Clinical management of drug-induced cardiotoxicity in patients with HER-2+ breast cancer: current recommendations and future outlook

ABSTRACT

Introduction

Human epidermal growth factor receptor two (HER2) target therapies have drastically revolutionized the treatment of HER2-positive breast cancer. Starting with trastuzumab, early phase III trials have already highlighted its significant cardiotoxicity, which is also present, albeit to a lesser extent, in the new generation drugs. Also given the growing population of patients with cardiovascular diseases, it is vital to set up proper long-term follow-up to prevent morbidity related to the development of cardiotoxicity.

Areas covered

This review discusses the mechanisms of action underlying the cardiotoxicity of HER2 targeted therapies and the main clinical evidence on the toxicity of these drugs. In addition, the patterns of patient assessment prior to the initiation of therapy with HER2 targeted therapies are discussed, as well as the main evidence concerning the follow-up and management of cardiotoxicity.

Expert opinion

The mechanisms of cardiotoxicity of new HER2 drugs need further study and, likewise, methods to prevent, monitor and identify HER-2-induced cardiotoxicity need to be implemented. Although some studies highlight the validity of cardiac biomarkers as predictive factors for cardiotoxicity, their actual usefulness and timing is still debated. Further studies are needed to assess the effectiveness of possible pharmacological primary prevention.

KEYWORDS:

• Cardiac biomarkers
• cardio-oncology
• cardiotoxicity
• HER-2
• cardiac imaging
• targeted therapies

Article highlights

• Breast cancer is a clinical entity of major epidemiological importance

• Target her 2 therapies, and in particular trastuzumab, are cardiotoxic, a relevant aspect in a growing population burdened with increased cardiovascular risk

• Cardiotoxicity from HER2 targeted therapies is mainly characterized by asymptomatic decrease in LVEF and, to a lesser extent, with the development of heart failure

• risk stratification is a vital aspect of the initial assessment of the patient candidate for HER2 targeted therapies

• Cardiac biomarkers and trans-thoracic ultrasound are the main diagnostic tools for assessing cardiotoxicity from HER2 targeted therapies

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or material discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or mending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.