Yao Ren Jie Robert, Gibson Jordan, Simmons Christine, Davis Margot K
Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
Department of Medicine, University of Calgary, Calgary, AB, Canada.
Cardiooncology. 2021 Mar 26;7(1):12. doi: 10.1186/s40959-021-00099-7.
Trastuzumab reduces risk of breast cancer recurrence but carries risk of cardiotoxicity that may be reversible upon treatment cessation and institution of left ventricular (LV) enhancement therapies (LVETx). We assessed management patterns of trastuzumab-induced cardiotoxicity (TIC) in a contemporary real-world setting.
We reviewed charts of all breast cancer patients who received adjuvant trastuzumab in British Columbia between January 2010 and December 2013, spanning the opening of a cardio-oncology clinic. LV dysfunction (LVD) was classified as minimal (LVEF nadir 45-49%), mild (40-44%) or moderate-severe (< 40%). Charts were reviewed for baseline characteristics, management strategies, and outcomes. Multivariable analysis was performed to identify patient characteristics associated with trastuzumab completion and cardiology referral.
Of 967 patients receiving trastuzumab, 171 (17.7%) developed LVD, including 114 patients (11.8%) with LVEF declines of ≥10 to < 50%. Proportions of patients receiving cardiology referrals and LVETx increased and wait times to consultation decreased after a dedicated cardio-oncology clinic opened. LVETx was used more frequently in patients with moderate-severe LVD compared to minimal or mild LVD. Factors associated with completion of trastuzumab included mastectomy (OR 5.1, 95% CI 1.1-23.0) and proximity to quaternary care centre (OR 7.7, 95% CI 2.2-26.2). Moderate-severe LVD was associated with a lower probability of completing trastuzumab (OR 0.07 vs. minimal LVD, 95% CI 0.01-0.74). Factors associated with cardiology referral included heart failure symptoms (OR 8.0, 95% CI 1.5-42.9), proximity to quaternary care centre (OR 6.8, 95% CI 1.3-34.2), later year of cancer diagnosis (OR 2.4 per year, 95% CI 1.4-4.3), node-positive disease (OR 0.18, 95% CI 0.06-0.56), mastectomy (OR 0.05, 95% CI 0.01-0.52), and minimal LVD (OR 0.14, 95% CI 0.05-0.46). LVEF recovered to > 50% in 90.7% of patients.
Management strategies in patients with TIC are associated with cancer characteristics and severity of cardiotoxicity. Access to dedicated cardio-oncology clinics may facilitate optimal care of this complex patient population.
曲妥珠单抗可降低乳腺癌复发风险，但存在心脏毒性风险，停药并采用左心室（LV）强化治疗（LVETx）后心脏毒性可能可逆。我们评估了当代真实世界环境中曲妥珠单抗所致心脏毒性（TIC）的管理模式。
我们回顾了2010年1月至2013年12月在不列颠哥伦比亚省接受辅助性曲妥珠单抗治疗的所有乳腺癌患者的病历，涵盖了心脏肿瘤门诊开诊期间。左心室功能障碍（LVD）分为轻度（左心室射血分数（LVEF）最低点为45 - 49%）、中度（40 - 44%）或重度（<40%）。查阅病历以了解基线特征、管理策略和结局。进行多变量分析以确定与曲妥珠单抗完成治疗及心脏科转诊相关的患者特征。
在967例接受曲妥珠单抗治疗的患者中，171例（17.7%）发生了LVD，其中114例（11.8%）的LVEF下降≥10%至<50%。在专门的心脏肿瘤门诊开诊后，接受心脏科转诊和LVETx的患者比例增加，会诊等待时间缩短。与轻度或中度LVD相比，重度LVD患者更频繁地使用LVETx。与完成曲妥珠单抗治疗相关的因素包括乳房切除术（比值比（OR）5.1，95%置信区间（CI）1.1 - 23.0）以及靠近四级医疗中心（OR 7.7，95% CI 2.2 - 26.2）。重度LVD与完成曲妥珠单抗治疗的可能性较低相关（与轻度LVD相比，OR 0.07，95% CI 0.01 - 0.74）。与心脏科转诊相关的因素包括心力衰竭症状（OR 8.0，95% CI 1.5 - 42.9）、靠近四级医疗中心（OR 6.8，95% CI 1.3 - 34.2）、癌症诊断年份较晚（每年OR 2.4，95% CI 1.4 - 4.3）、淋巴结阳性疾病（OR 0.18，95% CI 0.06 - 0.56）、乳房切除术（OR 0.05，95% CI 0.01 - 0.52）以及轻度LVD（OR 0.14，95% CI 0.05 - 0.46）。90.7%的患者LVEF恢复至>50%。
TIC患者的管理策略与癌症特征及心脏毒性严重程度相关。设立专门的心脏肿瘤门诊可能有助于为这一复杂患者群体提供最佳治疗。
