Indicaciones para el uso de pertuzumab en cáncer de mama HER2 positivono metastásico en los escenarios neoadyuvante y adyuvante. Revisión de la evidencia y abordaje terapéutico en el Instituto Nacional de Cancerología - Colombia / Indications for the use of pertuzumab in non-metastatic HER2-positive breast cancer in the neoadjuvant and adjuvant. Review of the literature and therapeutic approach at the Instituto Nacional de Cancerología - Colombia

La adición de la terapia dirigida a la quimioterapia citotóxica en pacientes con cáncer de mama ha mejorado significativamente los desenlaces oncológicos en las pacientes con tumores HER2 positivo. El uso de pertuzumab durante el manejo neoadyuvante incrementa significativamente la respuesta patológica completa y en la actualidad permite emplear regímenes libres de antraciclinas con una eficacia similar y menores efectos cardiovasculares (en especial sobre la fracción de eyección). El beneficio en supervivencia libre de enfermedad invasiva, de adicionar pertuzumab en el escenario adyuvante en las pacientes sin tratamiento anti HER2 previo, está limitado a aquellas con ganglios positivos. La implementación de esquemas con bloqueo dual anti HER2, durante el tratamiento inicial del cáncer de mama HER2 positivo, mejora significativamente el pronóstico oncológico en este grupo de pacientes.

The addition of targeted therapy to cytotoxic chemotherapy in patients with breast cancer has significantly improved oncologic outcomes in patients with HER2-positive tumors. The use of pertuzumab during neoadjuvant management significantly increases the complete pathological response and currently allows the use of anthracycline-free regimens with similar efficacy and fewer cardiovascular effects (especially on ejection fraction). The benefit of pertuzumab in disease-free survival in the adjuvant setting for patients without prior anti-HER2 treatment is limited to those with positive nodes. The implementation of schemes with dual anti-HER2 blockade during the initial treatment of HER2-positive breast cancer significantly improves the oncological outcomes in this group of patients.

Multiple cutaneous telangiectasias after the use of trastuzumab: a case report

We aim to report a particular case of cutaneous telangiectasias on the arms after immunotherapy with trastuzumab plus paclitaxel to treat breast cancer. New oncology therapies reflect a major advance in cancer treatment. They greatly increase survival; however, they still cause certain adverse cutaneous events that should be taken into account for their proper management.

Características y manejo del cáncer de mama precoz en mujeres añosas asistidas en la Unidad Docente Asistencial de Mastología del Hospital de Clínicas en el período 2011-2018 / Characteristics and management of early breast cancer in elderly women assisted in the Mastology Care Teaching Unit of the Hospital de Clínicas in the period 2011-2018 / Características e manejo do câncer de mama precoce em idosas atendidas na Unidade de Ensino de Mastologia do Hospital de Clínicas no período de 2011-2018

Introducción: Existen pocas pautas para el tratamiento del cáncer de mama (CM) en pacientes añosas, lo que puede conducir al sub o sobre tratamiento. Objetivo: Conocer las características, manejo y la evolución del CM precoz en mujeres añosas. Material y métodos: Estudio observacional, descriptivo, transversal. Se recolectaron datos relacionados con las características clínico-patológicas y la evolución de pacientes de 70 años o más tratadas por CM en el período comprendido entre el 1/1/ 2011 y el 31/12/ 2018, asistidas en el Hospital de Clínicas. Se utilizaron herramientas de estadística descriptiva y para calcular la sobrevida global (SVG) se utilizó el método de Kaplan-Meier. Resultados: se incluyeron 31 pacientes; la edad mediana al diagnóstico fue 76,8 años; las características clínico-patológicas fueron: carcinoma ductal: 71%; GH 1-2: 74,2%; estadio I: 54,8 %; sin metástasis axilares: 80,6 %; HER2-RE/RP+ 80,6%; HER2+ 16,7%, y triple negativas 3,2%. El 29% de las pacientes fueron diagnosticadas mediante tamizaje poblacional y el 74,2% recibieron tratamiento según pautas vigentes, mientras que el 38,7% fueron subtratadas y el 16,1% sobretratadas. La mediana de SVG fue de 98,7 meses. Conclusiones: Una minoría de las pacientes fue diagnosticada mediante tamizaje poblacional, el tipo histológico más frecuente fue el ductal y la prevalencia de los tumores HER2-RE/RP+ fue mayor que en las pacientes más jóvenes. La mayoría de las pacientes recibió tratamiento estandar.

