Multidisciplinary Strategy for Managing Cardiovascular Risks When Treating Patients with Early Breast Cancer

Living with the dilemma of the treatment for human epidermal growth factor receptor 2-positive breast cancer and the risk of incident heart disease: A qualitative investigation of patients' experiences

OBJECTIVE

Herceptin treatment improves survival and reduces the risk of recurrence in human epidermal growth factor receptor 2 (HER2)-positive breast cancer. Yet, it increases women's risk of developing burdensome cardiovascular complications. This study examines how women experience living with HER2-positive breast cancer and the risk of incident heart disease.

METHODS

Danish women with breast cancer (n = 12; aged 32-75) participated in semi-structured interviews. Themes were deducted using interpretative phenomenological analysis (IPA).

RESULTS

Women described breast cancer as having strong associations with death, whereas heart disease to them meant decreased physical functioning or "something fixable." MUGA scans of the heart during the treatment course made them feel safe, and generally, they did not worry about risk of heart disease. Coping strategies included the following: focus on the good aspects of herceptin and acceptance of risk of heart disease as the price to pay to survive. The two most predominant coping strategies used were information and avoidance.

CONCLUSION

The women's focus on cancer as the primary disease seems partly to be the result of a complex coping process, by which they dealt with the dilemma of weighing risks, where the risk of dying from breast cancer was perceived as the biggest risk.

Capecitabine in Elderly Patients with Metastatic Breast Cancer

Aims and background

Capecitabine is the reference treatment for anthracycline-and/or taxane-pretreated metastatic breast cancer (MBC). This study examined its efficacy, tolerability and impact on the quality of life of elderly patients with MBC.

Materials and methods

Between January 2002 and December 2009, 75 consecutive elderly patients with MBC received first-line chemotherapy with capecitabine 1000 mg/m2 twice daily for 14 days every 3 weeks. Endpoints were efficacy, tolerability and clinical-benefit response measured every 3 cycles.

Results

Median age was 76 years (range 65–88); median ECOG performance status was 1 (range 0–2); 51 patients (68%) had received adjuvant chemotherapy and all patients had received hormonal therapy. Median exposure was 6 cycles. After 3 cycles, 11 patients (14.7%) had a partial response, one patient experienced a complete response, and 49 patients (65.3%) had stable disease, amounting to a disease control rate of 81.3%. Stable disease was maintained in 45 patients (60%) after 6 cycles, in 21 patients (28%) after 9 cycles, and in 13 patients (17.3%) after 12 cycles. A clinical-benefit response was experienced by 42 patients (56%), indicating a positive impact on quality of life. Treatment was well tolerated, the most common grade 3 events being diarrhea (12%) hand-foot syndrome (8%), and mucositis (8%). Adverse events were managed with dose adjustments and supportive therapy when required.

Conclusions

Our results indicate that capecitabine is active and well tolerated in elderly patients with MBC. This dosing regimen warrants further study in the first-line setting for patients with less aggressive MBC who are not candidates for combination therapy.

Myocardial infarction, ischaemic stroke and pulmonary embolism before and after breast cancer hospitalisation

We studied the occurrence of myocardial infarction (MI), ischaemic stroke (IS) and pulmonary embolism (PE) before and after breast cancer hospitalisation compared with cancer-free controls. For this, women with a first breast cancer hospitalisation during 2000–2007 were selected from the PHARMO Record Linkage System, including drug use and hospitalisations of three million inhabitants in the Netherlands, and matched 1:10 by age to cancer-free women. The occurrence of MI, IS and PE were assessed in the 12 months before and after breast cancer hospitalisation. The study included 11,473 breast cancer patients, with a mean (± SD) age of 59 (± 14) years. Breast cancer patients were two to three times as likely as their cancer-free controls to have had a hospitalisation for PE, MI or IS in the 12 months before diagnosis, though prevalence was <1% in all groups. Breast cancer patients experienced an extreme high risk of PE in the first six months after diag- nosis (hazard ratio [HR] 23.5, 95% confidence interval [CI] 11.1–49.7 compared to controls), which declined gradually to a four times increased risk (HR 3.6, 95%CI 2.4–5.5) more than 12 months after breast cancer hospitalisation. However, incidence was low: less than five events per 1,000 person years during all time periods. For MI and IS we did not observe significant increased HRs after breast cancer hospitalisation compared to controls. Breast cancer patients seem to have a higher risk profile to develop MI and IS, and receive treatment that increases the risk of PE compared to cancer-free controls, although the frequency of hospitalisations was low.

