Table 1

Advantages and disadvantages of imaging and circulating biomarkers

AdvantagesDisadvantagesReferences
Imaging biomarkers
 LVEF—TTE

  • Widely accessible

  • Ease of use

  • Established prognostic value of abnormal LVEF in heart failure

  • Interobserver and intraobserver variability

  • Limited negative predictive value

  • LVEF may remain normal despite subclinical damage

  • Limited by image quality

  • Load dependent

7
 Global longitudinal strain—STE

  • Emerging data suggest strain can detect early cardiotoxicity prior to overt LVEF decline

  • Established prognostic value in other cardiovascular disease states (eg, heart failure and myocardial infarction)

  • Limited availability and expertise

  • Variability between different vendors

  • Similar to LVEF assessment, limited by image quality and also load dependent

  • Need for additional research prior to widespread clinical implementation

11–13
 Late gadolinium enhancement—cMRIAllows for detection of focal myocardial fibrosis or scar

  • Limited availability and potential cost of cMRI

  • Poor diagnostic and prognostic value for cardiotoxicity

15
 Extracellular volume—cMRIAllows for detection of diffuse myocardial fibrosis

  • Limited availability and high cost of cMRI

  • Limited data

16
Circulating Biomarkers
 Troponin

  • Widely available

  • Commonly studied cardiac biomarker for multiple cancers and treatment exposures

  • Elevated levels during cancer treatment may predict subsequent LVEF decline

  • Elevated levels may predict response to heart failure therapy

  • Established diagnostic reference ranges

  • Optimal threshold value for risk prediction uncertain

  • Unknown optimal timing (ie, before, during, or after treatment) or frequency of troponin testing

  • Limited availability of high-sensitivity assays

  • Inconsistent associations with cardiotoxicity risk

11 20–22 24 27 32–36
 Brain-type natriuretic peptide

  • Widely available

  • Gold-standard biomarker for clinical heart failure with established prognostic significance

  • Established diagnostic reference ranges

  • Optimal threshold value for risk prediction uncertain

  • Unknown optimal timing (ie, before, during or after treatment) or frequency of testing

  • Inconsistent associations with cardiotoxicity risk

11 26 31 33 35 37 38
 MyeloperoxidaseMay be mechanistically relevant and associated with risk of anthracycline and trastuzumab cardiotoxicity

  • Limited data and need for external validation

  • Sensitive to processing conditions

27 39

  • cMRI, cardiac MRI; LVEF, left ventricular ejection fraction; STE, speckle tracking echocardiogram; TTE, transthoracic echocardiogram.