Trastuzumab therapy in Australia: which patients with HER2+ metastatic breast cancer are assessed for cardiac
Christine Y Lu1, Preeyaporn Srasuebkul, Anna K Drew
1Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA 02215, USA. christine_lu@harvardpilgrim.org
Insights
Cardiac function assessments for patients receiving trastuzumab for breast cancer were inconsistent with guidelines. Clinicians appear to triage patients based on cardiac risk factors rather than routine monitoring.
Area of Science:
- Oncology
- Cardiology
- Pharmacovigilance
Background:
- Trastuzumab is a key treatment for HER2+ metastatic breast cancer.
- Trastuzumab can cause cardiotoxicity, necessitating cardiac monitoring.
- Guidelines recommend pre-treatment and regular during-treatment cardiac function assessments.
Purpose of the Study:
- To evaluate the rates of cardiac function assessment in patients receiving trastuzumab.
- To identify predictors of cardiac assessment in routine clinical care.
- To assess adherence to guidelines for trastuzumab-related cardiotoxicity management.
Main Methods:
- Retrospective cohort study of 3418 women receiving trastuzumab (2001-2010).
- Analysis of pre-treatment and during-treatment cardiac assessment rates.
- Logistic and zero-inflated Poisson regression used to identify predictors of assessment.
Main Results:
- Only 37.7% received pre-treatment assessment; 50.4% received during-treatment assessment.
- Cardiovascular history and anthracycline use predicted pre-treatment assessment.
- Concurrent chemotherapy and older age predicted during-treatment assessment, but multi-morbidities were associated with less assessment.
Conclusions:
- Cardiac function assessment rates did not align with clinical guidelines over a decade.
- Clinicians may be triaging patients for assessment based on perceived risk.
- Barriers to guideline implementation, especially for multi-morbid patients, require investigation.
Purpose:
To manage the potential trastuzumab mediated cardiotoxicity, clinical guidelines recommend pre-treatment cardiac function assessment and 3-monthly reassessment during therapy. This study examined rates of cardiac function assessment and predictors of assessment among patients receiving trastuzumab for HER2+ metastatic breast cancer treatment in routine clinical care.
Methods:
Our cohort comprised 3418 women receiving trastuzumab for HER2+ metastatic breast cancer under Australia's nationally funded Herceptin Program (2001-2010). We examined rates of pre-treatment and during-treatment assessment. We used logistic regression and zero-inflated Poisson regression to examine predictors of pre-treatment and during-treatment assessment respectively.
Results:
37.7% of patients were assessed pre-treatment, 50.4% during therapy, and 26.4% both before and during therapy. Among patients assessed for cardiac function, reassessment occurred regularly (median of 3.9 months). History of cardiovascular conditions and prior anthracycline use predicted pre-treatment assessment (OR = 1.32, 95% CI: 1.08-1.61; OR = 1.23, 95% CI: 1.05-1.44 respectively). Concurrent trastuzumab and taxane use, exposure to anthracyclines, and older age predicted during-treatment assessment (IRR = 1.17, 95% CI: 1.06-1.29; IRR = 1.12, 95% CI: 1.02-1.23; and IRR = 1.05, 95% CI: 1.01-1.09 respectively). Patients with multi-morbidities were less likely to receive during-treatment assessment.
Conclusion:
Over the last decade, cardiac function assessment in a large cohort of patients receiving trastuzumab was not consistent with guideline recommendations. The association between cardiac monitoring and risk factors for cardiac dysfunction suggest clinicians are triaging patients prior to implementing cardiac assessment. Efforts are needed to identify barriers to implementing current guidelines for cardiac monitoring in metastatic breast cancer patients undergoing trastuzumab treatment, particularly those with multi-morbidities.
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