Introduction Anthracycline chemotherapy, Herceptin and Pertuzumab are commonly used in the management of metastatic breast cancer. All three drugs are known to be cardiotoxic.
The aim of this audit was to see whether woman commenced on these medications were seen and reviewed in line with the guidance from the London cancer alliance and NICE. These guidelines recommend the assessment of cardiac risk factors and a baseline echo before these therapies are commenced. Additionally, patients started on Herceptin and Pertuzumab require an echo every 3 months. If the patient’s LVEF changes by 10% or more from the baseline and is between 40-50% they should be started on ramipril and their LVEF should be reassessed in 6-8 weeks.
Method This audit looked at 35 women with breast cancer between the ages of 30 and 70 who had an echo at Charing Cross Hospital between 15th April and 20th May 2019. All women were started on anthracycline chemotherapy, Herceptin or pertuzumab. For each woman a retrospective review of all their previous echos was completed. In total 119 echos were reviewed, with the oldest dating back to 2017.
34/35 patients had an echo before treatment
All 119 echos assessed the LVEF
All the patients on herceptin or pertuzumab had echos every 3 or 4 months.
1 patient’s LVEF fell to <50% and changed by >10% from their baseline. They were started on ramipril and had a repeat echo in 8 weeks. LVEF is stable at 49.
2 patients had a 10% or more change in their LVEF compared to their baseline echo. In both cases the LVEF remained above 50%. 1 of these individuals was referred to cardiology and started on enalapril 2.5 mg. In the second case there is no mention of any cardiology follow up and they have not been commenced on an ACE inhibitor.
27% of echos included measurements of right ventricle systolic function (both TAPSE and TDI s)
Adherence to local guidelines is consistent
When changes in LV function are seen no standardised approach exists to ensure action is consistently taken.
The latest guidance from the European Association of cardiovascular imaging (international) refers to further detailed LV and RV assessment which is currently missing from local guidance. For example research suggests that chemotherapy can also adversely affect right heart function. It has been hypothesised that a thinner RV may even be more sensitive to the toxic effects of chemotherapy than the thicker LV.
Therefore, in conclusion it is necessary to formalise a pathway for reviewing echos and acting on findings. This should be through formal echo MDT meetings. There should also be a Review of echo protocol to include LV and RV detailed serial measurement.
Conflict of Interest None
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