Rationale and design of the multidisciplinary team IntervenTion in cArdio-oNcology study (TITAN)

BACKGROUND

Cancer is the leading cause of premature death in Canada. In the last decade, important gains in cancer survival have been achieved by advances in adjuvant treatment. However, many oncologic treatments also result in cardiovascular "toxicity". Furthermore, cardiac risk factors such as hypertension, dyslipidemia, and diabetes mellitus are known to contribute to the progression of cardiac damage and clinical cardiotoxicity. As such, for many survivors, the risk of death from cardiac disease exceeds that of recurrent cancer. While provision of care by multidisciplinary teams has been shown to reduce mortality and hospitalizations among heart failure patients, the effect of assessments and interventions by multidisciplinary specialists in cancer patients receiving cardiotoxic chemotherapy regimens is currently unknown. Accordingly, we will examine the effect of a multi-disciplinary team interventions in the early assessment, identification and treatment of cardiovascular risk factors in cancer patients receiving adjuvant systemic therapy. Our main hypothesis is to determine if the incidence of LV dysfunction in cancer patients undergoing adjuvant therapy can be reduced through a multidisciplinary team approach.

METHODS/DESIGN

This is a randomized study comparing intensive multidisciplinary team intervention to usual care in the prevention of LV remodeling in patients receiving anthracycline or trastuzumab-based chemotherapy. Main objectives include early detection strategies for cardiotoxicity using novel biomarkers that reflect myocardial injury, remodeling and/or dysfunction; early identification and intensive treatment of cardiovascular risk factors; and early intervention with supportive care strategies including nutritional and pharmacist counselling, exercise training and cardiology team support. Secondary objectives include correlation of novel biomarkers to clinical outcomes; correlation of multidisciplinary interventions to adverse clinical outcomes; relationship of multidisciplinary interventions and chemotherapy dose density; preservation of lean muscle mass; and patient reported outcomes (symptom intensity and quality of life).

DISCUSSION

Cardiac toxicity as a result of cancer therapies is now recognized as a significant health problem of increasing prevalence. To our knowledge, TITAN will be the first randomized trial examining the utility of multidisciplinary team care in the prevention of cardiotoxicity. We expect our results to inform comprehensive and holistic care for patients at risk for negative cancer therapy mediated sequelae.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01621659 Registration Date 4 June 2012.

Genome-based risk prediction for early stage breast cancer

Tests to better characterize tumor genomic architecture are quickly becoming a standard of care in oncology. For breast cancer, the use of gene expression assays for early stage disease is already common practice. These tests have found a place in risk stratifying the heterogeneous group of stage I-II breast cancers for recurrence, for predicting chemotherapy response, and for predicting breast cancer-related mortality. In the last 5 years, more assays have become available to the practicing oncologist. Given the rapidity with which this field has evolved, it is prudent to review the tests, their indications, and the studies from which they have been validated. We present a comprehensive review of the available gene expression assays for early stage breast cancer. We review data for several individual tests and comparative studies looking at risk prediction and cost-effectiveness.

Evaluation of early subclinical cardiotoxicity of chemotherapy in breast cancer

Objective:

Cardiac effects of chemotherapy are usually recognized after clinical symptom or sign occurrence in patients with breast cancer. In this study, we aimed to determine the potential subclinical cardiotoxic effects of chemotherapy that were given lower dosage than well known cardiac safety dosage limits in patients with breast cancer during early period.

Methods:

Fifty-one patients consecutively enrolled to this prospective cohort study. All patients were diagnosed as breast cancer at oncology hospital in University of Gaziantep. Before chemotherapy, all of the patients underwent to detailed ECG and echocardiography (ECHO) examinations. After 6 months, detailed ECG and ECHO examinations were repeated and compared with baseline values. Statistical analysis was performed using Shapiro-Wilk tests, Student t-test and Spearman correlation test.

