of the coronary artery territories. RESULTS MBF decreased in 53% and increased in 33% of cases 2 months after RT in both left-sided and right-sided breast cancer patients. Stress testing was more sensitive than at-rest testing, demonstrating decreased perfusion in the segments supplied by the left anterior descending coronary artery (LAD) [5.41 ± 1.74 vs 4.52 ± 1.82 ml (g*min)-1; p = 0.018], which persisted at 6 months [5.41 ± 1.74 vs 4.40 ± 1.38 ml (g*min)-1; p = 0.032] and a decrease in global heart perfusion [5.14 ± 1.49 vs 4.46 ± 1.73 ml (g*min)-1; p = 0.036]. A minimal radiation dose applied to the LAD correlated with MBF changes observed 2 months after RT (r = -0.57; p = 0.032). Radiological findings were not correlated with clinical symptoms of heart toxicity. CONCLUSION 15O-H2O PET/CT is safe and effective for the early detection and quantitative analysis of subclinical post-RT changes in heart perfusion in breast cancer patients. The LV segments supplied by the LAD are the main site of MBF changes. A minimum radiation dose deposited in the LAD may be a predictor of radiation-induced heart toxicity. Advances in knowledge: This is the first time that 15O-H2O PET/CT has been used to assess MBF after RT and the first granular description of the distribution of blood flow changes after breast cancer RT.
Collapse
Affiliation(s)
- Agnieszka Żyromska
- 1 Department of Oncology and Brachytherapy, Nicolaus Copernicus University in Toruń Ludwik Rydygier, Collegium Medicum in Bydgoszcz , Bydgoszcz , Poland.,2 Radiology Therapeutic Center in Krakow , Amethyst Radiotherapy Center in Zgorzelec , Poland
| | - Bogdan Małkowski
- 1 Department of Oncology and Brachytherapy, Nicolaus Copernicus University in Toruń Ludwik Rydygier, Collegium Medicum in Bydgoszcz , Bydgoszcz , Poland.,3 Department of Nuclear Medicine, Franciszek Lukaszczyk Oncology Centre , Bydgoszcz , Poland
| | - Tomasz Wiśniewski
- 1 Department of Oncology and Brachytherapy, Nicolaus Copernicus University in Toruń Ludwik Rydygier, Collegium Medicum in Bydgoszcz , Bydgoszcz , Poland.,4 Department of Radiotherapy, Franciszek Lukaszczyk Oncology Centre , Bydgoszcz , Poland
| | - Karolina Majewska
- 1 Department of Oncology and Brachytherapy, Nicolaus Copernicus University in Toruń Ludwik Rydygier, Collegium Medicum in Bydgoszcz , Bydgoszcz , Poland.,5 Department of Medical Physics, Franciszek Lukaszczyk Oncology Centre , Bydgoszcz , Poland
| | - Joanna Reszke
- 4 Department of Radiotherapy, Franciszek Lukaszczyk Oncology Centre , Bydgoszcz , Poland
| | - Roman Makarewicz
- 1 Department of Oncology and Brachytherapy, Nicolaus Copernicus University in Toruń Ludwik Rydygier, Collegium Medicum in Bydgoszcz , Bydgoszcz , Poland
| |
Collapse
|
31
|
Nguyen MH, Lavilla M, Kim JN, Fang LC. Cardiac sparing characteristics of internal mammary chain radiotherapy using deep inspiration breath hold for left-sided breast cancer. Radiat Oncol 2018; 13:103. [PMID: 29855325 PMCID: PMC5984301 DOI: 10.1186/s13014-018-1052-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Accepted: 05/22/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND While breast radiotherapy typically includes regional nodal basins, the treatment of the internal mammary nodes (IMN) has been controversial due to concern for long-term cardiac toxicity. For high risk patients where IMN treatment is warranted, there is limited data with regards to the degree of heart sparing conferred by modern techniques. In this study, we sought to analyze the specific heart sparing metrics conferred by deep inspiration breath hold (DIBH) in the setting of IMN irradiation. METHODS From 2012 to 2015, 168 consecutive patients were treated with adjuvant left-sided radiotherapy using DIBH. Retrospective review identified 49 patients who received nodal irradiation, either to a supraclavicular field (SCF) and IMN (16), or to the SCF alone (33). Cardiac mean dose and dose volumes were calculated from free breathing (FB) and DIBH treatment plans, and compared by Wilcoxon signed-rank and Mann-Whitney U tests. RESULTS DIBH achieved significant reductions in mean heart dose (p < 0.001) in both the IMN treated group from 6.73 Gy to 2.79 Gy (- 56.4%) and the IMN untreated group from 4.77 Gy to 1.55 Gy (- 63.7%). There was a 7.3% difference in relative reduction that was not statistically significant (p = 0.216). Relative reductions in heart dose volume measures were all significantly lower for IMN-irradiated patients (p ≤ 0.012), with the greatest deficits at V5 that gradually diminish with increasing dose (V25). CONCLUSIONS The relative heart sparing benefits of the DIBH technique are retained even with IMN inclusion. However, the addition of IMN irradiation is associated with an intrinsically greater heart dose, which translates to an estimated 9.2% proportional increase in the risk of a subsequent major coronary event. In the setting of effective cardiac sparing techniques, clinicians should take these considerations into account to guide when IMN treatment is warranted.
