Abstract
Cancer therapy-induced cardiomyopathy (CCM) is associated with cumulative drug exposures and preexisting cardiovascular disorders. These parameters incompletely account for substantial interindividual susceptibility to CCM. We hypothesized that rare variants in cardiomyopathy genes contribute to CCM. We studied 213 patients with CCM from 3 cohorts: retrospectively recruited adults with diverse cancers (n=99), prospectively phenotyped adults with breast cancer (n=73), and prospectively phenotyped children with acute myeloid leukemia (n=41). Cardiomyopathy genes, including 9 prespecified genes, were sequenced. The prevalence of rare variants was compared between CCM cohorts and The Cancer Genome Atlas participants (n=2053), healthy volunteers (n=445), and an ancestry-matched reference population. Clinical characteristics and outcomes were assessed and stratified by genotypes. A prevalent CCM genotype was modeled in anthracycline-treated mice. CCM was diagnosed 0.4 to 9 years after chemotherapy; 90% of these patients received anthracyclines. Adult patients with CCM had cardiovascular risk factors similar to the US population. Among 9 prioritized genes, patients with CCM had more rare protein-altering variants than comparative cohorts ( P≤1.98e-04). Titin-truncating variants (TTNtvs) predominated, occurring in 7.5% of patients with CCM versus 1.1% of The Cancer Genome Atlas participants ( P=7.36e-08), 0.7% of healthy volunteers ( P=3.42e-06), and 0.6% of the reference population ( P=5.87e-14). Adult patients who had CCM with TTNtvs experienced more heart failure and atrial fibrillation ( P=0.003) and impaired myocardial recovery ( P=0.03) than those without. Consistent with human data, anthracycline-treated TTNtv mice and isolated TTNtv cardiomyocytes showed sustained contractile dysfunction unlike wild-type ( P=0.0004 and P<0.002, respectively). Unrecognized rare variants in cardiomyopathy-associated genes, particularly TTNtvs, increased the risk for CCM in children and adults, and adverse cardiac events in adults. Genotype, along with cumulative chemotherapy dosage and traditional cardiovascular risk factors, improves the identification of patients who have cancer at highest risk for CCM. URL: https://www.clinicaltrials.gov . Unique identifiers: NCT01173341; AAML1031; NCT01371981.
Highlights
Cancer therapy–induced cardiomyopathy (CCM) is associated with cumulative drug exposures and preexisting cardiovascular disorders
We demonstrate the direct and prevalent involvement of variants in genes associated with dilated cardiomyopathy and, in particular, titin-truncating variants (TTNtvs) in CCM
Two US cohorts were identified through prospective longitudinal cardiac evaluations obtained throughout cancer therapy: Cohort B comprised 73 patients with European, African, or Asian ancestry, enrolled from breast cancer clinics as part of a prospective study of who developed CCM during treatment; Cohort C comprised 41 pediatric patients with newly diagnosed acute myelogenous leukemia of diverse ancestries
Summary
We studied 213 patients with CCM from 3 cohorts: retrospectively recruited adults with diverse cancers (n=99), prospectively phenotyped adults with breast cancer (n=73), and prospectively phenotyped children with acute myeloid leukemia (n=41). Cohort A includes non-Finnish European patients with CCM retrospectively collected from 6 European heart failure or cardiac transplantation clinics in Spain and the United Kingdom. Cohort B includes prospectively enrolled patients with breast cancer, participating in cardiotoxicity studies of cancer treatments (clinicaltrials.gov NCT01173341). Cohort C includes pediatric patients with newly diagnosed acute myeloid leukemia, enrolled in a clinical therapy trial therapy (AAML1031; clinicaltrials.gov NCT01371981). Cohorts B and C are US patients with non-Finnish European, African, or Asian ancestry, who had prespecified clinical assessments with cardiac imaging (echocardiograms or multigated acquisition scans) before, during, and after chemotherapy.
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