Key Points
- Cardiac dysfunction is a serious side effect of certain cancer-directed therapies that can interfere with the efficacy of treatment, decrease quality of life, or impact the actual survival of the cancer patient.
- Heart failure (HF), presenting during or after completion of cancer treatment, is a well-recognized complication that begins with risk factors known to be associated with the development of HF, including the toxicity of chemotherapy and/or radiation (stage A), and is commonly progressive after structural changes to the heart occur.
- The initial manifestation may be asymptomatic.
- Onset may also be responsible for interruption or discontinuation of cancer-directed therapy, potentially reducing the chance for long-term survival.
Risk
Recommendation 1.1
- It is recommended that cancer patients who meet any of the following criteria should be considered at increased risk for developing cardiac dysfunction. (Moderate Recommendation; EB-B-I)
Treatment that includes any of the following:- High dose anthracycline (e.g. ≥250 mg/m 2 doxorubicin, ≥600 mg/m 2 epirubicin)
- High dose (≥30 Gy) radiotherapy where the heart is in the treatment field
- Lower dose anthracycline (e.g. <250 mg/m 2 doxorubicin, <600 mg/m 2 epirubicin) in combination with lower dose radiotherapy (<30 Gy) where the heart is in the treatment field
- Treatment with lower dose anthracycline (e.g. <250 mg/m 2 doxorubicin, <600 mg/m 2 epirubicin) or trastuzumab alone, and presence of any of the following risk factors:
- Multiple (≥2) cardiovascular risk factors, including: smoking, hypertension, diabetes, dyslipidemia, obesity during or after completion of therapy
- Older (≥60 years) age at cancer treatment
- Compromised cardiac function (e.g. borderline low LVEF [50–55%], history of myocardial infarction, ≥moderate valvular heart disease) at any time prior to or during treatment
- Treatment with lower dose anthracycline (e.g. <250 mg/m 2 doxorubicin, <600 mg/m 2 epirubicin) followed by trastuzumab (sequential therapy)
Recommendation 1.2
- No recommendation can be made on the risk of cardiac dysfunction in cancer patients with any of the following treatment exposures: (EB-L)
- Lower dose anthracycline (e.g. <250 mg/m 2 doxorubicin, <600 mg/m 2 epirubicin) or trastuzumab alone, and no additional risk factors (as defined in RISK)
- Lower dose radiotherapy (<30 Gy) where the heart is in the treatment field, and no additional cardiotoxic therapeutic exposures or risk factors (as defined in RISK)
- Kinase inhibitors
Prevention
Prevention PRIOR TO Initiation of Therapy
Recommendation 2.1
- Avoid or minimize the use of potentially cardiotoxic therapies if established alternatives exist that would not compromise cancer-specific outcomes. (Strong Recommendation; CB-B).
Recommendation 2.2
- Clinicians should perform a comprehensive assessment in cancer patients that includes a history and physical examination, screening for cardiovascular disease risk factors (hypertension, diabetes, dyslipidemia, obesity, smoking), and an echocardiogram prior to initiation of potentially cardiotoxic therapies. (Strong Recommendation; EB/CB-B-H)
Prevention DURING Potentially Cardiotoxic Cancer Therapy
Recommendation 3.1
- Clinicians should screen for and actively manage modifiable cardiovascular risk factors (smoking, hypertension, diabetes, dyslipidemia, obesity) in all patients receiving potentially cardiotoxic treatments. (Moderate Recommendation; IC/EB-B-Ins)
Recommendation 3.2
- Clinicians may incorporate a number of strategies, including use of the cardioprotectant dexrazoxane, or continuous infusion, or liposomal formulation of doxorubicin for prevention of cardiotoxicity in patients planning to receive high-dose (e.g. ≥250 mg/m2 doxorubicin, ≥600 mg/m2 epirubicin) anthracyclines. (Moderate Recommendation; EB-B-I)
Recommendation 3.3
- For patients who require mediastinal RT which might impact cardiac function, clinicians should select lower radiation doses when clinically appropriate, and use more precise or tailored radiation fields with exclusion of as much of the heart as possible. (Strong Recommendation; EB/IC-B-I)
These goals can be accomplished through use of advanced techniques including:- Deep inspiration breath-holding for patients with mediastinal tumors or breast cancer in which the heart might be exposed.
- Intensity-modulated radiation therapy that varies the radiation energy while treatment is delivered in order to precisely contour the desired radiation distribution and avoid normal tissues.