Collapse
Affiliation(s)
- Macklin H Nguyen
- School of Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA.
| | - Myra Lavilla
- Seattle Cancer Care Alliance, 825 Eastlake Avenue East, Seattle, WA, 98109, USA
| | - Janice N Kim
- Seattle Cancer Care Alliance, 825 Eastlake Avenue East, Seattle, WA, 98109, USA.,Department of Radiation Oncology, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA
| | - L Christine Fang
- Seattle Cancer Care Alliance, 825 Eastlake Avenue East, Seattle, WA, 98109, USA.,Department of Radiation Oncology, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA
| |
Collapse
|
32
|
Mehta LS, Watson KE, Barac A, Beckie TM, Bittner V, Cruz-Flores S, Dent S, Kondapalli L, Ky B, Okwuosa T, Piña IL, Volgman AS. Cardiovascular Disease and Breast Cancer: Where These Entities Intersect: A Scientific Statement From the American Heart Association. Circulation 2018; 137:e30-e66. [PMID: 29437116 PMCID: PMC6722327 DOI: 10.1161/cir.0000000000000556] [Citation(s) in RCA: 455] [Impact Index Per Article: 75.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Cardiovascular disease (CVD) remains the leading cause of mortality in women, yet many people perceive breast cancer to be the number one threat to women's health. CVD and breast cancer have several overlapping risk factors, such as obesity and smoking. Additionally, current breast cancer treatments can have a negative impact on cardiovascular health (eg, left ventricular dysfunction, accelerated CVD), and for women with pre-existing CVD, this might influence cancer treatment decisions by both the patient and the provider. Improvements in early detection and treatment of breast cancer have led to an increasing number of breast cancer survivors who are at risk of long-term cardiac complications from cancer treatments. For older women, CVD poses a greater mortality threat than breast cancer itself. This is the first scientific statement from the American Heart Association on CVD and breast cancer. This document will provide a comprehensive overview of the prevalence of these diseases, shared risk factors, the cardiotoxic effects of therapy, and the prevention and treatment of CVD in breast cancer patients.
Collapse
|
33
|
Dincoglan F, Beyzadeoglu M, Sager O, Oysul K, Kahya YE, Gamsiz H, Uysal B, Demiral S, Dirican B, Surenkok S. Dosimetric Evaluation of Critical Organs at Risk in Mastectomized Left-Sided Breast Cancer Radiotherapy Using Breath-Hold Technique. TUMORI JOURNAL 2018; 99:76-82. [DOI: 10.1177/030089161309900113] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aims and background The aim of the study was to evaluate the dosimetric impact of the active breathing control-moderate deep inspiration breath-hold (ABC-mDIBH) technique on normal tissue sparing in locally advanced left-sided breast cancer radiotherapy. Methods and study design Twenty-seven consecutive patients with left-sided locally advanced breast cancer referred to our department for adjuvant radiotherapy were enrolled in the study. Each patient was scanned at free breathing and ABC-mDIBH for radiation treatment planning. Two separate radiotherapy treatment plans were generated with and without ABC-mDIBH to investigate the dosimetric impact of ABC-mDIBH in breast cancer radiotherapy. Results Between June 2011 and February 2012, 27 consecutive patients with left-sided locally advanced breast cancer referred to our department for adjuvant radiotherapy were enrolled in the study. Dose-volume parameters of left anterior descending coronary artery, lungs, heart, contralateral breast, esophagus and spinal cord were significantly reduced with the use of ABC-mDIBH ( P <0.001). Conclusions Our study revealed that the use of ABC-mDIBH in the practice of locally advanced mastectomized left-sided breast cancer radiotherapy improves normal tissue sparing with the expected potential of decreasing treatment-related morbidity and mortality. Moreover, the resultant reduction achieved with ABC in doses to the left anterior descending coronary artery, which plays a central role in cardiac perfusion, may have implications for decreasing the potential of radiation-induced cardiac morbidity and mortality.
Collapse
Affiliation(s)
- Ferrat Dincoglan
- Department of Radiation Oncology, Gulhane Military Medical Academy, Ankara, Turkey
| | - Murat Beyzadeoglu
- Department of Radiation Oncology, Gulhane Military Medical Academy, Ankara, Turkey
| | - Omer Sager
- Department of Radiation Oncology, Gulhane Military Medical Academy, Ankara, Turkey
| | - Kaan Oysul
- Department of Radiation Oncology, Gulhane Military Medical Academy, Ankara, Turkey
| | - Yelda Elcim Kahya
- Department of Radiation Oncology, Gulhane Military Medical Academy, Ankara, Turkey
| | - Hakan Gamsiz
- Department of Radiation Oncology, Gulhane Military Medical Academy, Ankara, Turkey
| | - Bora Uysal
- Department of Radiation Oncology, Gulhane Military Medical Academy, Ankara, Turkey
| | - Selcuk Demiral
- Department of Radiation Oncology, Gulhane Military Medical Academy, Ankara, Turkey
| | - Bahar Dirican
- Department of Radiation Oncology, Gulhane Military Medical Academy, Ankara, Turkey
| | - Serdar Surenkok
- Department of Radiation Oncology, Gulhane Military Medical Academy, Ankara, Turkey
| |
Collapse
|
34
|
Hong JC, Rahimy E, Gross CP, Shafman T, Hu X, Yu JB, Ross R, Finkelstein SE, Dosoretz A, Park HS, Soulos PR, Evans SB. Radiation dose and cardiac risk in breast cancer treatment: An analysis of modern radiation therapy including community settings. Pract Radiat Oncol 2017; 8:e79-e86. [PMID: 28888675 DOI: 10.1016/j.prro.2017.07.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Revised: 07/06/2017] [Accepted: 07/09/2017] [Indexed: 01/11/2023]
Abstract
PURPOSE Adjuvant radiation therapy (RT) for breast cancer improves outcomes, but prior studies have documented substantive cardiac dose and cardiac risk. We assessed the mean heart dose (MHD) of RT and estimated the risk of RT-associated cardiac toxicity in women undergoing adjuvant RT for breast cancer in contemporary (predominantly) community practice. METHODS AND MATERIALS We identified women with left-sided breast cancer receiving adjuvant RT between 2012 and 2014 from 94 centers across 16 states. We used bivariate analyses and multivariable linear regression to assess associations between RT techniques and MHD. Excess RT-related cardiac risk by age 80 was estimated for women diagnosed at age 60 using the previously reported relationship between MHD and cardiac risk. RESULTS Among 1161 women, 77.3% were treated in community practice and with breast conservation (77.8%). The most common techniques were free-breathing (92.2%), supine (94.8%), and fixed gantry intensity modulated RT (FG-IMRT; 46.9%). The median MHD was 2.76 Gy (interquartile range, 1.47-5.03). In multivariable analyses, the predicted median MHD with deep inspiration breath hold was 2.41 Gy compared with 3.86 Gy with free-breathing (P < .001). Three-dimensional conformal RT (3D-CRT) was associated with a lower predicted median MHD (2.78 Gy) than FG-IMRT (4.02 Gy) or rotational IMRT, 6.60 Gy, P < .001). For 60-year-old women with the median MHD of the study population (2.76 Gy) and no cardiovascular risk factors, the 20-year predicted excess risk of death from ischemic heart disease attributable to radiation was 3.5 excess events/1000 patients, in contrast to estimates of 8 events/1000 from prior analyses. The predicted risk of cardiac events varied based on radiation technique, with 4 excess events/1000 with 3D-CRT, 5 excess events/1000 with FG-IMRT, and 8 excess events/1000 with rotational IMRT. CONCLUSIONS MHD varies substantially across patients and is influenced by technique in predominantly community settings. Overall risk of cardiac toxicity is modest.
