Roadmap for biomarkers of cancer therapy cardiotoxicity

Abstract

Contemporary cancer treatment uses multiple modalities such as chemotherapy, targeted therapy and radiotherapy. These therapies, often used in combination, are associated with an increased risk of cardiotoxicity, specifically cardiomyopathy and heart failure. Cardiologists and oncologists are faced with the challenge of maximising the clinical benefit from cancer therapy while minimising the risk of early and late-onset cardiotoxicity. The current paradigm for cardiotoxicity detection and management relies primarily upon the assessment of left ventricular ejection fraction (LVEF). However, LVEF alone is limited in both diagnostic and prognostic ability. There is growing enthusiasm over the identification of newer biomarkers of cardiotoxicity that can detect cardiac injury at earlier stages of disease and could be used as an adjunctive prognostic measure to routine LVEF assessment. Thus, imaging and circulating biomarkers are currently under active investigation for use throughout the continuum of cancer care-for risk stratification of cardiotoxicity prior to treatment, detection of early cardiotoxicity during treatment and diagnosis of late cardiotoxicity in survivorship. Myocardial strain, cardiac troponin and brain natriuretic peptide are the most prominent biomarkers currently being studied, although data on novel circulating biomarkers are emerging.

Figure 1

Biomarkers for risk stratification, surveillance and management of cardiotoxicity. During cancer treatment, progression from the presence of baseline risk factors to the development of overt cardiotoxicity can occur throughout the continuum of cancer treatment, from the time of cancer diagnosis to cancer survivorship. Use of imaging and circulating biomarkers may help to determine baseline risk of cardiotoxicity and identify patients that could benefit from intensive cardiac monitoring or cardioprotective strategies. Early detection of subclinical cardiotoxicity may provide an opportunity to intervene earlier in the course of disease. After the development of cardiotoxicity, biomarkers may provide important prognostic information and guide cardiotoxicity treatment. Further investigation is needed to determine the optimal timing and follow-up of biomarker testing. 2D, two dimensional; 3D, three dimensional.