乳腺癌放疗与心脏毒性反应循证述评
减少乳腺癌治疗相关心脏功能障碍风险，对于乳腺癌治疗之前、期间、之后迅速发现并管理心血管风险因素而言至关重要。随着乳腺癌治疗水平不断提高、乳腺癌死亡率不断降低，乳腺癌康复者的心血管疾病风险可能增加。心血管风险可能与多种治疗方法相关，包括全身治疗和乳腺癌放疗。
2021年3月4日，《美国医学会杂志》肿瘤学分册在线发表意大利佛罗伦萨大学卡雷吉医院、帕维亚大学圣马修综合医院、米兰大学欧洲肿瘤研究院、比利时安特卫普大学肿瘤医院、英国曼彻斯特大学肿瘤医院、牛津大学公共卫生学院、美国圣路易斯华盛顿大学肿瘤心脏病学中心的研究报告，对乳腺癌患者放疗所致心脏疾病相关心血管风险因素、预测模型、治疗和预防方法进行了述评。
观察发现，当存在其他经典的心血管风险因素，并且术后给予蒽环类辅助化疗时，左侧乳腺肿瘤患者的心脏疾病风险似乎增加，这表明存在协同关系。呼吸控制和现代放疗技术及其进一步完善，可能减少放疗所致心脏疾病的发生风险和严重程度。某些指南已经确定若干减少心脏毒性反应的心脏药物预防策略。不过，有必要开展进一步研究确定这些策略对于常规实践的可行性。
因此，该研究结果表明，目前仍然缺乏关于乳腺癌患者放疗后心脏疾病筛查、监测形式和频次以及治疗方法的循证推荐意见，多学科和多种方法对于指导优化乳腺癌放疗患者心脏管理至关重要。
相关链接
JAMA Oncol. 2021 Mar 4. Online ahead of print.
Association of Breast Cancer Irradiation With Cardiac Toxic Effects: A Narrative Review.
Meattini I, Poortmans PM, Aznar MC, Becherini C, Bonzano E, Cardinale D, Lenihan DJ, Marrazzo L, Curigliano G, Livi L.
University of Florence, Florence, Italy; Azienda Ospedaliero Universitaria Careggi, Florence, Italy; Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Matteo Polyclinic Foundation, Pavia, Italy; University of Pavia, Pavia, Italy; European Institute of Oncology, IRCCS, Milan, Italy; University of Milan, Milan, Italy; Iridium Kankernetwerk, Wilrijk-Antwerp, Belgium; University of Antwerp, Faculty of Medicine and Health Sciences, Wilrijk-Antwerp, Belgium; The University of Manchester, The Christie NHS Foundation Trust, Manchester, United Kingdom; University of Oxford, Oxford, United Kingdom; Washington University in St Louis, St Louis, Missouri.
This narrative review describes the cardiovascular risk factors, predictive models, and treatment and prevention approaches associated with radiation-induced heart disease in patients with cancer.
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.
PMID: 33662107
DOI: 10.1001/jamaoncol.2020.7468