Results:

The average age of patients was 51 and one was male. Statistically significant decrease in ejection fraction was found after treatment (62.3%±3.3 and 59.9%±5.9, p=0.002). Evaluation of diastolic parameters; significant increase in the transmitral A flow velocity and significant decrease of E/A ratio were observed on Doppler ECHO analysis (77.4±19.1 cm/sec versus 86±18 cm/sec, p<0.001; 1.01±0.3 versus 0.9±0.2, p=0.03, respectively). On tissue Doppler analysis we observed that significant reduction in the value of E’ and significantly increase E/E’ ratio were present (12.5±3.6 cm/sec versus 10.7±2.9 cm/sec, p=0.001; 6.6±2.9 versus 7.7±3.3, p=0.04, respectively).

Conclusion:

Chemotherapy has detrimental subclinical effect on both of systolic and diastolic function in early six months period despite the prescription of lower dosage of chemotherapy than well-known cardiac safety dosage limits. Tissue Doppler imaging may be more sensitive than ECG, conventional ECHO and Doppler for determining the subclinical cardiac damage.

Apoptosis induction of cardiomyocytes and subsequent fibrosis after irradiation and neoadjuvant chemotherapy

PURPOSE

Breast cancer treatments can induce important cardiovascular complications. The aim of this study was to evaluate cardiac alterations after irradiation and chemotherapy in an animal model.

MATERIAL AND METHODS

Wistar rats were divided into three groups: Control, TC+ IR (received chemotherapy and irradiation) and IR (received only irradiation). After 5 months, echocardiography was performed, the animals were euthanized, and the left ventricle was analyzed using light microscopy techniques and Polymerase Chain Reaction (PCR).

RESULTS

Echocardiography showed decreases in ejection fraction and cardiac output, in TC+ IR group. Both TC+ IR and IR showed reduced intramyocardial vessel-to-cardiomyocyte ratio, increased connective tissue, cardiomyocyte hypertrophy, increased numbers of apoptotic nuclei and increased Bax/Bcl2 expression. We also observed increased Transforming growth factor (TGF) beta 1 mRNA expression in both groups, but type 1 Procollagen expression was increased in TC+ IR group only.

CONCLUSIONS

The study suggests that the induced cardiac remodelling begins with the reduction of intramyocardial vessels in the left ventricle tissue. The main consequence is the loss of cardiomyocytes through apoptosis, leading to the replacement of healthy tissue by fibrous tissue. It was observed that the damage caused by the combination of irradiation and chemotherapy induced functional alterations that did not occur when the animals were only irradiated.

Cardiac toxicity of anticancer agents

Modern cancer therapies are highly effective in the treatment of various malignancies, but their use is limited by the potential for cardiotoxicity. The most frequent and typical clinical manifestation of cardiotoxicity is left ventricular dysfunction, induced not only by cytotoxic conventional cancer therapy like anthracyclines, but also by new antitumor targeted therapy such as trastuzumab. The current standard for monitoring cardiac function, based on periodic assessment of left ventricular ejection fraction detects cardiotoxicity only when a functional impairment has already occurred, precluding any chance of preventing its development. A novel approach, based on the use of cardiac biomarkers has emerged in the last decade, resulting in a cost-effective diagnostic tool for early, real-time identification, assessment and monitoring of cardiotoxicity. In particular, prophylactic treatment with enalapril in patients with an early increase in troponin after chemotherapy has been shown to be very effective in preventing left ventricular dysfunction and associated cardiac events. In patients developing cancer treatment induced-cardiomyopathy, complete left ventricular ejection fraction recovery and a reduction of cardiac events may be achieved only when left ventricular dysfunction is detected early after the end of cancer treatment and treatment with angiotensin-converting enzyme inhibitors, possibly in combination with beta-blockers, is promptly initiated.

Using cardiac biomarkers and treating cardiotoxicity in cancer

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

Phase I trial of exemestane in combination with metformin and rosiglitazone in nondiabetic obese postmenopausal women with hormone receptor-positive metastatic breast cancer

PURPOSE

Obese women with breast cancer have worse prognosis than women with normal body mass index. Endocrine therapy resistance is in part mediated by insulin resistance in obese women with breast cancer. We investigated the tolerability and pharmacokinetics of exemestane in combination with metformin and rosiglitazone in nondiabetic overweight and obese postmenopausal women with hormone receptor-positive metastatic breast cancer.

