For cancer patients whose medical treatments could put them at risk for future cardiac problems, strain echocardiography can help physicians detect early signs of cardiac toxicity. To help get this information out to those who need it, an American echocardiography society is preparing a guideline document outlining the best way to evaluate cancer patients, and has funded a research study to enhance identification of patients who are at risk.

In the past, when cancer treatments were not very effective and cancer was usually fatal, little attention was paid to the complications from treatment. With the advent of more successful new therapies for cancer that have raised survival rates, concerns about their long-term effects have now become paramount. “There are 2.2 million survivors of breast cancer in the US alone,” said Juan Carlos Plana, MD, codirector of cardio-oncology, Cleveland Clinic (Cleveland, OH, USA), “and heart disease, not cancer, is the biggest risk they face.”

When a patient is diagnosed with breast cancer, she (or he) is tested for the HER2 (human epidermal growth factor receptor 2) mutation, an aggressive form of cancer, which affects 20% to 25% of breast cancer patients, typically treated with Doxorubicin followed by Herceptin. Unfortunately, as many as one third of patients receiving these two drugs will develop cardiotoxicity, and some will progress to full-blown heart failure, which means they could potentially need mechanical devices or heart transplants in order to survive.

The introduction of strain echocardiography for early identification of cardiac problems is great news for those suffering from many forms of cancer. “The goal is not to stop cancer therapy, but to identify cardiotoxicity early and to protect the heart with medications so heart failure does not become a problem and the cancer treatment can be continued,” Dr. Plana explained. “Currently, 17% of patients receiving treatment for the most aggressive form of breast cancer have to stop therapy due to heart issues. The sensitivity of strain echo allows early detection so oncologists can treat their patients without fear of the downstream effects of the therapies.”

Dr. Plana, who is a fellow of the American Society of Echocardiography (ASE; Morrisville, NC, USA) and served as medical director of cardiac imaging at MD Anderson Cancer Center (Houston, TX, USA), now heads a newly-formed cardio-oncology center at the Cleveland Clinic, where every patient slated for a cancer therapy with the potential for toxicity receives an intensive left-ventricular mechanics protocol, which includes both three-dimensional (3D) echocardiography with contrast and strain imaging.

To highlight the benefits of these screenings, ASE has collaborated with the European Association of Echocardiography (Sophia Antipolis, France) and the American Society of Clinical Oncology (Alexandria, VA, USA) to organize a guideline-writing group, led by Dr. Plana. An earlier article written with ASE board of directors member Marielle Scherrer-Crosbie, MD, PhD, FASE, MCH, associate professor of medicine, Massachusetts General Hospital and Harvard Medical School (both based in Boston, MA, USA), and others for the American Journal of Cardiology, has already outlined exciting progress in this area.

ASE expects its new guideline to be available in 2012. To take the new clinical application for echocardiography one step further, the ASE Education and Research Foundation has also funded a career development award on the use of strain and 3D echocardiography to identify patients who are at high risk for developing heart complications even before they start chemotherapy treatment. The lead researcher, ASE member Timothy Tan, MBBS, PhD, clinical and research fellow, Massachusetts General Hospital and Harvard Medical School, hopes the research “will increase the understanding of heart failure associated with cancer treatment, potentially helping to decrease its morbidity and mortality.”

As the largest global organization for cardiovascular ultrasound imaging, the American Society of Echocardiography (ASE) is a leader and advocate, setting practice standards and guidelines. Comprised of over 15,000 physicians, sonographers, nurses, and scientists, ASE is a strong voice providing guidance, expertise, and education to its members with a commitment to improving the practice of ultrasound and imaging of the heart and cardiovascular system for better patient outcomes. The full text of ASE’s guidelines is available online

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