Radiation therapy-related cardiotoxicity: Every detail counts?

Abstract

Breast cancer is one of the most frequent cancers worldwide, and the “number one” cancer in women [ [1] Share of population with cancer. World. 2017; (Accessed on 31st October 2021)https://ourworldindata.org/cancer Google Scholar ]. Treatment allows high survival rates, and it can include surgery, radiation, chemotherapy (mostly anthracyclines), hormonal therapy and HER-targeted agents, all with potential cardiotoxic effect and thus, long-term effects of treatment are becoming more frequent [ [2] Totzecka M. Schulerbe M. Stuschkece M. Heuschd G. Rassafa T. Cardio-oncology - strategies for management of cancer-therapy related cardiovascular disease. Int. J. Cardiol. 2019; 288: 130-131 PubMed Google Scholar ]. Echocardiography is generally the initial imaging test for screening and the state-of-the-art technology to identify subclinical cardiotoxicity is Global Longitudinal Strain (GLS) [ [2] Totzecka M. Schulerbe M. Stuschkece M. Heuschd G. Rassafa T. Cardio-oncology - strategies for management of cancer-therapy related cardiovascular disease. Int. J. Cardiol. 2019; 288: 130-131 PubMed Google Scholar ]. A recent long-term imaging study (median follow-up of 11.5 years) in survivors, showed that by echocardiographic analysis, there were clinical or subclinical cardiovascular abnormalities in 50% of the patients, being subclinical in 25%, mostly detected by abnormal GLS, which allowed identification of patients which otherwise may have been missed [ [3] Puckett L.L. Saba S.G. Henry S. et al. Cardiotoxicity screening of long-term, breast cancer survivors-the CAROLE (cardiac-related oncologic late effects) study. Cancer Med. 2021; 10: 5051-5061 Crossref PubMed Scopus (1) Google Scholar ]. This high rate was apparent regardless treatment modality and was also present in patients that did not receive any cardiotoxic treatment. Echocardiographic surveillance in all breast cancer survivors is therefore essential because they all have an increased cardiac risk independently of treatment modality, particularly in elderly women, because age was the only independent predictor of cardiovascular abnormalities. In fact, overlapping of numerous risk factors between heart disease and breast cancer (e.g., age, obesity, diet, hormonal replacement therapy) and additional indirect cardiac effects of cancer treatment (e.g., decreased long-term fitness, exercise intolerance) can explain the findings observed in that study [ [3] Puckett L.L. Saba S.G. Henry S. et al. Cardiotoxicity screening of long-term, breast cancer survivors-the CAROLE (cardiac-related oncologic late effects) study. Cancer Med. 2021; 10: 5051-5061 Crossref PubMed Scopus (1) Google Scholar ]. Moreover, echocardiographic surveillance is also important because left ventricular ejection fraction (LVEF)-defined cardiotoxicity-guided cardioprotection treatment for patients at risk of breast cancer-related cardiotoxicity provides more quality-adjusted life-years at lower cost than universal cardioprotection [ [4] Sampayo F.M. Fiuza M. Pinto F. Fontes J. Cost-effectiveness of cardio-oncology clinical assessment for prevention of chemotherapy-induced cardiotoxicity. Rev. Port. Cardiol. 2021; 40: 475-483 Crossref PubMed Scopus (2) Google Scholar ]. Subclinical left ventricle impairment following breast cancer radiotherapy: Is there an association between segmental doses and segmental strain dysfunction?International Journal of CardiologyVol. 345PreviewCardiotoxicity following breast cancer radiotherapy (RT) represents one of the most redoubtable toxicities. The Global longitudinal strain measurement (GLS) based on 2D speckle tracking imaging (STI) allows detection of left ventricular (LV) dysfunction at a subclinical stage. The aim of this prospective study was to detect patients at risk of cardiotoxicity using echocardiographic parameters and to determine the association between segmental RT doses and early cardiac toxicity. Full-Text PDF