Truong Sandy R, Barry William T, Moslehi Javid J, Baker Emily L, Mayer Erica L, Partridge Ann H
Harvard Medical School, Boston, Massachusetts, USA Dana-Farber Cancer Institute, Boston, Massachusetts, USA.
School of Medicine, Vanderbilt University, Nashville, Tennessee, USA Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, USA.
Oncologist. 2016 Jun;21(6):666-70. doi: 10.1634/theoncologist.2015-0449. Epub 2016 Apr 22.
Cardiotoxicity can be a complication of anthracycline- or trastuzumab-based therapy for breast cancer patients. Screening echocardiograms (ECHOs) and radionuclide ventriculograms (RVGs) are often performed before administration of these agents to evaluate cardiac function. Limited evidence for the clinical utility of these screening tests is available.
Early-stage breast cancer patients diagnosed from 2006 to 2011 (n = 1,067) with baseline ECHOs/RVGs were identified in a single institution prospective registry. Medical record review was performed to obtain pre- and post-ECHO/RVG treatment plans, baseline ECHO/RVG results, cardiac risk factors, and cardiac events. Patients with cardiac history were excluded. ECHO/RVG abnormalities were defined as ejection fraction (EF) <55%, valvular disease, left ventricular hypertrophy, and diastolic dysfunction. Cardiac events were defined as heart failure, myocardial infarction, arrhythmia, valvular disease, or angina during or after chemotherapy.
Among 600 eligible patients, abnormal ECHO/RVG results were observed in 13 (2.2%, 1.2%-3.7%), including 9 with baseline EF <55%. There were no detected changes in treatment plans, although more frequent cardiac monitoring was recommended for 2 patients. There were no significant differences in age, race, menopausal status, smoking history, alcohol use, body mass index, or medical comorbidities between patients with abnormal and normal results. In follow-up (mean, 4.0 years; range, 0-8.3), 15 patients developed cardiac events (none of whom had had abnormal baseline ECHOs/RVGs).
Baseline ECHO/RVG in patients without prior cardiac history rarely yields an abnormality that prompts change in planned anthracycline- and/or trastuzumab-based treatment. Moreover, few cardiac events developed in this screened population in follow-up.
Baseline cardiac function screening with echocardiograms or radionuclide ventriculograms is frequently performed before administration of anthracycline- or trastuzumab-based chemotherapy in breast cancer patients due to the relatively low cost and risk to patients and the concern for potential cardiotoxicity. However, at a population level, these tests can take up time and can add up to significant costs for both patients and the health care system. This study finds that in patients with no history of cardiac disease, baseline cardiac function screening rarely identifies abnormalities that change treatment plans. Moreover, few cardiac events develop in an average of 4 years of follow-up, including none in patients with abnormal baseline cardiac function screening results. This suggests that baseline cardiac function screening may have limited utility in chemotherapy planning in young breast cancer patients with no history of cardiac disease.
心脏毒性可能是乳腺癌患者接受基于蒽环类药物或曲妥珠单抗治疗的并发症。在使用这些药物之前，通常会进行超声心动图（ECHO）筛查和放射性核素心室造影（RVG）以评估心脏功能。关于这些筛查试验临床效用的证据有限。
在一个单一机构的前瞻性登记处中，确定了2006年至2011年诊断的早期乳腺癌患者（n = 1067），这些患者有基线ECHO/RVG检查结果。进行病历审查以获取ECHO/RVG检查前后的治疗计划、基线ECHO/RVG结果、心脏危险因素和心脏事件。排除有心脏病史的患者。ECHO/RVG异常定义为射血分数（EF）<55%、瓣膜病、左心室肥厚和舒张功能障碍。心脏事件定义为化疗期间或化疗后发生的心力衰竭、心肌梗死、心律失常、瓣膜病或心绞痛。
在600名符合条件的患者中，观察到13例（2.2%，1.2% - 3.7%）ECHO/RVG结果异常，其中9例基线EF<55%。尽管建议对2例患者进行更频繁的心脏监测，但治疗计划没有变化。结果异常和正常的患者在年龄、种族、绝经状态、吸烟史、饮酒情况、体重指数或合并疾病方面没有显著差异。在随访中（平均4.0年；范围0 - 8.3年），15例患者发生了心脏事件（其中没有一人基线ECHO/RVG异常）。
在没有心脏病史的患者中，基线ECHO/RVG很少出现异常，从而促使基于蒽环类药物和/或曲妥珠单抗的计划治疗发生改变。此外，在这个经过筛查的人群中，随访期间很少发生心脏事件。
由于成本相对较低且对患者风险较小，同时考虑到潜在的心脏毒性，在乳腺癌患者接受基于蒽环类药物或曲妥珠单抗的化疗之前，经常进行超声心动图或放射性核素心室造影的基线心脏功能筛查。然而，在总体人群层面，这些检查会占用时间，并且会给患者和医疗保健系统带来显著成本。本研究发现，在没有心脏病史的患者中，基线心脏功能筛查很少能发现改变治疗计划的异常情况。此外，在平均4年的随访中，很少发生心脏事件，包括基线心脏功能筛查结果异常的患者中也没有发生。这表明基线心脏功能筛查在没有心脏病史的年轻乳腺癌患者化疗计划中的效用可能有限。
