|
众所周知，年龄越大，心衰风险越高。虽然乳腺癌术后辅助治疗可以改善癌症相关生存，但是可能引起不良事件。其中，心脏毒性是威胁生命的不良事件之一，可在治疗后短期或长期发生。不过，国际指南对于癌症生存者心脏功能的长期监测存在争议。美国综合癌症网络指南建议，蒽环类治疗完成后1年内应该进行充血性心力衰竭临床筛查。美国临床肿瘤学会指南还指出，高风险无症状癌症生存者癌症靶向治疗后6～12个月应该进行超声心动图检查。可是，欧洲肿瘤内科学会、加拿大心血管学会、美国超声心动图学会的指南提议对癌症生存者进行长期心脏监测。目前为止，关于乳腺癌生存者充血性心力衰竭真实发生率和自然病程的证据不足。既往研究仅局限于接受特定方案治疗的患者且样本量相对较小。其他根据医保索赔数据的研究主要针对高风险老年患者，或者根据不太准确的疾病诊断方法高估了充血性心力衰竭真实发生率。此外，大多数既往研究都集中于蒽环类所致充血性心力衰竭。因此，缺乏对其他心脏毒性反应（例如心肌梗塞或心肌炎）进行监测或管理的明确指南。 2019年8月27日，美国癌症学会《癌症》在线发表韩国顺天乡大学首尔医院、高阳一山医院、蔚山大学首尔峨山医院、全北大学医院、韩国天主教大学、国家癌症中心、顺天乡大学医学院、蔚山东冈医院、亚洲大学医学院的SMARTSHIP协作组全国范围大型回顾研究报告，其中包括全国医疗信息数据库9万多例乳腺癌生存者，调查了乳腺癌诊断两年以后迟发充血性心力衰竭的发生率，并与无癌症人群进行比较，分析了乳腺癌生存者迟发充血性心力衰竭的风险因素。 全国医疗保险服务中心是韩国政府的医疗保险机构，其全国医疗信息数据库可以提供将近97%的韩国公民全套医疗信息。许多研究都根据全国医疗信息数据库进行，其对于研究乳腺癌生存者的可行性已被证实。该研究按1∶3将乳腺癌生存者与无癌症对照者进行年龄和性别匹配，通过多因素比例风险回归模型，分析迟发充血性心力衰竭的发生率和风险因素。通过生存曲线分析和对数秩检验，评估迟发充血性心力衰竭的累计发病率。 结果，该研究对2007年1月～2013年12月的9万1227例乳腺癌生存者（28万6480人×年）和27万3681例无癌症对照者（88万4349人×年）进行了分析。 乳腺癌生存者与无癌症对照者相比：
根据多因素比例风险回归模型分析：
因此，该研究结果表明，年轻乳腺癌生存者与年轻无癌症对照者相比，两年以后迟发充血性心力衰竭发生风险较高。长期而言，应该更多关注接受紫杉类或蒽环类化疗方案的年轻乳腺癌生存者。 对此，美国威斯康星大学发表同期评论：乳腺癌治疗后迟发心力衰竭。该评论认为，虽然乳腺癌诊断以后迟发心力衰竭是罕见事件，但是有必要对潜在毒性药物化疗后心脏并发症保持警惕。 相关阅读 Cancer. 2019 Aug 27. [Epub ahead of print] Long-term risk of congestive heart failure in younger breast cancer survivors: A nationwide study by the SMARTSHIP group. Lee J, Hur H, Lee JW, Youn HJ, Han K, Kim NW, Jung S, Kim Z, Kim KS, Lee MH, Han S, Jung SH, Chung IY. Soonchunhyang University Seoul Hospital, Seoul, Korea; National Health Insurance Service Ilsan Hospital, Goyang-Si, Korea; Asan Medical Center University of Ulsan College of Medicine, Seoul, Korea; Chonbuk National University Hospital, Jeonju-Si, Korea; Catholic University of Korea, Seoul, Korea; National Cancer Center, Goyang, Korea; Soonchunhyang University College of Medicine, Bucheon, Korea; Dongkang Medical Center, Ulsan, Korea; Ajou University School of Medicine, Suwon, Korea. Young breast cancer survivors have a greater risk of late congestive heart failure in comparison with the young population without cancer. More attention should be paid to young breast cancer survivors over the long term. BACKGROUND: There is a controversy about late-onset congestive heart failure (CHF) among breast cancer survivors. This study investigated the incidence rate and risk factors of late-onset CHF more than 2 years after the breast cancer diagnosis. METHODS: A nationwide, retrospective study was conducted with the National Health Information Database. With 1:3 age- and sex-matched noncancer controls, Cox proportional hazard regression models were used to analyze the incidence and risk factors of late CHF. The cumulative incidence rate of late CHF was evaluated with a Kaplan-Meier analysis and a log-rank test. RESULTS: A total of 91,227 cases (286,480 person-years) and 273,681 controls (884,349 person-years) were evaluated between January 2007 and December 2013. The risks of late CHF were higher in cases than controls (hazard ratio [HR], 1.396; 95% confidence interval [CI], 1.268-1.538). Younger survivors (age ≤ 50 years) showed a higher risk of late CHF than their younger counterparts (HR, 2.903; 95% CI, 2.425-3.474). Although older age was a risk factor for late CHF, older survivors (age ≥ 66 years) showed no difference in the risk of late CHF in comparison with their counterparts (HR, 0.906; 95% CI, 0.757-1.084). Anthracyclines and taxanes were risk factors for late CHF, although trastuzumab, radiation, and endocrine therapy were not. CONCLUSIONS: Young breast cancer survivors have a greater risk of late CHF than the young population without cancer. More attention should be paid to young breast cancer survivors who receive taxane- or anthracycline-based regimens over the long term. KEYWORDS: adjuvant; adverse effects; breast neoplasms; chemotherapy; heart diseases; survivorship DOI: 10.1002/cncr.32485 Cancer. 2019 Aug 27. [Epub ahead of print] Late-onset heart failure after treatment for breast cancer. Steven M. Ewer, David D. Pham. University of Wisconsin Clinical Science Center, Madison, Wisconsin; University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. Late-onset heart failure after breast cancer is a rare event. It is necessary to remain vigilant for cardiac complications after potentially toxic cancer treatments. DOI: 10.1002/cncr.32483
|
|
|