METHODS

Patients had previously received chemotherapy and endocrine therapy for breast cancer. Exemestane was given as 25 mg orally per day. Metformin (M) and rosiglitazone (R) were given twice daily. Dose level 1 consisted of M 1,500 mg/day and R 6 mg/day. Dose level 2 consisted of M 2,000 mg/day and R 8 mg/day. Plasma concentrations of exemestane were measured on days 1, 8, and 15.

RESULTS

Twenty patients were enrolled. Fourteen patients received exemestane, metformin, and rosiglitazone. Six patients received exemestane with metformin only (2,000 mg/day). Both regimens were well tolerated at the highest doses tested, and there were no notable changes in plasma exemestane levels. Six patients (30%) had stable disease for 6 months or longer.

CONCLUSIONS

Oral daily administration of exemestane (25 mg) and metformin (2,000 mg) with and without rosiglitazone (8 mg) daily was well tolerated. Exemestane pharmacokinetics were not altered by metformin and rosiglitazone.

Putting the cardiovascular safety of aromatase inhibitors in patients with early breast cancer into perspective: a systematic review of the literature

In the adjuvant setting, the third-generation aromatase inhibitors (AIs) anastrozole, letrozole and exemestane are recommended at some point during treatment, either in the upfront, switch after tamoxifen or extended treatment setting after tamoxifen in postmenopausal patients with hormone receptor-positive early breast cancer. AIs have demonstrated superior disease-free survival and overall benefit-to-risk profiles compared with tamoxifen. Potential adverse events, including cardiovascular (CV) side effects, should be considered in the long-term management of patients undergoing treatment with AIs. AIs reduce estrogen levels by inhibiting the aromatase enzyme, thus reducing the levels of circulating estrogen. This further reduction in estrogen levels may potentially increase the risk of developing CV disease. This systematic review evaluated published clinical data for changes in plasma lipoproteins and ischaemic CV events during adjuvant therapy with AIs in patients with hormone receptor-positive early breast cancer. The electronic databases MEDLINE, EMBASE, Derwent Drug File and BIOSIS were searched to identify English-language articles published from January 1998 to 15 April 2011 that reported data on AIs and plasma lipoproteins and/or ischaemic CV events. Overall, available data did not show any definitive patterns or suggest an unfavourable effect of AIs on plasma lipoproteins from baseline to follow-up assessment in patients with hormone receptor-positive early breast cancer. Changes that occurred in plasma lipoproteins were observed soon after initiation of AI therapy and generally remained stable throughout the studies. Available data do not support a substantial risk of ischaemic CV events associated with adjuvant AI therapy; however, studies with longer follow-up are required to better characterize the CV profile of AIs.

Lifestyle interventions for cardiovascular risk reduction in women with breast cancer

PURPOSE

The purpose of this paper is to identify risk factors for cardiovascular disease in women with breast cancer and review healthy lifestyle behaviors as essential risk reduction strategies.

FINDINGS

Women with breast cancer account for 22% of the 12 million cancer survivors. Women diagnosed with breast cancer often present with modifiable and non-modifiable cardiovascular risk factors and/or pre-existing co-morbid illness. Any one or a combination of these factors may increase the risk of cardiovascular disease. There is strong evidence that healthy eating and routine physical activity can reduce cardiovascular disease. Exercise improves cardiovascular fitness, body composition and quality of life in breast cancer survivors and observational studies suggest a survival benefit.

CLINICAL IMPLICATIONS

Lifestyle interventions including a healthy diet, regular physical activity, weight management and smoking cessation should be integrated into a survivorship care plan to reduce cardiovascular disease risk and promote better health for women with breast cancer.

Cardiotoxicity of molecularly targeted agents

Cardiac toxicity of molecularly targeted cancer agents is increasingly recognized as a significant side effect of chemotherapy. These new potent therapies may not only affect the survival of cancer cells, but have the potential to adversely impact normal cardiac and vascular function. Unraveling the mechanisms by which these therapies affect the heart and vasculature is crucial for improving drug design and finding alternative therapies to protect patients predisposed to cardiovascular disease. In this review, we summarize the classification and side effects of currently approved molecularly targeted chemotherapeutics.