Introduction: There are few guidelines for the treatment of breast cancer (BC) in older patients, which can lead to under- or over-treatment. Objective: To understand the characteristics, management and evolution of early BC in older women. Material and methods: Observational, descriptive, cross-sectional study. Data were collected on the clinical-pathological characteristics and evolution of patients aged 70 years or older, treated for BC in the period from 1/1/ 2011 to 31/12/ 2018, at the Hospital de Clínicas. Descriptive statistical tools were used and the Kaplan-Meier method was applied to calculate the overall survival (OS) rate. Results: 31 patients were included; median age at diagnosis was 76.8 years old; the clinical-pathological characteristics were: ductal carcinoma: 71%; HG 1-2: 74.2%; stage I: 54.8%; no axillary metastases: 80.6%; HER2-ER/PR+ 80.6%; HER2+ 16.7%, and triple negative 3.2%. Of all the patients, 29% were diagnosed through screening and 74.2% were treated according to current guidelines, while 38.7% were under-treated and 16.1% over-treated. The median OS was 98.7 months. Conclusions: A minority of patients were diagnosed by screening, the most frequent histological type was ductal and the prevalence of HER2-RE/RP+ tumors was higher than in younger patients. Most patients received standard treatment.

Introdução: Existem poucas diretrizes para o tratamento do câncer de mama (CM) em pacientes idosos, o que pode levar ao sub ou excesso de tratamento. Objetivo: Conhecer as características, manejo e evolução do MC precoce em mulheres idosas. Material e métodos: estudo observacional, descritivo e transversal. Foram coletados dados relacionados às características clínico-patológicas e à evolução dos pacientes com 70 anos ou mais atendidos por CM no período de 01/01/2011 a 31/12/2018, atendidos no Hospital de Clínicas. Ferramentas de estatística descritiva foram usadas e o método de Kaplan-Meier foi usado para calcular a sobrevida global (SVG). Resultados: 31 pacientes foram incluídos; a mediana de idade ao diagnóstico foi de 76,8 anos; as características clínico-patológicas foram: carcinoma ductal: 71%; GH 1-2: 74,2%; estágio I: 54,8%; sem metástases axilares: 80,6%; HER2-RE / RP + 80,6%; HER2 + 16,7% e triplo negativo 3,2%. 29% dos pacientes foram diagnosticados por triagem populacional e 74,2% receberam tratamento de acordo com as diretrizes atuais, enquanto 38,7% foram subtratados e 16,1% supertratados. O SVG médio foi de 98,7 meses. Conclusões: A minoria dos pacientes foi diagnosticada por rastreamento populacional, o tipo histológico mais frequente foi ductal e a prevalência de tumores HER2-RE / RP + foi maior do que em pacientes mais jovens. A maioria dos pacientes recebeu tratamento padrão.

Factors affecting pathological complete response after neoadjuvant chemotherapy in breast cancer: a single-center experience

