Cardiac care

Ongoing assessment for toxicities/late effects

In patients with breast cancer ensure that follow-up care includes ongoing assessment and supportive care for possible long-term toxicities and late effects of adjuvant treatments (including secondary cancers, cardiovascular toxicity, lymphoedema, mental health (including distress, depression, anxiety, body image), sexual health, premature menopause, infertility, fatigue, weight gain, impaired cognitive function, musculoskeletal health, pain and neuropathy, and bone health).

Surveillance during treatment – Patients at increased risk of cardiac dysfunction

Consider routine surveillance, preferably with an echocardiogram, of asymptomatic patients considered to be at increased risk of developing cardiac dysfunction. Frequency of surveillance should be determined by patient baseline and future risk of cardiotoxicity.

Anthracyclines and taxanes – Cumulative toxicity

When choosing a chemotherapy regimen, consider the cumulative toxicity when an anthracycline and a taxane are used together.

Cardiac risk assessment

A baseline cardiac risk assessment, including an echocardiogram, should be undertaken for patients whose treatment will include chemotherapy (especially anthracyclines) or HER2 therapy (especially trastuzumab) or left-sided radiation therapy.

Use of potentially cardiotoxic therapies

Avoid or minimise the use of potentially cardiotoxic therapies if established alternatives exist that would not compromise cancer-specific outcomes.

Radiation therapy to the chest wall after mastectomy #2

For patients with breast cancer who have undergone a mastectomy and have macrometastases in 1-3 lymph nodes, consider adjuvant radiation therapy to the chest wall.

Radiation therapy and adverse effects

In patients undergoing radiation therapy use techniques that minimise the dose to the lung and heart, including deep inspiratory breath-holding for left-sided cancer.

Surveillance during follow-up – Patients at increased risk of cardiac dysfunction

In asymptomatic patients considered to be at increased risk of cardiac dysfunction, perform cardiac imaging (preferably an echocardiogram, or a cardiac MRI or a gated heart pool scan) between 6-12 months and at 24 months after completion of cancer-directed therapy.  

Fatigue assessment

Assess all patients with breast cancer for fatigue and advise patients on the importance of good sleep hygiene practices.

MDT treatment planning – Cardiac care

Close and early collaboration between oncologists and cardiologists is recommended for those patients that require treatment with a potentially cardiotoxic treatment, particularly in the context of existing cardiovascular disease or multiple cardiovascular risk factors.

Anti-HER2 therapy – Cardiac monitoring

In patients receiving trastuzumab, consider monitoring cardiac function during treatment (e.g. every 3 months) and follow-up. Early referral to a cardiologist should be considered in cases of deterioration in cardiac function.

Cardiac risk information

Inform patients and their GPs of potential cardiac risks associated with treatment, the importance of ongoing monitoring and management of cardiac health and cardiovascular risk factors based on their baseline and future risk of cardiac dysfunction, and, encourage a heart-healthy lifestyle.

Cardiac dysfunction – Symptomatic

In patients with clinical signs or symptoms of cardiac dysfunction during routine clinical assessment throughout treatment, the following approaches are recommended:
i. Echocardiogram for diagnostic workup
ii. Cardiac MRI can be performed if echocardiogram is not available or is not technically feasible (e.g. poor image quality). Alternatively, gated heart pool scan can be considered
iii. Serum cardiac biomarkers (troponins, natriuretic peptides) as an adjunct to imaging and clinical assessment
iv. Refer to a cardiologist based on clinical context and findings.

Consider deferral or cessation of cardiotoxic treatment where clinically indicated, in collaboration with a cardiologist.