Cardiovascular complications of breast cancer therapy in older adults

Older adults frequently have pre-existing and cancer-related risk factors for cardiovascular toxicity from cancer treatment. In this review, we discuss the risk factors and strategies for prevention and management of cardiovascular complications in older women with breast cancer.

Late effects of breast cancer treatment and potentials for rehabilitation

BACKGROUND

Breast cancer is the most frequent malignant disease among women world wide. Survival has been improving leading to an increasing number of breast cancer survivors, in the US estimated to about 2.6 million.

MATERIAL AND METHODS

The literature was reviewed with focus on data from the Nordic countries.

RESULTS

Local therapies such as breast cancer surgery and radiotherapy may cause persistent pain in the breast area, arm, and shoulder reported by 30-50% of patients after three to five years, lymphedema in 15-25% of patients, and restrictions of arm and shoulder movement in 35%. Physiotherapy is the standard treatment for the latter while no pain intervention trials have been published. Chemotherapy may cause infertility and premature menopause, resulting in vasomotor symptoms, sexual dysfunction, and osteoporosis, which are similar to the side effects of endocrine treatment in postmenopausal women. Awareness of cardiotoxicity is needed since anthracyclines, trastuzumab, and radiotherapy can damage the heart. Breast cancer survivors have an increased risk of a major depression and far from all receive adequate anti-depressive treatment. Other psychological symptoms include fear of recurrence, sleep disturbances, cognitive problems, fatigue, and sexual problems.

DISCUSSION

To improve rehabilitation, specific goals have to be formulated into national guidelines and high priority directed towards research into developing and testing new interventions for alleviating symptoms and side effects experienced by breast cancer survivors.

Cardiovascular effects of systemic cancer treatment

Many methods of systemic anticancer treatment have detrimental effects on the cardiovascular system, thus limiting the possibility of further therapy, worsening patients' quality of life and increasing mortality. The best recognized and most clinically relevant is the cardiotoxicity of anthracyclines. Other cytotoxic drugs associated with significant risk of cardiovascular complications include alkylating agents, 5-fluorouracil and paclitaxel. Cardiovascular adverse effects are also associated with the use of targeted therapies, such as trastuzumab, bevacizumab and tyrosine kinase inhibitors, and some of the drugs used in the treatment of hematological malignancies, such as all-trans-retinoic acid and arsenic trioxide. The most serious cardiac complication of anticancer therapy is congestive heart failure, associated predominantly with the use of anthracyclines, trastuzumab and high-dose cyclophosphamide. Myocardial ischemia is mainly caused by antimetabolite and interferon alpha treatment. Other adverse effects may include hypotension, hypertension, arrhythmias and conduction disorders, edema, pericarditis and thrombo-embolic complications. The aim of this review is to summarize and critically analyze the available evidence on the cardiovascular toxicity of systemic anticancer therapies, with particular attention to the recently recognized adverse effects of targeted therapies.

Reversibility of left ventricular dysfunction resulting from chemotherapy: can this be expected?

Recent advances in cancer management have improved long-term survival. Increased longevity has been accompanied by a rise in the frequency of age-related cardiovascular disease and treatment-related cardiotoxicity. Chemotherapy-related left ventricular dysfunction has historically been considered resistant to conventional therapy and to carry a poorer prognosis than other cardiomyopathies. However, these conclusions were drawn primarily from trials that predate contemporary heart failure therapy and where treatment was often initiated only after the development of symptoms. More recent data suggest that selected forms of chemotherapy-related cardiomyopathy are, to some degree, reversible, but response is dependent on early detection and prompt intervention. This challenges us to develop more sophisticated risk stratification and monitoring strategies that include symptom detection, noninvasive imaging, and carefully applied biomarkers. This paradigm also suggests that a multidisciplinary team of cardiologists and oncologists may provide more comprehensive care to this complex patient population.

Developing a cardiology-oncology clinical practice guideline

Clinical Practice Guidelines (CPG) have become an increasingly common method to assist practitioner and patient decisions about health care for specific medical problems. CPGs generally address a single medical diagnosis or syndrome leaving practitioners and patients with little guidance when two major medical diagnoses exist such as in the case of heart disease and cancer. As cancer and heart disease are both diseases of the elderly and share many common risk factors it is likely they will coexist in many patients. Thus screening for and preventing and treating heart disease in the cancer patient assumes increasing importance as aggressive cancer therapies are applied to older patients and as a growing number of cardiovascular side effects of anti-cancer therapy are described. Careful evaluation of heart disease in the cancer patient will likely improve quality of life but may also improve mortality as the presence or development of heart disease may significantly limit life-saving cancer therapies. The rationale, potential problems, and important steps in developing a cardiology-oncology guideline are discussed.