SUMMARY OBJECTIVE: The aim of this study was to examine the characteristics of patients admitted to our hospital with a diagnosis of breast cancer who reached pathological complete response after being operated following eight cycles of neoadjuvant chemotherapy. METHODS: Between 2015-2020, patients with pathological complete response who were operated on after neoadjuvant chemotherapy and sent to our clinic for radiotherapy were evaluated. RESULTS: The median age of the patients was 51 years. The most common histological type was invasive ductal cancer. The number of pathological complete response patients was 74 (28%), and the number of non-pathological complete response patients was 188 (72%). Patients with pathological complete response had a smaller tumor diameter than the non-pathological complete response group (p=0.001). For pathological complete response, T1 stage, N1 stage, NG 3, Ki-67 >20%, negative estrogen receptor, negative progesterone receptor, positive Cerb-B2, and adding trastuzumab to chemotherapy were statistically significant (p<0.05). Before neoadjuvant chemotherapy, stage T1-T2 (p=0.036), LN0-1 (p=0.026), Cerb-B2 positivity (p=0.025), and an initial nuclear grade of three (p=0.001) were found to be the factors affecting pathological complete response. CONCLUSIONS: With neoadjuvant chemotherapy, the size of locally advanced tumors decreases, allowing breast conserving surgery. The neoadjuvant chemotherapy response can be used as an early indicator of the prognosis of patients with breast cancer. Today, neoadjuvant chemotherapy is also used for patients with early-stage, operable breast cancer because it has been shown in many studies that reaching pathological complete response is associated with positive long-term results. If we can identify patients who have reached pathological complete response before neoadjuvant chemotherapy, we think we can also determine a patient-specific treatment plan at the beginning of treatment.

La importancia de la determinación del HER2 en el cáncer gástrico avanzado: a propósito de un caso clínico / Importance of HER2 status determination in advanced gastric cancer: A case study

Resumen El cáncer gástrico avanzado es una entidad que incluye dos situaciones clínicas distintas: el cáncer gástrico localmente avanzado no resecable y la enfermedad metastásica, cuyo tratamiento estándar es la quimioterapia. La sobreexpresión del receptor 2 del factor de crecimiento epidérmico humano (HER2) se puede presentar en esta enfermedad de un 9 % a un 38 % y ha sido el primer biomarcador predictivo utilizado para el tratamiento dirigido con trastuzumab en pacientes con tumores gástricos y de la región gastroesofágica avanzados. Se presenta en este artículo el caso de un paciente con cáncer gástrico avanzado con HER2 positivo manejado con quimioterapia convencional más trastuzumab como terapia blanco con adecuada respuesta clínica.

Abstract Advanced gastric cancer (AGC) is an entity that encompasses two distinct clinical situations: locally advanced unresectable gastric cancer and metastatic disease, with chemotherapy as the standard treatment. HER2 overexpression can occur in 9% to 38% of the cases with this disease and has been the first predictive biomarker used for trastuzumab-targeted therapy in patients with advanced gastric and gastroesophageal tumors. This article presents a patient with AGC and positive HER2 treated with conventional chemotherapy plus trastuzumab as targeted therapy with adequate clinical response.

Cardiotoxicidad inducida por trastuzumab en paciente con carcinoma de mama HER-2 positivo / Trastuzumab-induced cardiotoxicity in a patient with HER-2 positive breast carcinoma

Introducción: La disfunción cardíaca emerge como una de las principales causas de morbilidad y mortalidad entre los sobrevivientes de cáncer. En la actualidad, el trastuzumab se considera parte de la terapia estándar para el cáncer de mama; sin embargo, se asocia a una variada incidencia de cardiotoxicidad. Caso clínico: Paciente femenina de 52 años que recibió neoadyuvancia con antraciclinas, y luego, taxanos combinados a trastuzumab. Se le realizó una cuadrantectomía de mama izquierda por un carcinoma ducto lobulillar infiltrante, etapa IIIa, con un fenotipo: luminal B- Her2 positivo. Desarrolló una insuficiencia cardiaca congestiva, luego de dos dosis de trastuzumab posoperatorio. La fracción de eyección ventricular izquierda descendió de 65 por ciento (previo al tratamiento con antraciclinas) a 44 por ciento. Recibió tratamiento con enalapril, carvedilol, y espironolactona. Se recuperó la fracción de eyección ventricular izquierda a 57 por ciento, por lo que se reintrodujo el trastuzumab y así completar las 18 dosis planificadas, luego de cuatro meses de suspensión. Actualmente, está libre de enfermedad, en tratamiento hormonal con letrozol y sin síntomas cardiovasculares. Conclusiones: La cardiotoxicidad por trastuzumab puede ser reversible, si se trata adecuada y oportunamente, en el marco de grupos multidisciplinarios y Unidades de Cardio-Oncología(AU)

