A Prospective Cohort Study on Cardiotoxicity of Adjuvant Trastuzumab Therapy in Breast Cancer Patients

Risk factors from Framingham risk score for anthracyclines cardiotoxicity in breast cancer: A systematic review and meta-analysis

Background

Framingham risk score (FRS) is an effective tool for evaluating the 10-year risk of cardiovascular diseases. However, the sensitivity of FRS for anthracycline-induced cardiotoxicity is unclear. This meta-analysis aims to evaluate the correlation between risk factors (hypertension, hyperlipidemia, diabetes, smoking, and obesity) in FRS and anthracycline-induced cardiotoxicity in breast cancer.

Methods

We searched PubMed, EMBASE, and Cochrane Library for studies published from inception to January 2022 which reported cardiotoxicity due to anthracycline. Cardiotoxicity defined as any cardiac events were used as the primary endpoint. A total of 33 studies involving 55,708 breast cancer patients treated with anthracyclines were included in this meta-analysis.

Results

At least one risk factor was identified at baseline for the 55,708 breast cancer patients treated with anthracycline. Hypertension [I 2 = 45%, Fixed, RR (95% CI) = 1.40 (1.22, 1.60), p < 0.00001], hyperlipidemia [I 2 = 0%, Fixed, RR (95% CI): 1.35 (1.12, 1.62), p = 0.002], diabetes [I 2 = 0%, Fixed, RR (95% CI): 1.29 (1.05, 1.57), p = 0.01], and obesity [I 2 = 0%, Fixed, RR (95% CI): 1.32 (1.05, 1.67), p = 0.02] were associated with increased risks of cardiac events. In addition, smoking was also associated with reduced left ventricular ejection fraction (LVEF) during anthracycline chemotherapy [I 2 = 0%, Fixed, OR (95% CI): 1.91 (1.24, 2.95), p = 0.003] in studies that recorded only the odds ratio (OR).

Conclusion

Hypertension, hyperlipidemia, diabetes, smoking, and obesity are associated with increased risks of anthracycline-induced cardiotoxicity. Therefore, corresponding measures should be used to manage cardiovascular risk factors in breast cancer during and after anthracycline treatment.

Chemotherapy-associated steatohepatitis was concomitant with epicardial adipose tissue volume increasing in breast cancer patients who received neoadjuvant chemotherapy

OBJECTIVES

To investigate the prevalence of chemotherapy-associated steatohepatitis, quantitate the epicardial adipose tissue (EAT) volume in breast cancer patients, and explore the mediating effect of liver fat content on EAT volume in breast cancer patients who received neoadjuvant chemotherapy (NAC).

METHODS

From October 2018 to April 2020, patients were retrospectively reviewed and divided into breast cancer non-NAC and NAC groups. The prevalence of chemotherapy-associated steatohepatitis was evaluated through quantitative MRI mDIXON-Quant examinations by using defined proton density fat fraction cutoffs of liver fat. The EAT volume was quantified on chest CT by semi-automatic volume analysis software. Bootstrap analysis was used in the breast cancer NAC group to test the significance of the mediating effect of liver fat content on EAT volume.

RESULTS

A total of 662 breast cancer patients (non-NAC group: 445 patients; NAC group: 217 patients) were included. The prevalence of chemotherapy-associated steatohepatitis in the NAC group was significantly higher than the prevalence of hepatic steatosis in the non-NAC group (42.8% vs. 33.3%, p < 0.001). EAT volume was measured in 561 of 662 breast cancer patients, and was significantly higher in the NAC group than in the non-NAC group (137.26 ± 53.48 mL vs. 125.14 ± 58.77 mL, p = 0.020). In the breast cancer NAC group, the indirect effect of liver fat content on EAT volume was 2.545 (p < 0.001), and the contribution rate to the effect was 69.1%.

CONCLUSIONS

EAT volume was significantly higher in the BC-NAC group than in the BC-non-NAC group.

KEY POINTS

• The prevalence of CASH was as high as 42.8% in BC patients. • NAC significantly increased the EAT volume in BC patients. • The liver fat content caused the change of EAT volume through mediating effect.

Trastuzumab-induced cardiotoxicity: a review of clinical risk factors, pharmacologic prevention, and cardiotoxicity of other HER2-directed therapies

PURPOSE

Despite great success as a targeted breast cancer therapy, trastuzumab use may be complicated by heart failure and loss of left ventricular contractile function. This review summarizes the risk factors, imaging, and prevention of cardiotoxicity associated with trastuzumab and other HER2-targeted therapies.

FINDINGS

Cardiovascular disease risk factors, advanced age, and previous anthracycline treatment predispose to trastuzumab-induced cardiotoxicity (TIC), with anthracycline exposure being the most significant risk factor. Cardiac biomarkers such as troponins and pro-BNP and imaging assessments such as echocardiogram before and during trastuzumab therapy may help in early identification of TIC. Initiation of beta-adrenergic antagonists and angiotensin converting enzyme inhibitors may prevent TIC. Cardiotoxicity rates of other HER2-targeted treatments, such as pertuzumab, T-DM1, lapatinib, neratinib, tucatinib, trastuzumab deruxtecan, and margetuximab, appear to be significantly lower as reported in the pivotal trials which led to their approval.