Collapse
Affiliation(s)
- Julian C Hong
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut; Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Elham Rahimy
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Cary P Gross
- Cancer Outcomes, Public Policy and Effectiveness Research Center, Yale School of Medicine, New Haven, Connecticut; Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - Xin Hu
- Cancer Outcomes, Public Policy and Effectiveness Research Center, Yale School of Medicine, New Haven, Connecticut; Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - James B Yu
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut; Cancer Outcomes, Public Policy and Effectiveness Research Center, Yale School of Medicine, New Haven, Connecticut
| | - Rudi Ross
- 21st Century Oncology, Fort Myers, Florida
| | | | - Arie Dosoretz
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Henry S Park
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Pamela R Soulos
- Cancer Outcomes, Public Policy and Effectiveness Research Center, Yale School of Medicine, New Haven, Connecticut; Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Suzanne B Evans
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut; Cancer Outcomes, Public Policy and Effectiveness Research Center, Yale School of Medicine, New Haven, Connecticut.
| |
Collapse
|
35
|
Effect of Breast Irradiation on Cardiac Disease in Women Enrolled in BCIRG-001 at 10-Year Follow-Up. Int J Radiat Oncol Biol Phys 2017; 99:541-548. [PMID: 29280448 DOI: 10.1016/j.ijrobp.2017.06.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 05/04/2017] [Accepted: 06/15/2017] [Indexed: 11/24/2022]
Abstract
PURPOSE To investigate cardiac toxicity associated with breast radiation therapy (RT) at 10-year follow-up in BCIRG-001, a phase 3 trial comparing adjuvant anthracycline chemotherapy (fluorouracil, doxorubicin, and cyclophosphamide) with anthracycline-taxane chemotherapy (docetaxel, doxorubicin, and cyclophosphamide) in women with lymph node-positive early breast cancer. METHODS AND MATERIALS Prospective data from all 746 patients in the control arm (fluorouracil, doxorubicin, and cyclophosphamide) of BCIRG-001 at 10-year follow-up were obtained from Project Data Sphere. Cardiac toxicities examined included myocardial infarction (MI), heart failure (HF), arrhythmias, and relative and absolute left ventricular ejection fraction decrease of >20% from baseline. Toxicities were compared between patients who received RT versus no RT, left-sided RT versus no RT, and internal mammary nodal RT versus no RT. RESULTS Of the 746 patients, 559 (75%) received RT to a median dose of 50 Gy. Myocardial infarction occurred in 3 RT patients (0.5%) versus 6 no-RT patients (3%) (P=.01). Heart failure was seen in 15 RT patients (2.7%) versus 3 no-RT patients (1.6%) (P=.6). Among these, 35 RT patients (18%) had a left ventricular ejection fraction relative decrease of >20% baseline versus 7 (10%) who did not receive RT (P=.1). Arrhythmias were more common in RT patients (3.2%) versus no-RT patients (0%) (P=.01). On univariable and multivariable analysis HF was not significantly associated with RT, and MI was negatively associated with RT. CONCLUSIONS In this retrospective analysis of prospective toxicity outcomes, there is an increased risk of arrhythmias but no clear evidence of significantly increased risk of MI or HF at 10 years in lymph node-positive women treated with breast RT and uniform adjuvant doxorubicin-based chemotherapy. Given the low incidence of these outcomes, studies with larger numbers are needed to confirm our findings.
