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Breast cancer therapy-associated cardiovascular disease

Nature Reviews Clinical Oncology volume 13, pages 172–184 (2016)Cite this article

Subjects

Key Points

  • Breast cancer treatment-related cardiovascular disease is an established effect, although its absolute incidence is low, and these risks must be balanced with the potential for cure

  • Receiving radiation therapy is a known risk factor for developing cardiovascular disease

  • The latency period to radiation-induced cardiovascular disease was once thought to be decades, but newer evidence suggests that it can manifest within several years after treatment

  • The specific portion of the heart and the actual dose it receives are paramount to the development of radiation-induced cardiovascular disease; various technical modifications can limit cardiac exposure to radiation

  • Numerous systemic therapies for breast cancer, such as anthracyclines and trastuzumab, are known to be cardiotoxic

  • Routinely used cardiovascular medications might be effective in the prevention of chemotherapy-related cardiac injury, and their use should be considered

Abstract

Breast cancer treatments have evolved over the past decades, although several widely used treatments have adverse cardiac effects. Radiotherapy generally improves the survival of women with breast cancer, although its deleterious cardiovascular effects pose competing risks of morbidity and/or mortality. In the past, radiation-associated cardiovascular disease was a phenomenon considered to take more than a decade to manifest, but newer research suggests that this latency is much shorter. Knowledge of coronary anatomy relative to the distribution of the delivered radiation dose has improved over time, and as a result, techniques have enabled this risk to be decreased. Studies continue to be performed to better understand, prevent and mitigate against radiation-associated cardiovascular disease. Treatments such as anthracyclines, which are a mainstay of chemotherapy for breast cancer, and newer targeted agents such as trastuzumab both have established risks of cardiotoxicity, which can limit their effectiveness and result in increased morbidity and/or mortality. Interest in whether β-blockers, statins and/or angiotensin-converting enzyme (ACE)-inhibitors might have therapeutic and/or preventative effects in these patients is currently increasing. This Review summarizes the incidence, risks and effects of treatment-induced cardiovascular disease in patients with breast cancer and describes strategies that might be used to minimize this risk.

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Figure 1: Hypothetical interaction between two mechanisms of radiation therapy-associated heart disease.
Figure 2: Variations between planned and delivered doses of radiation.
Figure 3: Adverse cardiac effects of radiation therapy in patients with breast cancer.
Figure 4: Effects of delaying cardioprotective medications after anthracycline administration.
Figure 5: Proposed algorithm for the management of cardiotoxicity in patients receiving anthracyclines.
Figure 6: Strategies to reduce incidental cardiac exposure to radiation in patients with left-sided breast cancer.
Figure 7: Algorithm used to select methods to minimize cardiac exposure during radiation therapy in patients with left-sided breast tumours.

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Acknowledgements

We thank Sarah Darby for her thoughtful review and advice for our manuscript.

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Authors and Affiliations

  1. Department of Radiation Oncology, University of North Carolina, 101 Manning Drive, Campus Box 7512, Chapel Hill, 27599, North Carolina, USA

    Timothy M. Zagar & Lawrence B. Marks

  2. Cardioncology Unit, European Institute of Oncology, Via Ripamonti 435, Milan, 20141, Italy

    Daniela M. Cardinale

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All authors researched data for the article, provided substantial contributions to discussions of its content, wrote the article and edited the manuscript before submission.

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Correspondence to Timothy M. Zagar.

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Zagar, T., Cardinale, D. & Marks, L. Breast cancer therapy-associated cardiovascular disease. Nat Rev Clin Oncol 13, 172–184 (2016). https://doi.org/10.1038/nrclinonc.2015.171

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