Introduction: Cardiac dysfunction emerges as one of the main causes of morbidity and mortality among cancer survivors. Currently, trastuzumab is considered part of the standard therapy for breast cancer; however, it is associated with a varied incidence of cardiotoxicity. Clinical case report: A case of a 52-year-old female patient is reported here, because she received neoadjuvant therapy with anthracyclines and later, taxanes combined with trastuzumab. She underwent a quadrantectomy of her left breast for an infiltrating lobular duct carcinoma, stage IIIa, with a phenotype: luminal B-Her2 positive. She developed congestive heart failure after two doses of postoperative trastuzumab. The left ventricular ejection fraction decreased from 65 percent (prior to anthracycline treatment) to 44 percent. She was treated with enalapril, carvedilol, and spironolactone. The left ventricular ejection fraction was recovered to 57 percent, so trastuzumab was reintroduced and thus complete the 18 planned doses, after four months of suspension. Currently, she is disease-free, on hormonal treatment with letrozole, and without cardiovascular symptoms. Conclusions: Cardiotoxicity due to trastuzumab can be reversible, if it is appropriately and timely treated, within the framework of multidisciplinary groups and Cardio-Oncology Units(AU)

Incidence of central nervous system metastases in patients with human epidermal growth factor receptor 2-positive metastatic breast cancer treated with trastuzumab: A meta-analysis

This study aimed to estimate the incidence of central nervous system (CNS) metastases in patients with human epidermal growth factor receptor 2 (HER2)-positive metastatic breast cancer (MBC) treated with trastuzumab. Studies were identified through a literature search of electronic databases. Random-effects meta-analyses were performed to estimate the incidence rate of CNS metastases, trastuzumab therapy duration, and time from trastuzumab therapy to CNS metastasis diagnosis. A meta-analysis of odds ratios was performed to evaluate the significance of a difference in CNS metastasis incidence between patients with and without trastuzumab treatment. Thirty studies (8121 trastuzumab-treated and 3972 control patients) were included. The follow-up duration was 18.9 months (95% confidence interval [CI]: 13.8, 24.1). The trastuzumab treatment duration was 9.0 months (95% CI: 7.0, 11.0). The median interval between the start of trastuzumab therapy and CNS metastasis diagnosis was 12.2 months (95% CI: 9.5, 14.7). The incidence of CNS metastasis after the start of trastuzumab therapy was 22% (95% CI: 16, 27). The incidence of CNS metastases was significantly higher in trastuzumab-treated than in non-trastuzumab-treated patients (odds ratio: 1.39 [95% CI: 1.06, 1.82], p=0.02). The survival time from the start of the study was 23.4 months (95% CI: 19.7, 27.1) in trastuzumab-treated patients and 18.4 months (95% CI: 12.7, 24.1) in patients treated with control regimens. The survival time after the development of CNS metastases in trastuzumab-treated patients was 19.2 months (95% CI: 15.6, 25.9). Approximately 22% of patients with HER2-positive MBC who were treated with trastuzumab developed CNS metastases. However, trastuzumab-treated patients had a longer survival than patients who were not treated with trastuzumab.