Collapse
|
36
|
Patel SA, Lu HM, Nyamwanda JA, Jimenez RB, Taghian AG, MacDonald SM, Depauw N. Postmastectomy radiation therapy technique and cardiopulmonary sparing: A dosimetric comparative analysis between photons and protons with free breathing versus deep inspiration breath hold. Pract Radiat Oncol 2017; 7:e377-e384. [PMID: 28734644 DOI: 10.1016/j.prro.2017.06.006] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 05/25/2017] [Accepted: 06/16/2017] [Indexed: 11/26/2022]
Abstract
PURPOSE Dosimetric studies have suggested greater cardiopulmonary sparing with protons over photons for left-sided postmastectomy radiation therapy (PMRT). Modern techniques such as deep inspiration breath hold (DIBH) can help spare the heart. This analysis compares photon and proton delivery with and without DIBH. METHODS AND MATERIALS Ten women with left breast cancer referred for PMRT on a prospective clinical trial with unfavorable cardiac anatomy underwent free breathing (FB) and DIBH computed tomography simulation. A partially wide tangent photon (PWTF) during DIBH, passively scattered proton during FB, pencil-beam scanning (PBS) proton during FB, and PBS proton during DIBH plan was completed for each patient. Plans were designed to achieve 95% prescription dose coverage to 95% of chest wall and regional lymphatics while maximally sparing heart and lungs. RESULTS All techniques resulted in similar target coverage, although protons improved homogeneity indices and cardiopulmonary sparing (omnibus P < .0001 for each metric). Heart/lung metrics for PWTF with DIBH, scattered protons with FB, PBS protons with FB, and PBS protons with DIBH, respectively, were as follows: mean heart dose (2.09, 0.39, 0.98, 0.71 Gy relative biological effectiveness [RBE]), mean left ventricle dose (3.72, 0.08, 0.19, 0.21 GyRBE), V20 left ventricle (2.73, 0.03, 0, 0%), maximum left anterior descending artery dose (46.14, 8.28, 4.58, 4.63 GyRBE), mean lung dose (13.30, 5.74, 7.63, 7.49 GyRBE), and V20 lung (26.04, 12.04, 15.18, 14.43 %). Pairwise testing confirmed an improvement in each metric with all proton plans compared with PWTF with DIBH; there were no differences in homogeneity indices or cardiopulmonary sparing between passively scattered and PBS protons, regardless of addition of DIBH. CONCLUSIONS For left-sided PMRT, passively scattered or PBS protons with or without DIBH improves homogeneity and cardiopulmonary sparing without compromise in target coverage compared with PWTF photons with DIBH. Furthermore, the addition of DIBH to proton therapy did not provide a significant dosimetric benefit.
Collapse
Affiliation(s)
- Sagar A Patel
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, Massachusetts.
| | - Hsiao-Ming Lu
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Rachel B Jimenez
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Alphonse G Taghian
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Shannon M MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Nicolas Depauw
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
37
|
Stewart MH, Jahangir E, Polin NM. Valvular Heart Disease in Cancer Patients: Etiology, Diagnosis, and Management. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2017; 19:53. [PMID: 28547673 DOI: 10.1007/s11936-017-0550-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OPINION STATEMENT Cardiac valvular disease as consequence of radiation and chemotherapy during treatment for malignancy is growing in its awareness. While the overwhelming emphasis in this population has been on the monitoring and preservation of left ventricular systolic function, we are now developing a greater appreciation for the plethora of cardiac sequelae beyond this basic model. To this end many institutions across the country have developed cardio-oncology programs, which are collaborative practices between oncologists and cardiologists in order to minimize a patient's cardiovascular risk while allowing them to receive the necessary treatment for their cancer. These programs also help to recognize early nuanced treatment complications such as valvular heart disease, and provide consultation for the most appropriate course of action. In this article we will discuss the etiology, prevalence, diagnosis, and current treatment options of valvular heart disease as the result of chemotherapy and radiation.
Collapse
Affiliation(s)
- Merrill H Stewart
- John Ochsner Heart and Vascular Institute, University of Queensland School of Medicine, 1514 Jefferson Highway, New Orleans, LA, 70121, USA.
| | - Eiman Jahangir
- Division of Cardiology, Kaiser Permanente Northern California, 401 Bicentennial Drive, Santa Rosa, CA, 95403, USA
| | - Nichole M Polin
- John Ochsner Heart and Vascular Institute, University of Queensland School of Medicine, 1514 Jefferson Highway, New Orleans, LA, 70121, USA
| |
Collapse
|
38
|
Abstract
Breast-conserving therapy is one of the most remarkable achievements of modern cancer care. The authors review the evidence supporting the role of adjuvant radiotherapy as the standard of care for breast cancer after breast-conserving surgery, consensus guidelines for margins in invasive cancer disease and ductal carcinoma in situ, the role of partial-breast irradiation and hypofractionated whole-breast irradiation, and the evolving indications for postmastectomy radiation therapy and extent of nodal coverage. Areas of research include specific methods of partial-breast irradiation, interactions between neoadjuvant chemotherapy and radiotherapy, and integration of molecular profiles with the selection of the best treatment modality and timing.
Collapse
|
39
|
Saiki H, Petersen IA, Scott CG, Bailey KR, Dunlay SM, Finley RR, Ruddy KJ, Yan E, Redfield MM. Risk of Heart Failure With Preserved Ejection Fraction in Older Women After Contemporary Radiotherapy for Breast Cancer. Circulation 2017; 135:1388-1396. [PMID: 28132957 DOI: 10.1161/circulationaha.116.025434] [Citation(s) in RCA: 145] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 01/13/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND Cardiomyocytes are resistant to radiation. However, cardiac radiation exposure causes coronary microvascular endothelial inflammation, a perturbation implicated in the pathogenesis of heart failure (HF) and particularly HF with preserved ejection fraction (HFpEF). Radiotherapy for breast cancer results in variable cardiac radiation exposure and may increase the risk of HF. METHODS We conducted a population-based case-control study of incident HF in 170 female residents of Olmsted County, Minnesota (59 cases and 111 controls), who underwent contemporary (1998-2013) radiotherapy for breast cancer with computed tomography-assisted radiotherapy planning. Controls were matched to cases for age, tumor side, chemotherapy use, diabetes mellitus, and hypertension. Mean cardiac radiation dose (MCRD) in each patient was calculated from the patient's computed tomography images and radiotherapy plan. RESULTS Mean age at radiotherapy was 69±9 years. Of HF cases, 38 (64%) had EF≥50% (HFpEF), 18 (31%) had EF<50% (HF with reduced EF), and 3 (5%) did not have EF measured. The EF was ≥40% in 50 of the 56 HF cases (89%) with an EF measurement. The mean interval from radiotherapy to HF was 5.8±3.4 years. The odds of HF was higher in patients with a history of ischemic heart disease or atrial fibrillation. The MCRD was 2.5 Gy (range, 0.2-13.1 Gy) and higher in cases (3.3±2.7 Gy) than controls (2.1±2.0 Gy; P=0.004). The odds ratio (95% confidence interval) for HF per log MCRD was 9.1 (3.4-24.4) for any HF, 16.9 (3.9-73.7) for HFpEF, and 3.17 (0.8-13.0) for HF with reduced EF. The increased odds of any HF or HFpEF with increasing MCRD remained significant after adjustment for HF risk factors and in sensitivity analyses matching by cancer stage rather than tumor side. Only 18.6% of patients experienced new or recurrent ischemic events between radiotherapy and the onset of HF. CONCLUSIONS The relative risk of HFpEF increases with increasing cardiac radiation exposure during contemporary conformal breast cancer radiotherapy. These data emphasize the importance of radiotherapy techniques that limit MCRD during breast cancer treatment. Moreover, these data provide further support for the importance of coronary microvascular compromise in the pathophysiology of HFpEF.
