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Most heart damage from anthracycline chemotherapy appears within the first year after it finishes, and most of it improves at least partly when it is caught and treated. Heart muscle weakened by trastuzumab usually recovers when the drug is stopped. Radiotherapy to the chest raises the risk of coronary disease years later, in proportion to the dose the heart received.
The best single description of anthracycline cardiotoxicity comes from a cohort of 2,625 patients whose ejection fraction was measured before treatment, every three months during it and for a year afterwards, then twice yearly. Cardiotoxicity, defined as a fall in ejection fraction of more than ten absolute points to below 50 per cent, occurred in 9 per cent. The median time from the end of chemotherapy was 3.5 months, and 98 per cent of cases appeared within the first year. Everyone affected was started on heart failure treatment: 11 per cent recovered fully to their baseline ejection fraction and most of the rest recovered partly. That reframes the old idea of late-onset damage appearing out of nowhere decades later: the first year is when to look.
Trastuzumab is a different and gentler picture. In the HERA trial, one year of trastuzumab after anthracycline chemotherapy caused severe heart failure in 0.8 per cent against none in the observation arm, and a confirmed significant fall in ejection fraction in 3.6 per cent against 0.6 per cent. Of the 73 patients in the trastuzumab arm who reached a cardiac endpoint, 59 reached acute recovery.
Radiotherapy is slower. In a case-control study of 2,168 women treated in Sweden and Denmark between 1958 and 2001, the rate of major coronary events rose by 7.4 per cent for every gray of mean heart dose, with no apparent threshold, starting within five years and continuing into the third decade. Those women were treated with older techniques and received an average mean heart dose of 4.9 gray; breath-hold, prone positioning and modern planning have cut cardiac doses substantially since, so the risk per patient today is lower while the dose-response relationship still holds.
Who is watched, and how. ASCO's 2017 guideline says the threshold for cardiac evaluation should be low in anyone who received potentially cardiotoxic therapy, that higher-risk survivors may benefit from prevention and screening during treatment, and that routine imaging surveillance after treatment may be warranted for higher-risk survivors so that progression can be halted or reversed. The 2022 European Society of Cardiology guideline, the first devoted to cardio-oncology, is the reference for baseline risk stratification and the surveillance schedule. Echocardiography with global longitudinal strain detects dysfunction earlier than ejection fraction, and troponin rises before either.
What comes back, and when: usually partial, sometimes complete, and the timing favours the watchful. For anthracyclines, 11 per cent of those affected returned fully to baseline and most of the rest improved, with treatment started promptly. For trastuzumab, recovery after stopping is the usual outcome. For radiation coronary disease, nothing reverses, which is why the lever is the dose at planning rather than anything done afterwards.
Anthracyclines damage cardiomyocytes through topoisomerase-2-beta-mediated DNA damage and oxidative stress, causing cell loss that is largely irreversible once established but partly compensated if heart failure treatment starts early. Trastuzumab blocks HER2 signalling that cardiomyocytes use for repair, which is why its effect is usually reversible on withdrawal. Radiation injures the coronary microvasculature and endothelium, producing accelerated atherosclerosis years later.
Query for this technology: (TITLE:"Heart function after anthracyclines, trastuzumab and chest radiotherapy" OR ABSTRACT:"Heart function after anthracyclines, trastuzumab and chest radiotherapy") AND (cancer OR tumor OR tumour OR oncology OR carcinoma OR lymphoma OR leukemia OR leukaemia OR myeloma OR sarcoma OR melanoma OR glioma). Results are unfiltered search hits about Heart function after anthracyclines, trastuzumab and chest radiotherapy, not a curated reading list.
Shares Late effects and survivorship toxicity, Survivorship care and late-effects surveillance, Toxicity and quality of life are undervalued, IMRT / IGRT (modern external beam) and the tags rejuvenation, survivorship.
Shares Late effects and survivorship toxicity, Survivorship care and late-effects surveillance, Survivorship and late effects are neglected, Toxicity and quality of life are undervalued and the tags rejuvenation, survivorship.
Shares Late effects and survivorship toxicity, Survivorship care and late-effects surveillance, Survivorship and late effects are neglected, Toxicity and quality of life are undervalued and the tags rejuvenation, survivorship.
Shares Late effects and survivorship toxicity, Survivorship care and late-effects surveillance, Survivorship and late effects are neglected, Toxicity and quality of life are undervalued and the tags rejuvenation, survivorship.
Shares Late effects and survivorship toxicity, Survivorship care and late-effects surveillance, Survivorship and late effects are neglected, Doxorubicin and the tags rejuvenation, survivorship.
Shares Late effects and survivorship toxicity, Survivorship care and late-effects surveillance, Survivorship and late effects are neglected, Toxicity and quality of life are undervalued and the tags rejuvenation, survivorship.
Shares Late effects and survivorship toxicity, Survivorship care and late-effects surveillance, Survivorship and late effects are neglected, Hodgkin lymphoma and the tags rejuvenation, survivorship.
Shares Late effects and survivorship toxicity, Survivorship care and late-effects surveillance, Survivorship and late effects are neglected, Toxicity and quality of life are undervalued and the tags rejuvenation, survivorship.