RT Book, Section
A1 Chowdhury, M.H. Ruhe
A1 Hardwick, Joanna
A1 Kinirons, Mark
A1 Harries, Mark
A2 Ring, Alistair
A2 Harari, Danielle
A2 Kalsi, Tania
A2 Mansi, Janine
A2 Selby, Peter
SR Print(0)
ID 1152358807
T1 A Patient with Breast Cancer Experiencing Cardiac Toxicity on Chemotherapy
T2 Problem Solving in Older Cancer Patients
YR 2018
FD 2018
PB Clinical Publishing
PP New York, NY
SN 9781846921100
LK hemonc.mhmedical.com/content.aspx?aid=1152358807
RD 2021/03/06
AB A  76-year-old  woman  had  a  right-side  wide  local  excision  with  axillary  nodal  clearance  for  early  breast  cancer.  Histology  showed  a  pT2  32  mm  grade  2  ductal  carcinoma,  oestrogen  receptor-positive  (7/8),  progesterone  receptor-positive  (7/8)  and  human  epidermal  growth  factor  receptor  2-positive  (3+)  with  4/22  lymph  node  involvement.  At  the  multidisciplinary  team  (MDT)  meeting  it  was  decided  that  she  should  be  offered  chemotherapy  and  trastuzumab,  followed  by  radiotherapy  and  an  aromatase  inhibitor.An  essential  cardiac  history  was  taken:  she  had  had  angina  10  years  previously  and  undergone  coronary  stent  insertion.  She  had  not  had  chest  pain  since,  but  she  did  describe  a  2  year  history  of  fatigue  on  moderate  exertion,  no  shortness  of  breath  and  occasional  ankle  swelling.  ECG  showed  poor  R  wave  progression.  Other  comorbidities  were  hypertension.  Clinically,  she  appeared  anxious,  BP  150/80  mmHg,  with  no  drop  in  lying  to  standing,  jugular  venous  pressure  not  raised,  no  heart  murmurs,  clear  lungs,  and  mild  pitting  oedema  on  both  ankles.  Medications  included  bisoprolol,  aspirin  75  mg,  and  simvastatin.  An  echocardiogram  showed  apical  dyskinesia  (consistent  with  ECG)  and  an  ejection  fraction  of  50%.Optimal  adjuvant  systemic  therapy  guidance  in  the  absence  of  comorbidities  would  suggest  that  she  should  be  offered  an  anthracycline,  taxane  and  trastuzumab-based  regimen.  Cardiac  optimization  prior  to  treatment  was  undertaken,  including  increasing  the  dose  of  bisoprolol,  starting  an  ACE  inhibitor  (ramipril),  and  instituting  strategies  to  reduce  anxiety  levels.The  patient's  ejection  fraction  decreased  during  treatment  and  she  was  managed  according  to  Figure  23.1,  with  an  increase  in  the  dose  of  ramipril  from  1.25  to  3.75  mg.  Her  ejection  fraction  increased  to  52%  and  she  was  able  to  resume  trastuzumab  and  complete  the  standard  18  cycles.What  is  the  patient's  risk  of  cardiotoxicity  from  chemotherapy?How  would  cardiotoxicity  present  itself?How  can  cardiac  risk  be  assessed  and  monitored?How  can  the  patient's  cardiac  status  be  optimized  medically?Can  alternative  chemotherapy  regimens  be  considered  to  reduce  the  risk?