Succeeding with Cancer: Using Imaging to Avoid Treatment-induced Heart Failure

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Treating today’s cancer patient no longer means simply targeting the cancer. Given the known cardiotoxicities of some established chemotherapies and the possibility that newer approaches may damage the heart, oncologists, cardiologists and imaging specialists now work together to detect and minimize the risk of treatment-induced heart failure.

A complicated equation

Anthracyclines have long been oncologists’ first line of attack against a broad array of solid tumors and hematological malignancies because of their effectiveness. While the drugs destroy cancer cells, they also may induce cardiomyocyte death that leads to adverse left ventricular remodeling.

To prevent the risk of patients developing heart failure, oncologists now typically monitor left ventricular ejection fraction (LVEF) using either echocardiography or equilibrium radionuclide angiography/multigated acquisition (ERNA/MUGA) and discontinue or pause treatment if LVEF measures drop below a threshold.

Anthracyclines, probably the most commonly prescribed type of anticancer agent, are being joined by an expanding array of therapies, says Raymond R. Russell, MD, PhD, director of nuclear cardiology at the Cardiovascular Institute at Rhode Island Hospital in Providence and director of its cardio-oncology program. His research has helped elucidate the cellular pathways for anthracycline-induced heart failure.

Besides anthracyclines, oncologists may consider conventional therapies such as taxanes, an antimicrotubule agent, and radiation. Newer approaches include biological drugs such as trastuzumab, a monoclonal antibody; 5-fluorouracil, an antimetabolite; small molecule tyrosine kinase inhibitors; proteasome inhibitors; and immune therapy. Each is designed to exploit a potential vulnerability in cancer cells, widening physicians’ arsenal against the disease. And each carries its own potential, and sometimes as yet unknown drawbacks.

“There have been dramatic changes in what is being done for cancer, [but] there are some unique forms of cardiotoxicity with different agents,” says Russell, the lead author of an information statement from the American Society of Nuclear Cardiology (ASNC) on multimodality imaging and its role in the management of cardiac complications in patients under treatment for cancer (J Nucl Cardiol 2016;23[4]:856-84).

Cardiovascular risk factors and individual variability add other layers of complexity. Cumulative dose is the largest predictor of cardiotoxicity with anthracyclines, for instance, but some patients may develop LV dysfunction after one treatment and others may fare relatively well through a full cycle. The challenge with anthracyclines and other options is identifying who is at risk, or if complications develop, intervening early enough to reverse or minimize the development of heart failure.

“Part of [the risk of developing heart failure] is due to the cancer treatment, but there definitely is individual susceptibility,” says Ana Barac, MD, PhD, a cardiologist at MedStar Washington Hospital Center in Washington, D.C., who specializes in cardiac imaging. “There is also an increasing role of cardiovascular risk factors, in particular hypertension. While there are cancer treatments that are known to cause cardiomyopathy and lead to heart failure, there is this larger unknown yet to be discovered of individual susceptibility.”

Representative example of high-efficiency CZT (Cadmium Zinc Telluride) ECG-gated SPECT equilibrium radionuclide angiocardiography (ERNA) from a 37-year-old woman with estrogen receptor/progesterone receptor/HER2/neu-positive pT1cN0MX infiltrating ductal carcinoma of the right breast status post-bilateral mastectomy undergoing treatment with trastuzumab and tamoxifen. Limited echocardiographic imaging due to acoustic artifact suggesting a decline in left ventricular ejection fraction (LVEF) by serial echocardiography led to referral for ERNA. The study demonstrates normal LV volume indices and slightly reduced calculated EF (49%). The right ventricular size is normal and the calculated right ventricular ejection fraction (40%) is slightly reduced with mild diffuse dysfunction. The LVEF returned to normal (65%) following completion of a full course of trastuzumab.
Source: J Nucl Cardiol 2016;23(4):856-84; reprinted with permission from the American Society of Nuclear Cardiology; originally presented in “The Role and Clinical Effectiveness of Multimodality Imaging in the Management of Cardiac Complications