Cardiac toxicity in breast cancer patients: from a fractional point of view to a global assessment

When focusing on heart disease, most available studies split the two different parts of the adjuvant treatment, i.e., systemic therapies and radiation therapy, making it difficult to implement efficient strategies for preventing treatment-induced cardiac toxicity. This paper reviews the current understanding of treatments-induced cardiac toxicity in a global approach. Many factors should be considered when assessing the cardiac hazard. Treatment-related risk factors include heart dose exposure, chemotherapy, targeted agents such as HER2 inhibitors, but also endocrine agents, or anesthetic procedure. Patients' characteristics should also be taken into account. Age, menopausal status, stress, previous history of cardiac disease, genetic profile, and body mass index could all impact on cardiac function after adjuvant therapies. Cardiac toxicity should not be analyzed as the consequence of a specific therapy, but should be considered as the result of additive or supra-additive toxicities. By this way, it will be possible to implement new strategies for preventing treatment-induced cardiac toxicity.

Caring for the breast cancer survivor: a guide for primary care physicians

Breast cancer accounts for more than 25% of cancers in women. Because of improved screening and treatment modalities, mortality has decreased significantly. Currently, over 2.5 million breast cancer survivors live in the US and receive care from a primary care provider. Providers need to be aware of common and serious complications of breast cancer treatment. In this review we discuss complications of local and systemic treatment for breast cancer, including lymphedema, osteoporosis, cardiovascular disease, and vasomotor symptoms. Current strategies for screening, monitoring, and treating these complications also are outlined.

Cardiotoxicity of anticancer drugs: the need for cardio-oncology and cardio-oncological prevention

Due to the aging of the populations of developed countries and a common occurrence of risk factors, it is increasingly probable that a patient may have both cancer and cardiovascular disease. In addition, cytotoxic agents and targeted therapies used to treat cancer, including classic chemotherapeutic agents, monoclonal antibodies that target tyrosine kinase receptors, small molecule tyrosine kinase inhibitors, and even antiangiogenic drugs and chemoprevention agents such as cyclooxygenase-2 inhibitors, all affect the cardiovascular system. One of the reasons is that many agents reach targets in the microenvironment and do not affect only the tumor. Combination therapy often amplifies cardiotoxicity, and radiotherapy can also cause heart problems, particularly when combined with chemotherapy. In the past, cardiotoxic risk was less evident, but it is increasingly an issue, particularly with combination therapy and adjuvant therapy. Today's oncologists must be fully aware of cardiovascular risks to avoid or prevent adverse cardiovascular effects, and cardiologists must now be ready to assist oncologists by performing evaluations relevant to the choice of therapy. There is a need for cooperation between these two areas and for the development of a novel discipline, which could be termed cardio-oncology or onco-cardiology. Here, we summarize the potential cardiovascular toxicities for a range of cancer chemotherapeutic and chemopreventive agents and emphasize the importance of evaluating cardiovascular risk when patients enter into trials and the need to develop guidelines that include collateral effects on the cardiovascular system. We also discuss mechanistic pathways and describe several potential protective agents that could be administered to patients with occult or overt risk for cardiovascular complications.

Cardiac dysfunction induced by novel targeted anticancer therapy: an emerging issue

Increasing use of targeted anticancer agents that inhibit tyrosine kinase signaling (monoclonal antibodies or tyrosine kinase inhibitors) has dramatically improved the survival of patients with malignancies. However, cardiotoxicity, including heart failure, left ventricular dysfunction, hypertension, myocardial infarction, and thromboembolism, has occurred. Importantly, these cardiotoxicities are at least partially reversible and responsive to medical management. Early recognition of cardiovascular side effects is vital to allow long-term, continuous therapy with these life-prolonging agents. This article reviews potential cardiovascular side effects of frequently used inhibitors of tyrosine kinase activity (eg, trastuzumab, sunitinib) and discusses the diagnosis and management of cardiotoxicity associated with targeted therapy.