Optimal duration of cardiac monitoring in metastatic HER2-positive breast cancer patients receiving trastuzumab

This audit aims to determine whether the duration of routine cardiac monitoring could be reduced in patients receiving trastuzumab with palliative intent.

Cardiac toxicity is a well-recognised side effect of trastuzumab. Patients with metastatic HER-2 positive breast cancer commonly receive trastuzumab longer than the 12-month adjuvant period. NICE recommends 3-monthly cardiac function assessments during adjuvant treatment, though there is no guidance for patients with advanced disease. NCRI recommends these patients are monitored for 8 months, followed by individualised strategies.

The standard: 

• The results of the audit are compared with the current guidance from NCRI and NICE regarding duration of cardiac monitoring for patients receiving trastuzumab

• NICE defines cardiac toxicity as:

   - Left-ventricular ejection fraction (LVEF) drops by = 10% from baseline and to below 50%   - Patient becomes symptomatic of cardiac toxicity

Target: 

Determine optimum duration of regular cardiac monitoring in metastatic HER-2 positive breast cancer patients receiving trastuzumab.

Indicators: 

Duration of trastuzumab treatment prior to development of cardiac toxicity.

Data items to be collected: 

• Patient details

• Age when treatment started

• Past history of ischaemic heart disease, hypertension, diabetes, or previous use of anthracyclines or ACE-i

• Number of previous lines of chemotherapy

• Previous radiotherapy (site and date)

• Treatment and outcome details

• Date trastuzumab started

• Date of first echocardiogram

• Baseline LVEF

• Intervals of subsequent echocardiograms

• Lowest LVEF

   - Which cycle

   - Did this result in treatment being stopped

   - Was this symptomatic

• Total number of cycles given

• Reason for stopping treatment

• Number of months elapsed before treatment restarted

• Other adverse events

Suggested number: 

All patients with metastatic breast cancer receiving palliative trastuzumab over at least at 2 year period.

To record and justify the duration and frequency of cardiac monitoring on an individual basis.

• Patients identified from previous trastuzumab prescriptions in collaboration with pharmacists

• Review of medical notes, echocardiogram results and trastuzumab prescriptions

1. A l Jones, M Barlow, P J Barrett-Lee. Management of cardiac health in trastuzumab-treated patients with breast cancer: updated United Kingdom National Cancer Research Institute recommendations for monitoring. Br J Cancer. 2009 March 10; 100(5): 684-692

2. National Institute for Health and Clinical Excellence. Trastuzumab for the adjuvant treatment of early-stage HER-2 positive breast cancer. August 2006

Dr Kevin Chiu