Gliomas de Alto Grado del Adulto, Biología Molecular (Parte I) / High-Grade Gliomas of the Adult, Molecular Biology (Part I)

Introducción: Los tumores gliales, dentro de las lesiones neuroepiteliales, son las neoplásicas intraaxiales más comunes. Representan alrededor del 45% de todos los tumores primarios del sistema nervioso central (SNC) y el 77% de todos los tumores primarios malignos del SNC. El promedio de supervivencia media de los pacientes con glioblastoma multiforme (GBM) cuando se utiliza el tratamiento multimodal es de 15-18 meses y de 2 a 5 años con gliomas anaplásicos. Los tratamientos convencionales de los tumores cerebrales incluyen cirugía, radioterapia y quimioterapia. El tratamiento quirúrgico representa la primera aproximación para la gran mayoría de tumores cerebrales, sin embargo, la resección total no siempre es alcanzable en relación con la localización del tumor, de vital importancia para preservar estructuras nerviosas o vasculares. Modalidades de tratamiento agresivas han extendido la supervivencia media, pero la supervivencia a menudo se asocia con un deterioro significativo en la calidad de vida. La eficacia de quimioterapia sistémica está limitada por la presencia de la barrera hemato encefálica (BHE), la que limita el paso de una amplia variedad de agentes anti cancerígenos, la acción de los agentes alquilantes, está limitado por la activación de metil-guanina-metil-transferasa. El advenimiento de los estudios moleculares permite una nueva evaluación de la biología de los gliomas con, un nivel de precisión que promete interesantes avances hacia el desarrollo de terapias específicas eficaces. Las terapias dirigidas bloquean la activación de vías oncogénicas, ya sea a nivel de la interacción ligando-receptor o mediante la inhibición vías de transducción de señales, corriente abajo, inhibiendo así el crecimiento y la progresión del cáncer. El objetivo del presente trabajo fue realizar una revisión bibliográfica acerca de los aspectos relacionados con la patogénesis molecular en la progresión de estos tumores en los adultos, y sus potenciales blancos terapéuticos.

Introduction:Glial tumors, within neuroepithelial lesions, are the most common intraaxial neoplastic. They represent about 45% of all primary central nervous system (CNS) tumors and 77% of all malignant primary CNS tumors. The median median survival of patients with glioblastoma multiforme (GBM) when multimodal treatment is used is 15-18 months and 2-5 years with anaplastic gliomas. Conventional treatments for brain tumors include surgery, radiation therapy, and chemotherapy. Surgical treatment represents the first approach for the vast majority of brain tumors; however, total resection is not always achievable in relation to the location of the tumor, which is vitally important to preserve nerve or vascular structures.Aggressive treatment modalities have extended median survival, but survival is often associated with a significant deterioration in quality of life. The efficacy of systemic chemotherapy is limited by the presence of the blood-brain barrier (BBB), which limits the passage of a wide variety of anticancer agents, the action of alkylating agents, is limited by the activation of methyl-guanine-methyltransferase. The advent of molecular studies allows a new evaluation of the biology of gliomas with, a level of precision that promises interesting advances towards the development of effective specific therapies. Targeted therapies block the activation of oncogenic pathways, either at the level of ligand-receptor interaction or by inhibiting downstream signal transduction pathways, thus inhibiting cancer growth and progression.The objective of the present work was to carry out a bibliographic review about the aspects related to the molecular pathogenesis in the progression of these tumors in adults, and their potential therapeutic targets.

Tratamiento Neoadyuvante en cáncer de mama HER2 positivo. La era de la terapia dirigida / Neoadjuvant treatment in HER2 positive breast cancer. The Age of Targeted Therapy

