Heart failure after treatment for breast cancer

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.

The cancer patient and cardiology

“…Women with breast cancer who received radiotherapy had a 30% greater risk for coronary heart disease, and a 38% greater risk for cardiac death compared with those who did not 69 . The risk for cardiotoxicity is increased when radiotherapy is used with concomitant anthracyclines 70,71 . Radiotherapy‐specific risk factors include the volume and dose to which the heart and its substructures are irradiated 72,73 .…”

February 2020 at a glance: acute heart failure and cardio‐oncology

“…Patients treated with anthracyclines had lower left ventricular ejection fraction and higher global longitudinal strain and N‐terminal pro‐B‐type natriuretic peptide compared to the others. Boekel et al . demonstrated a dose‐dependent increase in HF risk after anthracycline therapy.…”

Heart failure after treatment for breast cancer: old cancer therapies, new clinical data. What do we need to complete the puzzle?

“…In this issue of the Journal, Boekel et al 13 present a meticulous analysis of a prospective cohort of long-term BC survivors in a serious attempt to settle the question of the relationship between BC therapy and subsequent HF with reduced EF. The study population is limited to 102 middle-aged women with BC (median age: 51 years), who are compared to an ad hoc cohort of 306 women with similar characteristics, followed between 1976 and 2009.…”

“…2 Although these definitions have been proposed in consensus documents, 2,3 the ESC HF guidelines apply a somewhat different and more precise definition. 11 Additionally, the cases do not reflect the real BC population because the authors 13 In conclusion, cancer therapy-related CV events are widely recognized as a global issue, but it should be remembered that these cancer treatments allow patients to survive. CTox-HF is an ongoing phenomenon with a narrow therapeutic window for left ventricular dysfunction recovery and unfortunately we currently lack a global solution.…”

“…In this issue of the Journal, Boekel et al . present a meticulous analysis of a prospective cohort of long‐term BC survivors in a serious attempt to settle the question of the relationship between BC therapy and subsequent HF with reduced EF.…”