Imaging and biomarkers combined may be valuable in the detection of cardiotoxicity. For example, a change in longitudinal strain and troponin I at 3 months after doxorubicin chemotherapy predicted cardiotoxicity at the 6-month follow-up.9 In addition, the number of segments with change in longitudinal strain at 3 months predicted cardiotoxicity.9

If a patient is older than 60 years at the time of cancer treatment, has at least 2 CVD risk factors during or after treatment (eg, diabetes, dyslipidemia, hypertension, obesity, or smoking), or has a history of myocardial infarction, moderate valvular disease, or low-normal left ventricular function (50%-55%) before or after treatment, she is considered at increased risk for cardiotoxicity.1


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Future Directions

The AHA called for the following actions to improve outcomes:

  • Improved screening and risk factor assessment in people being treated for cancer
  • Development of oncologic therapies with limited adverse CVD effects
  • Better understanding of combined chemotherapy and radiotherapy effects on CVD
  • Earlier detection of CVD effects
  • Terminology consistency to describe cardiovascular effects and use in clinical trials as end points
  • Formal guidelines for cardiotoxicity prevention
  • Reduction in racial disparities in CVD outcomes and increased access to care
    Creation of a national or international database on cardiovascular and oncologic outcomes1

To gain more insight into the connection between CVD and breast cancer and to help clinicians optimize patient care, Cardiology Advisor interviewed Paula Klein, MD, medical director of Breast Cancer Clinical Trials at the Mount Sinai Health System in New York City, New York.

Cardiology Advisor: In patients receiving high-dose chemotherapy associated with cardiotoxicity (including doxorubicin ≥250 mg/m2 or epirubicin ≥600 mg/m2), do you recommend routine screening of left ventricular function at predetermined intervals without any clinical symptoms?

Dr Klein: For those patients who will be treated with adjuvant adriamycin and cytoxan, a baseline echocardiogram or MUGA is done for cardiac clearance. This is not repeated unless clinically indicated.

For those patients who will be treated with curative intent trastuzumab and pertuzumab, a baseline echocardiogram or MUGA is done for cardiac clearance and is then repeated quarterly while patients are on treatment.

Cardiology Advisor: How is this determination guided by patient-specific factors, including the identification that cardiotoxicity is more likely to develop in certain patients (including older age, ≥2 CVD risk factors during or after cancer treatment: diabetes mellitus, dyslipidemia, hypertension, obesity, smoking, history of myocardial infarction, moderate valvular disease)?

Dr Klein: We certainly take into account preexisting risk factors for heart disease. Specifically, age and uncontrolled hypertension have been associated with trastuzumab-induced cardiotoxicity. These preexisting factors are also considered in predicting the most likely cause of mortality over 10 years and if it is not breast cancer, then treatments can be tailored accordingly. Treatment is usually less aggressive and may involve omission of cardiotoxic agents.

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Cardiology Advisor: For cardiotoxicity screening, can you discuss your clinical decision making with regard to when MUGA scanning and cardiac magnetic resonance imaging are necessary in addition to standard echocardiography?

Dr Klein: Our standard is to order an echocardiogram, as this does not involve venipuncture (MUGA uses intravenous contrast) and it spares the arms of patients who have had axillary surgery as part of their surgical management. There are occasions when an echocardiogram cannot be done technically and then a MUGA scan is preferred.

Cardiology Advisor: Because there are currently no consensus-based definitive guidelines addressing CVD prevention in patients with breast cancer, how should oncologists and cardiologists approach preventive care appointments? 

Dr Klein: We always encourage patients to follow up with their primary care physician for routine health maintenance, which may include lipid profiles and other risk factors for future CVD (eg, hypertension, diabetes).

References

  1. Mehta LS, Watson KE, Barac A, et al; for the American Heart Association Cardiovascular Disease in Women and Special Populations Committee of the Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; and Council on Quality of Care and Outcomes Research. Cardiovascular disease and breast cancer: where these entities intersect: a scientific statement from the American Heart Association. Circulation. 2018;137(8):e30-e66.
  2. Benjamin EJ, Blaha MJ, Chiuve SE, et al; on behalf of the American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics: 2017 update: a report from the American Heart Association [published corrections appear in Circulation. 2017;135:e646 and Circulation. 2017;136:e196]. Circulation. 2017;135:e146-e603.
  3. Cancer stat facts: female breast cancer. Surveillance, Epidemiology, and End Results Program website. https://seer.cancer.gov/statfacts/html/breast.html. Accessed April 18, 2018.
  4. Heidenreich PA, Trogdon JG, Khavjou OA, et al; on behalf of the American Heart Association Advocacy Coordinating Committee; Stroke Council; Council on Cardiovascular Radiology and Intervention; Council on Clinical Cardiology; Council on Epidemiology and Prevention; Council on Arteriosclerosis; Thrombosis and Vascular Biology; Council on Cardiopulmonary; Critical Care; Perioperative and Resuscitation; Council on Cardiovascular Nursing; Council on the Kidney in Cardiovascular Disease; Council on Cardiovascular Surgery and Anesthesia, and Interdisciplinary Council on Quality of Care and Outcomes Research.  Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association. Circulation. 2011;123(8):933-944.
  5. Mariotto AB, Yabroff KR, Shao Y, Feuer EJ, Brown ML. Projections of the cost of cancer care in the United States: 2010-2020. J Natl Cancer Inst. 2011;103:117-128.
  6. Hvidtfeldt UA, Tolstrup JS, Jakobsen MU, et al. Alcohol intake and risk of coronary heart disease in younger, middle-aged, and older adults. Circulation. 2010;121:1589-1597.
  7. Armstrong ME, Green J, Reeves GK, et al; on behalf of the Million Women Study Collaborators. Frequent physical activity may not reduce vascular disease risk as much as moderate activity: large prospective study of women in the United Kingdom. Circulation. 2015;131:721-729.
  8. Gebel K, Ding D, Chey T, Stamatakis E, Brown WJ, Bauman AE. Effect of moderate to vigorous physical activity on all-cause mortality in middle-aged and older Australians. JAMA Intern Med. 2015;175:970-977.
  9. Sawaya H, Sebag IA, Plana JC, et al. Assessment of echocardiography and biomarkers for the extended prediction of cardiotoxicity in patients treated with anthracyclines, taxanes, and trastuzumab. Circ Cardiovasc Imaging. 2012;5:596-603.