Introducción: El tratamiento neodyuvante del cáncer de mama HER2 positivo ha ido evolucionando a través del tiempo, con la implementación de nuevas estrategias de manejo terapéutico. Es de esta manera como el trastuzumab, un anticuerpo monoclonal anti-HER2sigue siendo el tratamiento estándar en este subtipo de cáncer, los primeros estudios en los que se evidencia su eficacia son el realizado por el Dr. Buzdar y el estudio NOAH en los cuales las pacientes alcanzaron mayores tasas de respuesta patológica completa en comparación con quimioterapia sola, así como también un mayor número de cirugías conservadoras de mama en lugar de mastectomía.Con el paso de los años se han ido desarrollando nuevas estrategias de manejo terapéutico, así tenemos el doble bloqueo anti-HER2 con los anticuerpos monoclonales trastuzumab y pertuzumab que han mejorado las tasas de respuesta patológica completa. Además se ha incluido al lapatinib un inhibidor de tirosina quinasa como parte de las terapias dirigidas. Se ha dilucidado si las antraciclinas confieren un beneficio adicional al tratamiento neoadyuvante y los estudios demuestran que el beneficio es el mismo queotros esquemas de quimioterapia. Es en realidad la quimioterapia indispensable en la neoadyuvancia, el estudio PHERGain demuestra que existen pacientes que pueden alcanzar respuesta patológica completa solo con el doble bloqueo anti-her2 (trastuzumab y pertuzumab) lo que evitaría la toxicidad innecesaria por quimioterapia, y se podrían desarrollar estrategias para el manejo de aquellas pacientes que no alcanzaron una respuestapatológica completa posterior al doble bloqueo. Aún queda un campo amplio por explorar y con estudios en curso al momento. Palabras claves:DsCS:Receptor ErbB-2, Trastuzumab, Neoplasias de la Mama, Quimioterapia Adyuvante, Ado-Trastuzumab Emtansina

Introduction:The neodyuvanttreatment of HER2 positive breast cancer has evolved over time, with the implementation of new therapeutic management strategies. It is in this way that trastuzumab, an anti-HER2 monoclonal antibody continues to be the standard treatment in this subtype of cancer, the first studies in which its efficacy is evidenced are the one carried out by Dr. Buzdar and the NOAH study in which patients achieved higher rates of complete pathological response compared to chemotherapy alone, as well as a higher number of breast-conserving surgeries rather than mastectomy.Over the years, new therapeutic management strategies have been developed, thus we have the double anti-HER2 blockade with the monoclonal antibodies trastuzumab and pertuzumab that have improved the ratesof complete pathological response. In addition, lapatinib, a tyrosine kinase inhibitor, has been included as part of targeted therapies. It has been elucidated whether anthracyclines confer an additional benefit to neoadjuvant treatment and studies show that the benefit is the same as other chemotherapy regimens.It is actually the essential chemotherapy in neoadjuvant therapy, the PHERGain study shows that there are patients who can achieve a complete pathological response only with the double anti-her2 blockade (trastuzumab and pertuzumab), which would avoid unnecessary toxicity due to chemotherapy, and strategies could be developed for the management of those patients who did not achieve a complete pathological response after double blockade. There is still a wide field to explore and with studies underway at the moment. Keywords:MESH:Receptor, ErbB-2;Trastuzumab; Breast Neoplasms; Chemotherapy, Adjuvant; Ado-Trastuzumab Emtansine

Cardiotoxicidad de los quimioterapéuticos diferentes a antraciclinas de la lista oficial de medicamentosde la Caja Costarricense del Seguro Social / Cardiotoxicity of chemotherapeutics other than anthracyclines from the official list of medications of the Costa Rican Social Security Fund

Resumen La Cardio-oncología es una nueva disciplina que busca enfocarse en el tamizaje, monitoreo y tratamiento de los pacientes con cáncer que presentan enfermedad cardiaca durante o después de recibir tratamiento. Esto debido a que el efecto cardiotóxico asociado a los quimioterapéuticos es ampliamente conocido y respaldado por abundantes estudios clínicos. Sin embargo, no es hasta épocas recientes que en Costa Rica se desarrollaron por primera vez Unidades Cardio-oncológicas, los cuales actualmente se ubican en diversos centros médicos de nuestro sistema de salud público. A continuación, se presenta un resumen de las manifestaciones clínicas de las diversas terapias oncológicas diferentes a las antraciclinas que tenemos a disposición en la Caja Costarricense del Seguro Social (CCSS).