Collapse
Affiliation(s)
- Hirofumi Saiki
- From Department of Cardiovascular Disease (H.S., S.M.D., M.M.R.), Department of Radiation Oncology (I.A.P., R.R.F., E.Y.), Department of Health Science Research (C.G.S., K.R.B., S.M.D.), and Division of Medical Oncology (K.J.R.), Mayo Clinic and Foundation, Rochester, MN
| | - Ivy A Petersen
- From Department of Cardiovascular Disease (H.S., S.M.D., M.M.R.), Department of Radiation Oncology (I.A.P., R.R.F., E.Y.), Department of Health Science Research (C.G.S., K.R.B., S.M.D.), and Division of Medical Oncology (K.J.R.), Mayo Clinic and Foundation, Rochester, MN
| | - Christopher G Scott
- From Department of Cardiovascular Disease (H.S., S.M.D., M.M.R.), Department of Radiation Oncology (I.A.P., R.R.F., E.Y.), Department of Health Science Research (C.G.S., K.R.B., S.M.D.), and Division of Medical Oncology (K.J.R.), Mayo Clinic and Foundation, Rochester, MN
| | - Kent R Bailey
- From Department of Cardiovascular Disease (H.S., S.M.D., M.M.R.), Department of Radiation Oncology (I.A.P., R.R.F., E.Y.), Department of Health Science Research (C.G.S., K.R.B., S.M.D.), and Division of Medical Oncology (K.J.R.), Mayo Clinic and Foundation, Rochester, MN
| | - Shannon M Dunlay
- From Department of Cardiovascular Disease (H.S., S.M.D., M.M.R.), Department of Radiation Oncology (I.A.P., R.R.F., E.Y.), Department of Health Science Research (C.G.S., K.R.B., S.M.D.), and Division of Medical Oncology (K.J.R.), Mayo Clinic and Foundation, Rochester, MN
| | - Randi R Finley
- From Department of Cardiovascular Disease (H.S., S.M.D., M.M.R.), Department of Radiation Oncology (I.A.P., R.R.F., E.Y.), Department of Health Science Research (C.G.S., K.R.B., S.M.D.), and Division of Medical Oncology (K.J.R.), Mayo Clinic and Foundation, Rochester, MN
| | - Kathryn J Ruddy
- From Department of Cardiovascular Disease (H.S., S.M.D., M.M.R.), Department of Radiation Oncology (I.A.P., R.R.F., E.Y.), Department of Health Science Research (C.G.S., K.R.B., S.M.D.), and Division of Medical Oncology (K.J.R.), Mayo Clinic and Foundation, Rochester, MN
| | - Elizabeth Yan
- From Department of Cardiovascular Disease (H.S., S.M.D., M.M.R.), Department of Radiation Oncology (I.A.P., R.R.F., E.Y.), Department of Health Science Research (C.G.S., K.R.B., S.M.D.), and Division of Medical Oncology (K.J.R.), Mayo Clinic and Foundation, Rochester, MN
| | - Margaret M Redfield
- From Department of Cardiovascular Disease (H.S., S.M.D., M.M.R.), Department of Radiation Oncology (I.A.P., R.R.F., E.Y.), Department of Health Science Research (C.G.S., K.R.B., S.M.D.), and Division of Medical Oncology (K.J.R.), Mayo Clinic and Foundation, Rochester, MN.
| |
Collapse
|
40
|
Cao L, Cai G, Chang C, Yang ZZ, Feng Y, Yu XL, Ma JL, Wu J, Guo XM, Chen JY. Early cardiac toxicity following adjuvant radiotherapy of left-sided breast cancer with or without concurrent trastuzumab. Oncotarget 2016; 7:1042-54. [PMID: 26460956 PMCID: PMC4808050 DOI: 10.18632/oncotarget.6053] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Accepted: 09/23/2015] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To evaluate the influence of concurrent trastuzumab on the cardiotoxicity in patients receiving left-sided adjuvant radiotherapy. MATERIALS AND METHODS Medical records of stage I-III left-sided breast cancer patients, including 64 receiving concurrent trastuzumab with radiotherapy and 73 receiving radiotherapy alone were retrospectively reviewed. All of the patients had normal LVEF after adjuvant chemotherapy. Information of doses volume to cardiac structures was collected. Cardiac events were assessed according to CTC 2.0. RESULTS Median follow-up of LVEF and clinical assessment of cardiac function from the initiation of radiotherapy was 6.7 months (range 3-60.9) and 26 months (range 6.4-60.9), respectively. Grade 1 LVEF dysfunction occurred in 5 (7.8%) and 3 (4.1%) patients of the concurrent-trastuzumab and radiotherapy alone cohort, respectively. Trastuzumab was the only significant factor influencing absolute LVEF decrease in univariate analysis. In multivariate analysis of concurrent-trastuzumab cohort, IMC radiotherapy and start trastuzumab during radiotherapy were independent risk factors. For concurrent cohort, mean heart dose, as well as D10-D30, D50-D55, V5-V20 of the heart and D30-D45, D65-D75, V6-V15 of the LV were significantly higher in patients developing LVEF dysfunction. CONCLUSIONS Concurrent trastuzumab and left-sided radiotherapy is well tolerated in terms of cardiotoxicity in patients with normal baseline cardiac function after adjuvant chemotherapy. However, increases in mean dose and low-dose volume of cardiac structures are associated with a higher risk of acute LVEF dysfunction.
