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. 2025 Jun 20;11(1):56.
doi: 10.1186/s40959-025-00356-z.

Use of anthracyclines and trastuzumab for breast cancer in women with and without a history of cardiovascular disease in Sweden: a national cross-sectional study

Helena Carreira #  1 , Helen Strongman #  2 , Maria Feychting  3 , Laila Hubbert  4 , Elham Hedayati  3 , Patrick Bidulka  2 , Anthony Matthews #  3 , Krishnan Bhaskaran #  2
Affiliations

Use of anthracyclines and trastuzumab for breast cancer in women with and without a history of cardiovascular disease in Sweden: a national cross-sectional study

Helena Carreira et al. Cardiooncology. .

Abstract

Background: Cardiovascular toxicity concerns have limited the use of anthracyclines and trastuzumab among breast cancer patients with cardiovascular disease (CVD) but evidence on real-world prescribing patterns is scarce. We aimed to describe the use of these drugs in women with and without CVD when diagnosed with non-metastatic breast cancer in Sweden.

Methods: Using Swedish national registers (2010-15), we identified breast cancer treatment and prior CVD from hospital and prescription data. We calculated prevalence of anthracycline and trastuzumab use in women with and without prior CVD, and estimated prevalence ratios (PR) comparing these groups, adjusted for age, stage, and other patient and tumour-related factors.

Results: Among 32,590 women with breast cancer, 10,702 (33%) had prior CVD. Anthracycline use was lower in those with vs without prior CVD (2,169/10,702 [20.3%] vs 8,654/21,888 [39.5%], crude PR 0.51, 0.49-0.53); the PR attenuated after adjustment for age and other factors (adj-PR 0.90, 0.87-0.93). There was substantial variation by type of CVD: patients with heart failure were much less likely to receive anthracyclines (adj-PR 0.46, 0.35-0.57) while prior venous thromboembolism (VTE) had no impact (adj-PR 0.98, 0.88-1.09). Among HER2 + patients, trastuzumab use showed similar patterns, with prevalence of 630/1,100 [57.3%] vs 2,279/2,866 [79.5%] for any vs no prior CVD (crude PR = 0.72, 0.68-0.76, adjusted PR = 0.95, 0.90-0.99); adjusted PRs for specific outcomes ranged from 0.77 (0.61-0.93) for heart failure, to 1.04 (0.92-1.15) for VTE.

Conclusion: While prior CVD was associated with lower use of potentially cardiotoxic breast cancer therapies, substantial numbers of patients with CVD still received these treatments, with marked variation by type of CVD. These real-world data suggest variable cardiovascular toxicity risk stratification before anticancer therapy and highlight the need for evidence-based guidance on negotiating the risk-benefit balance in these patients.

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Conflict of interest statement

Declarations. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Association between cardiovascular diseases and anthracyclines and trastuzumab† use. Min. adjusted = Prevalence ratios adjusted for age (5-year age groups). Fully adjusted = Prevalence ratios adjusted for age (5-year age groups), region, socio-economic variables (education, civil status, and disposable income), comorbidities (chronic kidney disease, chronic obstructive pulmonary disease and diabetes), and tumour-related variables (stage at diagnosis, HER2 receptor status for anthracyclines, tumour grade and diagnostic subtype). † Analyses of trastuzumab include only breast cancer patients with HER2 + tumours. Crude prevalences are shown. CVD = cardiovascular disease, includes coronary heart disease (CAD), heart failure, primary hypertension and stroke; CAD = coronary artery disease; CI = confidence interval; Ref. = reference; VTE = venous thromboembolism
Fig. 2
Fig. 2
Association between cardiovascular diseases and anthracyclines use stratified by subtype of breast cancer. Min. adjusted = Prevalence ratios adjusted for age (5-year age groups). Fully adjusted = Prevalence ratios adjusted for age (5-year age groups), region, socio-economic variables (education, civil status, and disposable income), comorbidities (chronic kidney disease, chronic obstructive pulmonary disease and diabetes), and tumour-related variables (stage at diagnosis, HER2 receptor status for anthracyclines, tumour grade and diagnostic subtype). * Crude prevalences are shown. CVD = cardiovascular disease, includes coronary heart disease (CAD), heart failure, primary hypertension and stroke; CAD = coronary artery disease; CI = confidence interval; Ref. = reference; VTE = venous thromboembolism
Fig. 3
Fig. 3
Proportion of breast cancer patients treated with chemotherapy, anthracyclines, trastuzumab, and both an anthracycline and trastuzumab, by history of cardiovascular disease, between 210 and 2015. Prevalence of trastuzumab use among all breast cancers, for comparison purposes; treatment categories not mutually exclusive
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References

    1. Bray F, Laversanne M, Sung H, Ferlay J, Siegel RL, Soerjomataram I, Jemal A. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2024;74(3):229–63. - DOI - PubMed
    1. Lundberg FE, Kroman N, Lambe M, Andersson TM, Engholm G, Johannesen TB, Virtanen A, Pettersson D, Olafsdottir EJ, Birgisson H, et al. Age-specific survival trends and life-years lost in women with breast cancer 1990–2016: the NORDCAN survival studies. Acta Oncol. 2022;61(12):1481–9. - DOI - PubMed
    1. Swain SM, Whaley FS, Ewer MS. Congestive heart failure in patients treated with doxorubicin: a retrospective analysis of three trials. Cancer. 2003;97(11):2869–79. - DOI - PubMed
    1. de Azambuja E, Ponde N, Procter M, Rastogi P, Cecchini RS, Lambertini M, Ballman K, Aspitia AM, Zardavas D, Roca L, et al. A pooled analysis of the cardiac events in the trastuzumab adjuvant trials. Breast Cancer Res Treat. 2020;179(1):161–71. - DOI - PMC - PubMed
    1. Curigliano G, Cardinale D, Suter T, Plataniotis G, de Azambuja E, Sandri MT, Criscitiello C, Goldhirsch A, Cipolla C, Roila F, et al. Cardiovascular toxicity induced by chemotherapy, targeted agents and radiotherapy: ESMO Clinical Practice Guidelines. Ann Oncol. 2012;23(Suppl 7):vii155-166. - DOI - PubMed