Abstract Cardio-oncology is a new discipline that looks to focus on the screening, monitoring and treatment of patients withcancer that show up with heart disease during and after their treatment. This is due to the fact that the cardiotoxic effectsassociated to chemotherapeutics is widely known and backed up with abundant clinical trials. Nevertheless, it is not untilrecently that in Costa Rica the Cardio-oncologic Units were created for the first time, which now can be found in multiplemedical centers of our public health system. Up next, we present a summary of the clinical manifestations of the diversenon-anthracycline oncologic therapies that are available in the "Caja Costarricense del Seguro Social".

Impacto del cambio de presentación del trastuzumab para la Seguridad Social de Costa Rica, estudio de minimización de costos / Impact of the change of presentation of the trastuzumab for the Social Security of Costa Rica, cost minimization study

Resumen Objetivo: dado que en este momento está disponible a nivel de la Seguridad Social Costarricense tanto trastuzumab para administración intravenosa como para administración subcutánea, y que la presentación para administración subcutánea ha documentado ser no inferior a la intravenosa, resulta pertinente contar con un estudio de minimización de costes que permita documentar cuál de las formulaciones resulta más conveniente mantener en el sistema público de salud, con base en criterios de eficiencia de la intervención. Métodos: se desarrolló un estudio que evaluó desde la perspectiva financiera de la Seguridad Social de Costa Rica, dos opciones diferentes de aplicación del trastuzumab en pacientes con cáncer de mama. Los procedimientos relacionados fueron identificados y documentados para los dos tipos de aplicación del tratamiento intravenosa y subcutánea. Ambas opciones de tratamiento se basaron en esquemas de diecisiete dosis, con la estimación de los suministros y el tiempo del profesional sanitario para cada posibilidad. El análisis incluyó la evaluación desde la perspectiva del paciente. Resultados: la evaluación económica del procedimiento de administración para ambas alternativas evidenció que la opción subcutánea tenía un costo de aplicación de $ 78,6 y $ 467,34 para la opción intravenosa. Desde la perspectiva financiera, la opción subcutánea constituye la alternativa con un costo menor: $ 4000,00 por tratamiento por paciente, y desde la perspectiva de este, implica un 45,0 % menos de tiempo por sesión de tratamiento por paciente, que en la opción intravenosa. Conclusiones: la formulación de trastuzumab subcutánea evidenció una reducción sustancial de tiempo y costo en comparación con la presentación intravenosa en el sistema de Seguridad Social Costarricense.

Abstract Objective: Given that at this time is available at the Costa Rican Social security both trastuzumab for intravenous as for subcutaneous administration, and that the presentation for subcutaneous administration has documented to be not inferior to the intravenous. It is relevant to have a study of cost minimization to investigate what formulation is more convenient to maintain in the public health system, based on criteria of efficiency of the intervention. Methods: A study was developed to evaluate, from the financial perspective of the Social Security of Costa Rica, two different options of application of trastuzumab in patients with breast cancer. The related procedures were identified and documented for the two types treatment application. Both treatment options were based on seventeen dose schemes, with the estimate of supplies and the time of the health professional for each possibility. The analysis also included the evaluation from the patient's perspective. Results: The economic evaluation of the application procedure for both alternatives evidenced that the subcutaneous option had an application cost of $78.6 and $467.34 for the intravenous option. From the financial perspective the subcutaneous option constitutes the alternative with lower cost, with a cost around $4000.0 by treatment per patient, and from the patient perspective implies a 45.0% less time for session than then intravenous option. Conclusions: Trastuzumab subcutaneous formulation evidenced a substantial time and cost reduction in comparison with the intravenous formulation in the Costa Rican Social Security System.