Collapse
Affiliation(s)
- Lu Cao
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.,Shanghai Medical College, Fudan University, Shanghai, China
| | - Gang Cai
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.,Shanghai Medical College, Fudan University, Shanghai, China
| | - Cai Chang
- Department of Ultrasound, Fudan University Shanghai Cancer Center, Shanghai, China.,Shanghai Medical College, Fudan University, Shanghai, China
| | - Zhao-Zhi Yang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Shanghai Medical College, Fudan University, Shanghai, China
| | - Yan Feng
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Shanghai Medical College, Fudan University, Shanghai, China
| | - Xiao-Li Yu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Shanghai Medical College, Fudan University, Shanghai, China
| | - Jin-Li Ma
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Shanghai Medical College, Fudan University, Shanghai, China
| | - Jiong Wu
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.,Shanghai Medical College, Fudan University, Shanghai, China
| | - Xiao-Mao Guo
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Shanghai Medical College, Fudan University, Shanghai, China
| | - Jia-Yi Chen
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.,Shanghai Medical College, Fudan University, Shanghai, China
| |
Collapse
|
41
|
Abstract
BACKGROUND Cardiovascular disease (CVD) is of increasing concern among breast cancer survivors. However, the burden of this comorbidity in this group relative to the general population, and its temporal pattern, remains unknown. METHODS We compared deaths due to CVD in a population-based sample of 1,413 women with incident breast cancer diagnosed in 1996-1997, and 1,411 age-matched women without breast cancer. Date and cause of death through December 31, 2009 were assessed through the national death index and covariate data was gathered through structured interviews and medical record abstraction. Hazard ratios (HR) and 95% confidence intervals were calculated using Cox regression for overall mortality (HR) and CVD-specific death (cause-specific HR). Subdistribution HRs for CVD death were estimated from the Fine-Gray model. RESULTS Risk of death was greater among breast cancer survivors compared with women without breast cancer (HR: 1.8 [1.5, 2.1]). An increase in CVD-related death among breast cancer survivors was evident only 7 years after diagnosis (years 0-7, cause-specific HR: 0.80 [0.53, 1.2], subdistribution HR: 0.59 [0.40, 0.87]); years 7+, cause-specific HR: 1.8 [1.3, 2.5], subdistribution HR: 1.9 [1.4, 2.7]; P interaction: 0.001). An increase in CVD-related mortality was observed among breast cancer survivors receiving chemotherapy. CONCLUSIONS Breast cancer survivors are at greater risk for CVD-related mortality compared with women without breast cancer and this increase in risk is manifested approximately 7 years after diagnosis. Efforts should be made to identify risk factors and interventions that can be employed during this brief window to reduce the excess burden of CVD in this vulnerable population.
Collapse
|
42
|
Russell RR, Alexander J, Jain D, Poornima IG, Srivastava AV, Storozynsky E, Schwartz RG. The role and clinical effectiveness of multimodality imaging in the management of cardiac complications of cancer and cancer therapy. J Nucl Cardiol 2016; 23:856-84. [PMID: 27251147 DOI: 10.1007/s12350-016-0538-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 04/13/2016] [Indexed: 12/24/2022]
Abstract
With the increasing number of individuals living with a current or prior diagnosis of cancer, it is important for the cardiovascular specialist to recognize the various complications of cancer and its therapy on the cardiovascular system. This is true not only for established cancer therapies, such as anthracyclines, that have well established cardiovascular toxicities, but also for the new targeted therapies that can have "off target" effects in the heart and vessels. The purpose of this informational statement is to provide cardiologists, cardiac imaging specialists, cardio-oncologists, and oncologists an understanding of how multimodality imaging may be used in the diagnosis and management of the cardiovascular complications of cancer therapy. In addition, this document is meant to provide useful general information concerning the cardiovascular complications of cancer and cancer therapy as well as established recommendations for the monitoring of specific cardiotoxic therapies.
Collapse
Affiliation(s)
- Raymond R Russell
- Rhode Island Cardiovascular Institute, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, 593 Eddy Street, APC 737, Providence, RI, 02903, USA.
| | - Jonathan Alexander
- Cardiology Division, Western Connecticut Medical Center at Danbury Hospital, Danbury, CT, USA
| | - Diwakar Jain
- Section of Cardiovascular Medicine, New York Medical College and Westchester Medical Center, Valhalla, NY, USA
| | - Indu G Poornima
- Division of Cardiology, Allegheny Health Network, Pittsburgh, PA, USA
| | - Ajay V Srivastava
- Division of Cardiovascular Medicine, Scripps Clinic, La Jolla, CA, USA
| | - Eugene Storozynsky
- Cardiology Division, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Ronald G Schwartz
- Cardiology Division, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
- Nuclear Medicine Division, Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
| |
Collapse
|
43
|
Abstract
Through the success of basic and disease-specific research, cancer survivors are one of the largest growing subsets of individuals accessing the healthcare system. Interestingly, cardiovascular disease is the second leading cause of morbidity and mortality in cancer survivors after recurrent malignancy. This recognition has helped stimulate a collaboration between oncology and cardiology practitioners and researchers, and the portmanteau cardio-oncology (also known as onco-cardiology) can now be found in many medical centers. This collaboration promises new insights into how cancer therapies impact cardiovascular homeostasis and long-term effects on cancer survivors. In this review, we will discuss the most recent views on the cardiotoxicity related to various classes of chemotherapy agents and radiation. We will also discuss broadly the current strategies for treating and preventing cardiovascular effects of cancer therapy.