CONCLUSIONS

Risk assessment for TIC should include cardiac imaging assessment and should incorporate prior anthracycline use, the strongest risk factor for TIC. Screening and prediction of cardiotoxicity, referral to a cardio-oncology specialist, and initiation of effective prophylactic therapy may all improve prognosis in patients receiving HER2-directed therapy. Beta blockers and ACE inhibitors appear to mitigate risk of TIC. Anthracycline-free regimens have been proven to be efficacious in early HER2-positive breast cancer and should now be considered the standard of care for early HER2-positive breast cancer. Newer HER2-directed therapies appear to have significantly lower cardiotoxicity compared to trastuzumab, but trials are needed in patients who have experienced TIC and patients with pre-existing cardiac dysfunction.

Management strategies and clinical outcomes in breast cancer patients who develop left ventricular dysfunction during trastuzumab therapy

BACKGROUND

Trastuzumab reduces risk of breast cancer recurrence but carries risk of cardiotoxicity that may be reversible upon treatment cessation and institution of left ventricular (LV) enhancement therapies (LVETx). We assessed management patterns of trastuzumab-induced cardiotoxicity (TIC) in a contemporary real-world setting.

METHODS

We reviewed charts of all breast cancer patients who received adjuvant trastuzumab in British Columbia between January 2010 and December 2013, spanning the opening of a cardio-oncology clinic. LV dysfunction (LVD) was classified as minimal (LVEF nadir 45-49%), mild (40-44%) or moderate-severe (< 40%). Charts were reviewed for baseline characteristics, management strategies, and outcomes. Multivariable analysis was performed to identify patient characteristics associated with trastuzumab completion and cardiology referral.

RESULTS

Of 967 patients receiving trastuzumab, 171 (17.7%) developed LVD, including 114 patients (11.8%) with LVEF declines of ≥10 to < 50%. Proportions of patients receiving cardiology referrals and LVETx increased and wait times to consultation decreased after a dedicated cardio-oncology clinic opened. LVETx was used more frequently in patients with moderate-severe LVD compared to minimal or mild LVD. Factors associated with completion of trastuzumab included mastectomy (OR 5.1, 95% CI 1.1-23.0) and proximity to quaternary care centre (OR 7.7, 95% CI 2.2-26.2). Moderate-severe LVD was associated with a lower probability of completing trastuzumab (OR 0.07 vs. minimal LVD, 95% CI 0.01-0.74). Factors associated with cardiology referral included heart failure symptoms (OR 8.0, 95% CI 1.5-42.9), proximity to quaternary care centre (OR 6.8, 95% CI 1.3-34.2), later year of cancer diagnosis (OR 2.4 per year, 95% CI 1.4-4.3), node-positive disease (OR 0.18, 95% CI 0.06-0.56), mastectomy (OR 0.05, 95% CI 0.01-0.52), and minimal LVD (OR 0.14, 95% CI 0.05-0.46). LVEF recovered to > 50% in 90.7% of patients.

CONCLUSIONS

Management strategies in patients with TIC are associated with cancer characteristics and severity of cardiotoxicity. Access to dedicated cardio-oncology clinics may facilitate optimal care of this complex patient population.

Cardiac monitoring in HER2-positive patients on trastuzumab treatment: A review and implications for clinical practice

Trastuzumab prolongs progression-free and overall survival in patients with human epidermal growth factor receptor 2 (HER2) positive breast cancer. However, trastuzumab treatment is hampered by cardiotoxicity, defined as a left ventricular ejection fraction (LVEF) decline with a reported incidence ranging from 3 to 27% depending on variable factors. Early identification of patients at increased risk of trastuzumab-induced myocardial damage is of great importance to prevent deterioration to irreversible cardiotoxicity. Although current cardiac monitoring with multi gated acquisition (MUGA) scanning and/or conventional 2D-echocardiography (2DE) have a high availability, their reproducibility are modest, and more sensitive and reliable techniques are needed such as 3D-echocardiography (3DE) and speckle tracking echocardiography (STE). But which other diagnostic imaging modalities are available for patients before and during trastuzumab treatment? In addition, what is the optimal frequency and duration of cardiac monitoring? At last, which biomarker monitoring strategies are currently available for the identification of cardiotoxicity in patients treated with trastuzumab?

