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March 4, 2021

Association of Breast Cancer Irradiation With Cardiac Toxic Effects: A Narrative Review

Author Affiliations
  • 1Department of Experimental and Clinical Biomedical Sciences Mario Serio, University of Florence, Florence, Italy
  • 2Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
  • 3Department of Radiation Oncology, Iridium Kankernetwerk, Wilrijk-Antwerp, Belgium
  • 4University of Antwerp, Faculty of Medicine and Health Sciences, Wilrijk-Antwerp, Belgium
  • 5Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, The Christie NHS Foundation Trust, Manchester, United Kingdom
  • 6Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
  • 7Department of Radiation Oncology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Matteo Polyclinic Foundation, Pavia, Italy
  • 8PhD School in Experimental Medicine, University of Pavia, Pavia, Italy
  • 9Cardioncology Unit, European Institute of Oncology, IRCCS, Milan, Italy
  • 10Cardio-Oncology Center of Excellence, Washington University in St Louis, St Louis, Missouri
  • 11Medical Physics Unit, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
  • 12Division of Early Drug Development, European Institute of Oncology, IRCCS, Milan, Italy
  • 13Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
JAMA Oncol. 2021;7(6):924-932. doi:10.1001/jamaoncol.2020.7468

Importance  To promptly recognize and manage cardiovascular (CV) risk factors before, during, and after cancer treatment, decreasing the risk of cancer therapy–related cardiac dysfunction is crucial. After recent advances in breast cancer treatment, mortality rates from cancer have decreased, and the prevalence of survivors with a potentially higher CV disease risk has increased. Cardiovascular risks might be associated with the multimodal approach, including systemic therapies and breast radiotherapy (RT).

Observations  The heart disease risk seems to be higher in patients with tumors in the left breast, when other classic CV risk factors are present, and when adjunctive anthracycline-based chemotherapy is administered, suggesting a synergistic association. Respiratory control as well as modern RT techniques and their possible further refinement may decrease the prevalence and severity of radiation-induced heart disease. Several pharmacological cardioprevention strategies for decreasing cardiac toxic effects have been identified in several guidelines. However, further research is needed to ascertain the feasibility of these strategies in routine practice.

Conclusions and Relevance  This review found that evidence-based recommendations are lacking on the modalities for and intensity of heart disease screening, surveillance of patients after RT, and treatment of these patients. A multidisciplinary and multimodal approach is crucial to guide optimal management.

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