Collapse
Affiliation(s)
- Carrie G Lenneman
- From the Department of Medicine, University of Louisville School of Medicine, KY (C.G.L.); and Cardiovascular Institute, Maine Medical Center, Portland (D.B.S.).
| | - Douglas B Sawyer
- From the Department of Medicine, University of Louisville School of Medicine, KY (C.G.L.); and Cardiovascular Institute, Maine Medical Center, Portland (D.B.S.)
| |
Collapse
|
44
|
Nolan MT, Russell DJ, Marwick TH. Long-term Risk of Heart Failure and Myocardial Dysfunction After Thoracic Radiotherapy: A Systematic Review. Can J Cardiol 2016; 32:908-20. [DOI: 10.1016/j.cjca.2015.12.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 11/16/2015] [Accepted: 12/07/2015] [Indexed: 01/12/2023] Open
|
45
|
Chargari C, Magne N, Guy JB, Rancoule C, Levy A, Goodman KA, Deutsch E. Optimize and refine therapeutic index in radiation therapy: Overview of a century. Cancer Treat Rev 2016; 45:58-67. [DOI: 10.1016/j.ctrv.2016.03.001] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 02/25/2016] [Accepted: 03/01/2016] [Indexed: 12/20/2022]
|
46
|
Meattini I, Guenzi M, Fozza A, Vidali C, Rovea P, Meacci F, Livi L. Overview on cardiac, pulmonary and cutaneous toxicity in patients treated with adjuvant radiotherapy for breast cancer. Breast Cancer 2016; 24:52-62. [DOI: 10.1007/s12282-016-0694-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 03/20/2016] [Indexed: 12/25/2022]
|
47
|
Wu YY, Huang TC, Tsai TN, Chen JH, Dai MS, Chang PY, Ho CL, Ye RH, Chung TR, Chen YC, Chao TY. The Clinical Efficacy and Cardiotoxicity of Fixed-Dose Monthly Trastuzumab in HER2-Positive Breast Cancer: A Single Institutional Analysis. PLoS One 2016; 11:e0151112. [PMID: 26953588 PMCID: PMC4783010 DOI: 10.1371/journal.pone.0151112] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Accepted: 02/22/2016] [Indexed: 01/03/2023] Open
Abstract
Objective Trastuzumab-containing treatment regimens have been shown to improve survival outcomes in HER2-positive breast cancer (BC). It is much easier to infuse a fixed one-vial dose to every patient on a regular schedule in the general clinical setting. The aims of this study were evaluating the efficacy of a 440 mg fixed-dose of trastuzumab administered on a monthly infusion schedule, and the risk factors for cardiac events. Patients and methods We retrospectively reviewed data from 300 HER2-positive BC patients in our institute: 208 were early-stage BC patients undergoing adjuvant trastuzumab treatment, and 92 were metastatic BC patients treated with trastuzumab infusions until disease progression. There were 181 patients receiving regular trastuzumab infusions every 3 weeks (Q3W; 8 mg/kg loading dose followed by 6 mg/kg every 3 weeks), and the other 119 patients were treated monthly with a fixed 440 mg dose (QM; fixed 440 mg every 4 weeks). Results The medians of progression-free survival (PFS) and overall survival (OS) in the adjuvant setting were not reached in both treatment groups. In the metastatic setting, there was no significant difference between groups in PFS or OS. The median time to significant cardiovascular (CV) dysfunction was 4.54 months. The incidence of congestive heart failure requiring medication in our cohort was 3.4%. Conclusion In our study, we found that fixed-dose monthly trastuzumab was feasible and effective. In addition, the CV risk was not higher with the fixed-dose protocol. This treatment modality could lower the cost and was easier to implement in clinical practice. Larger prospective randomized studies with longer-term follow up are needed to confirm our results.