BNP as a marker for early prediction of anthracycline-induced cardiotoxicity in patients with breast cancer

Anthracycline chemotherapy serves an important role in treating patients with breast cancer but is associated with cardiotoxicity. Although brain natriuretic peptide (BNP) is not the ideal marker for detecting the presence of diseases of the heart, several studies have demonstrated the predictive utility of BNP in the diagnosis of anthracycline-induced cardiotoxicity (AIC). The aim of the present study was to evaluate the role of BNP as a marker for the early prediction of AIC in patients with breast cancer. In the present study, a total of 149 patients with breast cancer who received anthracycline therapy were evaluated. The levels of BNP and echocardiography were detected during the anthracycline-based chemotherapy and patients were followed up after chemotherapy to determine the cardiotoxicity-free survival times. In the patients who received chemotherapy, an increase in the levels of BNP was observed. The concentration of BNP was significantly higher in the cardiotoxicity group during anthracycline chemotherapy (P=0.022) compared with the non-cardiotoxicity group and it was an independent predictor of cardiotoxicity (P=0.028). The optimal diagnostic threshold of BNP after the last anthracycline chemotherapy treatment was 107.9 pg/ml, the diagnostic sensitivity was 0.538, the specificity was 0.794, the Youden index was 0.332, the positive predictive value was 0.583 and the negative predictive value was 0.762. Based on the BNP threshold, a log-rank test was performed and it was determined that the cardiotoxicity-free survival rate of the group with higher levels of BNP was always lower compared with the group with lower levels of BNP. BNP elevation was associated with cardiotoxicity during the anthracycline chemotherapy. Detecting BNP after the final treatment of anthracycline chemotherapy may contribute to the early detection of cardiotoxicity.

Global Longitudinal Strain Accuracy for Cardiotoxicity Prediction in a Cohort of Breast Cancer Patients During Anthracycline and/or Trastuzumab Treatment

Background

The high cardiotoxicity morbidity and mortality rates associated with the antineoplastic therapy for breast cancer could be reduced with the early use of cardioprotective drugs. However, the low sensitivity of left ventricular ejection fraction limits its use in that preventive strategy. New parameters, such as global longitudinal strain, are being used in the early detection of contractile function changes.

Objectives

To assess the incidence of cardiotoxicity in patients treated for breast cancer, the independent factors associated with that event, and the ability of strain to identify it early.

Methods

Prospective observational study of consecutive outpatients diagnosed with breast cancer, with no previous antineoplastic treatment and no ventricular dysfunction, who underwent anthracycline and/or trastuzumab therapy. The patients were quarterly evaluated on a 6- to 12-month follow-up by an observer blind to therapy. Cox regression was used to evaluate the association of cardiotoxicity with clinical, therapeutic and echocardiographic variables. A ROC curve was built to identify the strain cutoff point on the third month that could predict the ejection fraction reduction on the sixth month. For all tests, the statistical significance level adopted was p ≤ 0.05.

Results

Of 49 women (mean age, 49.7 ± 12.2 years), cardiotoxicity was identified in 5 (10%) on the third (n = 2) and sixth (n = 3) months of follow-up. Strain was independently associated with the event (p = 0.004; HR = 2.77; 95%CI: 1.39-5.54), with a cutoff point for absolute value of -16.6 (AUC = 0.95; 95%CI: 0.87-1.0) or a cutoff point for percentage reduction of 14% (AUC = 0.97; 95%CI: 0.9-1.0).

Conclusion

The 14% reduction in strain (absolute value of -16.6) allowed the early identification of patients who could develop anthracycline and/or trastuzumab-induced cardiotoxicity.

Prevalence and risk factors of atrial fibrillation during lung and esophageal surgery: A Prospective observational study

The aim of this prospective observational study was to screen for risk factors of intraoperative atrial fibrillation (AF) during noncardiac thoracic surgery. The study was conducted as a single-institution study in Zhejiang Cancer Hospital, Hangzhou, China. All the participants were patients with cancer scheduled for thoracotomy.This study was conducted from July 2013 to August 2016 and included 144 patients scheduled for thoracotomy under general anesthesia. We collected the patients' demographic and perioperative medical data in our hospital. AF was diagnosed using electrocardiography (ECG), on the basis of the presence of characteristic ECG features of AF by one or more ECG leads for at least 30 seconds.Of the participants, 144 completed the study and 18 developed intraoperative AF. Higher percentages of subjects in the AF group than in the non-AF group had histories of chemotherapy (P = .014) and alcohol consumption (P = .034) before surgery. The AF group had a lower mean body mass index (P = .019), significantly higher mean heart rate (P < .001), and lower tidal volume (P = .01) than the non-AF group. After the logistic regression analysis, only alcohol consumption (odds ratio [OR] = 5.279; 95% confidence interval [CI]: 1.432-19.467), history of chemotherapy (OR = 4.019; 95% CI: 1.504-15.334), and high heart rate (OR = 1.093; 95% CI: 1.033-1.156) during 1-lung ventilation were identified as the risk factors of AF during lung and esophageal surgeries.The incidence of intraoperative AF during noncardiac thoracic surgery was 12.5%. Alcohol consumption, history of chemotherapy, and high heart rate during 1-lung ventilation were the risk factors related to intraoperative AF.