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.
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.