Collapse
Affiliation(s)
- Yi-Ying Wu
- Division of Hematology/Oncology, Department of Medicine, Tri-Service General Hospital, Taipei City, Taiwan, Republic of China
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei City, Taiwan, Republic of China
| | - Tzu-Chuan Huang
- Division of Hematology/Oncology, Department of Medicine, Tri-Service General Hospital, Taipei City, Taiwan, Republic of China
| | - Tsung-Neng Tsai
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei City, Taiwan, Republic of China
- Division of Cardiology, Department of Medicine, Tri-Service General Hospital, Taipei City, Taiwan, Republic of China
| | - Jia-Hong Chen
- Division of Hematology/Oncology, Department of Medicine, Tri-Service General Hospital, Taipei City, Taiwan, Republic of China
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei City, Taiwan, Republic of China
| | - Ming-Shen Dai
- Division of Hematology/Oncology, Department of Medicine, Tri-Service General Hospital, Taipei City, Taiwan, Republic of China
| | - Ping-Ying Chang
- Division of Hematology/Oncology, Department of Medicine, Tri-Service General Hospital, Taipei City, Taiwan, Republic of China
| | - Ching-Liang Ho
- Division of Hematology/Oncology, Department of Medicine, Tri-Service General Hospital, Taipei City, Taiwan, Republic of China
| | - Ren-Hua Ye
- Division of Hematology/Oncology, Department of Medicine, Tri-Service General Hospital, Taipei City, Taiwan, Republic of China
| | - Tsai-Rong Chung
- National Institute of Cancer Research, Miaoli County, Taiwan, Republic of China
| | - Yeu-Chin Chen
- Division of Hematology/Oncology, Department of Medicine, Tri-Service General Hospital, Taipei City, Taiwan, Republic of China
| | - Tsu-Yi Chao
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei City, Taiwan, Republic of China
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei City, Taiwan, Republic of China
- Division of Hematology and Oncology, Department of Medicine, Taipei Medical University, Shuang-Ho Hospital, New Taipei City, Taiwan, Republic of China
- * E-mail:
| |
Collapse
|
48
|
Tan CH, Chao TT, Liu JC, Lin CH, Huang YS, Chang CM, Lin HY, Su YC, Chen YL, Lee CC. Breast cancer therapy and age difference in cardiovascular disease risks: A population-based cohort study in Taiwan. Taiwan J Obstet Gynecol 2016; 55:98-103. [DOI: 10.1016/j.tjog.2015.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2014] [Indexed: 12/31/2022] Open
|
49
|
Vourch S, Miglierini P, Miranda O, Malhaire JP, Boussion N, Pradier O, Schick U. Bénéfices de la radiothérapie avec asservissement respiratoire dans le traitement du cancer du sein. Cancer Radiother 2016; 20:30-5. [DOI: 10.1016/j.canrad.2015.09.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Revised: 08/28/2015] [Accepted: 09/11/2015] [Indexed: 10/22/2022]
|
50
|
Boero IJ, Paravati AJ, Triplett DP, Hwang L, Matsuno RK, Gillespie EF, Yashar CM, Moiseenko V, Einck JP, Mell LK, Parikh SA, Murphy JD. Modern Radiation Therapy and Cardiac Outcomes in Breast Cancer. Int J Radiat Oncol Biol Phys 2015; 94:700-8. [PMID: 26972642 DOI: 10.1016/j.ijrobp.2015.12.018] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 11/12/2015] [Accepted: 12/02/2015] [Indexed: 01/10/2023]
Abstract
PURPOSE Adjuvant radiation therapy, which has proven benefit against breast cancer, has historically been associated with an increased incidence of ischemic heart disease. Modern techniques have reduced this risk, but a detailed evaluation has not recently been conducted. The present study evaluated the effect of current radiation practices on ischemia-related cardiac events and procedures in a population-based study of older women with nonmetastatic breast cancer. METHODS AND MATERIALS A total of 29,102 patients diagnosed from 2000 to 2009 were identified from the Surveillance, Epidemiology, and End Results-Medicare database. Medicare claims were used to identify the radiation therapy and cardiac outcomes. Competing risk models were used to assess the effect of radiation on these outcomes. RESULTS Patients with left-sided breast cancer had a small increase in their risk of percutaneous coronary intervention (PCI) after radiation therapy-the 10-year cumulative incidence for these patients was 5.5% (95% confidence interval [CI] 4.9%-6.2%) and 4.5% (95% CI 4.0%-5.0%) for right-sided patients. This risk was limited to women with previous cardiac disease. For patients who underwent PCI, those with left-sided breast cancer had a significantly increased risk of cardiac mortality with a subdistribution hazard ratio of 2.02 (95% CI 1.23-3.34). No other outcome, including cardiac mortality for the entire cohort, showed a significant relationship with tumor laterality. CONCLUSIONS For women with a history of cardiac disease, those with left-sided breast cancer who underwent radiation therapy had increased rates of PCI and a survival decrement if treated with PCI. The results of the present study could help cardiologists and radiation oncologists better stratify patients who need more aggressive cardioprotective techniques.
Collapse
Affiliation(s)
- Isabel J Boero
- Department of Radiation Medicine and Applied Sciences, Moores Cancer Center, University of California, San Diego, La Jolla, California
| | - Anthony J Paravati
- Department of Radiation Medicine and Applied Sciences, Moores Cancer Center, University of California, San Diego, La Jolla, California
| | - Daniel P Triplett
- Department of Radiation Medicine and Applied Sciences, Moores Cancer Center, University of California, San Diego, La Jolla, California
| | - Lindsay Hwang
- Department of Radiation Medicine and Applied Sciences, Moores Cancer Center, University of California, San Diego, La Jolla, California
| | - Rayna K Matsuno
- Department of Radiation Medicine and Applied Sciences, Moores Cancer Center, University of California, San Diego, La Jolla, California
| | - Erin F Gillespie
- Department of Radiation Medicine and Applied Sciences, Moores Cancer Center, University of California, San Diego, La Jolla, California
| | - Catheryn M Yashar
- Department of Radiation Medicine and Applied Sciences, Moores Cancer Center, University of California, San Diego, La Jolla, California
| | - Vitali Moiseenko
- Department of Radiation Medicine and Applied Sciences, Moores Cancer Center, University of California, San Diego, La Jolla, California
| | - John P Einck
- Department of Radiation Medicine and Applied Sciences, Moores Cancer Center, University of California, San Diego, La Jolla, California
| | - Loren K Mell
- Department of Radiation Medicine and Applied Sciences, Moores Cancer Center, University of California, San Diego, La Jolla, California
| | - Sahil A Parikh
- University Hospitals Case Medical Center, Harrington Heart and Vascular Institute, and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - James D Murphy
- Department of Radiation Medicine and Applied Sciences, Moores Cancer Center, University of California, San Diego, La Jolla, California.
| |
Collapse
|