Management of cardiac health in trastuzumab-treated patients with breast cancer: updated United Kingdom National Cancer Research Institute recommendations for monitoring

Abstract

More women are living with and surviving breast cancer, because of improvements in breast cancer care. Trastuzumab (Herceptin) has significantly improved outcomes for women with HER2-positive tumours. Concerns about the cardiac effects of trastuzumab (which fundamentally differ from the permanent myocyte loss associated with anthracyclines) led to the development of cardiac guidelines for adjuvant trials, which are used to monitor patient safety in clinical practice. Clinical experience has shown that the trial protocols are not truly applicable to the breast cancer population as a whole, and exclude some women from receiving trastuzumab, even though they might benefit from treatment without long-term adverse cardiac sequelae. Consequently, five oncologists who recruited patients to trastuzumab trials, some cardiologists with whom they work, and a cardiovascular lead general practitioner reviewed the current cardiac guidelines in the light of recent safety data and their experience with adjuvant trastuzumab. The group devised recommendations that promote proactive pharmacological management of cardiac function in trastuzumab-treated patients, and that apply to all patients who are likely to receive standard cytotoxic chemotherapy. Key recommendations include: a monitoring schedule that assesses baseline and on-treatment cardiac function and potentially reduces the overall number of assessments required; intervention strategies with cardiovascular medication to improve cardiac status before, during, and after treatment; simplified rules for starting, interrupting and discontinuing trastuzumab; and a multidisciplinary approach to breast cancer care.

Figure 1

Current recommendations for cardiac monitoring in trastuzumab-treated patients (reproduced from Suter et al, 2007; online Appendix only). Reproduced with permission of the American Society of Clinical Oncology, from Suter et al, 2007.

Figure 2

Traffic light system to prevent, monitor, and manage cardiac events in patients undergoing cytotoxic chemotherapy. (A) Patient assessment during trastuzumab therapy; (B–D) indications for ACEi therapy and referral to a cardiologist before (B) and after (C) chemotherapy, and (D) during trastuzumab therapy, when additional cardiac assessments may also be required. ACEi=angiotensin-converting enzyme inhibitor.