Adjuvant trastuzumab in routine clinical practice and the impact of cardiac monitoring guidelines on treatment delivery

Abstract

Trastuzumab delivery and changes in left ventricular ejection fraction (LVEF) in 110 patients receiving adjuvant trastuzumab in routine practice are investigated. The potential impact of new, less stringent UK cardiac monitoring guidelines is examined. 86 patients (78%) completed trastuzumab on schedule. 11 (10%) completed treatment despite delay(s) to allow LVEF recovery, 7 (6%) discontinued trastuzumab because of insufficient LVEF recovery, 2 (2%) of whom developed symptomatic cardiotoxicity. 6 (5%) discontinued trastuzumab for non-cardiac reasons. With the newer guidelines, the value of LVEF lower limit of normal is important in determining the proportion of patients who require angiotensin-converting enzyme inhibitors (ACEIs) and cardiology referral: up to 100% could potentially complete trastuzumab on schedule with up to 60% receiving ACEIs and 25% requiring cardiology referral. Adjuvant trastuzumab was well tolerated overall. The new guidelines potentially allow more patients to complete trastuzumab on schedule but require higher levels of cardiological intervention.

Exploring the use and impact of adjuvant Trastuzumab for HER2-positive breast cancer patients in a large UK cancer network

“…Interestingly, the proportion of patients stopping treatment early for cardiac toxicity fell from 22.2% in 2006 to 5.2% in 2008, which may reflect increasing clinician confidence in managing the cardiac effects of Trastuzumab. Similar figures are reproduced in other retrospective series (Murray et al , 2010). …”

Trastuzumab interruption and treatment-induced cardiotoxicity in early HER2-positive breast cancer

“…In the HERA trial, 9.8 % of patients treated with trastuzumab compared to 2.9 % in the control group had at least one significant decline in LVEF [6]. In clinical practice, up to 23 % of patients will develop asymptomatic left ventricular (LV) dysfunction [9–11]. …”

Is trastuzumab-induced cardiotoxicity involved in onco-cardiology outcome?

“…In contrast, there would be more delays in treatment schedule and over-treatment with cardiac medication. It is important to highlight that the effectiveness of ACEIs is assumed in all patients in this study and we also have no knowledge about the results in the prospective cohort about treatment delivery [24].…”

“…This retrospective review was based on a cohort of 110 women with breast cancer who received adjuvant trastuzumab following the original guidelines from the National Cancer Research Institute Breast Clinical Studies Group. All the women were supposed to undergo the same treatment but with a different, less stringent follow-up (including the debate on whether the lower limit of normality for LVEF values should be lower or not) and proposing the introduction of ACEIs in early decrease of LVEF in order to avoid an early discontinuation of trastuzumab [24].…”