Left Ventricular Regional Wall Motion Abnormality is a Strong Predictor of Cardiotoxicity in Breast Cancer Patients Undergoing Chemotherapy / Alteração Contrátil Segmentar Ventricular Esquerda é Preditor Independente de Cardiotoxicidade em Pacientes com Câncer de Mama em Tratamento Quimioterápico

Abstract Background: Chemotherapeutic agents of anthracyclines class and humanized monoclonal antibodies are effective treatments for breast cancer, however, they present a potential risk of cardiotoxicity. Several predictors have been recognized as predictors in the development of cardiac toxicity, and the evaluation of left ventricular segmental wall motion abnormalities (LVSWMA) has not been studied. Objective: To analyze prospectively the role of LVSWMA among echocardiographic parameters in the prediction of development of cardiotoxicity in breast cancer patients undergoing treatment with chemotherapy. Methods: Prospective cohort of patients diagnosed with breast cancer and in chemotherapy treatment with potential cardiotoxicity medications including doxorubicin and trastuzumab. Transthoracic echocardiograms including speckle tracking strain echocardiography were performed at standard times before, during and after the treatment to assess the presence (or lack thereof) of cardiotoxicity. Cardiotoxicity was defined by a 10% decrease in the left ventricular ejection fraction, on at least one echocardiogram. Multivariate logistic regression models were used to verify the predictors related to the occurrence of cardiotoxicity over time. Results: Of the 112 patients selected (mean age 51,3 ± 12,9 years), 18 participants (16.1%) had cardiotoxicity. In the multivariate analysis using the logistic regression model, those with LVWMA (OR = 6.25 [CI 95%: 1.03; 37.95], p < 0,05), LV systolic dimension (1.34 [CI 95%: 1.01; 1.79], p < 0,05) and global longitudinal strain by speckle tracking (1.48 [CI 95%: 1.02; 2.12], p < 0,05) were strongly associated with cardiotoxicity. Conclusion: In the present study, we showed that LVWMA, in addition to global longitudinal strains, were strong predictors of cardiotoxicity and could be useful in the risk stratification of these patients.

Resumo Fundamento: Os agentes quimioterápicos da classe das antraciclinas e dos anticorpos monoclonais humanizados são tratamentos eficazes para o câncer de mama, entretanto, apresentam alto risco de cardiotoxicidade. Diversos parâmetros têm sido reconhecidos como preditores no desenvolvimento de toxicidade cardíaca, sendo que a avaliação da alteração contrátil segmentar ventricular esquerda (ACSVE) ainda não foi estudada. Objetivo: Analisar a associação entre o surgimento de ACSVE e o desenvolvimento de cardiotoxicidade em pacientes com câncer de mama em tratamento com quimioterapia. Métodos: Coorte prospectiva de pacientes diagnosticados com câncer de mama e em tratamento quimioterápico com doxorrubicina e/ou trastuzumab. Foram realizados ecocardiogramas transtorácicos antes, durante e depois do tratamento para avaliar a presença ou não de cardiotoxicidade. A cardiotoxicidade foi definida por um decréscimo de 10% na fração de ejeção do ventrículo esquerdo, em pelo menos um ecocardiograma. Modelos de regressão logística multivariada foram utilizados para verificar os fatores preditores na ocorrência de cardiotoxicidade ao longo do tempo. Resultados: Dos 112 pacientes selecionados (idade média = 51,3 ± 12,9 anos), 18 (16,1%) apresentaram cardiotoxicidade. Na análise multivariada os pacientes com ACSVE (OR = 6,25 [IC 95%: 1,03; 37,95], p < 0,05), diâmetro sistólico do VE (OR = 1,34 [IC 95%:1,01; 1,79], p < 0,05) e strain longitudinal global pela técnica de speckle tracking (OR = 1,48 [IC 95%: 1,02; 2,12], p < 0,05) foram preditores significativos e independentes na predição de cardiotoxidade. Conclusão: Mostramos que ACSVE, bem como a redução do strain longitudinal global foram preditores independentes para cardiotoxicidade, podendo ser úteis na estratificação de risco destes pacientes.

Cardiotoxicidade nas Terapias Neoadjuvante e Adjuvante do Câncer de Mama / Cardiotoxicity in Adjuvant and Neoadjuvant Therapy for Breast Cancer / Cardiotoxicidad en Terapias de Cáncer de Mama Neoadyuvante y Adyuvante

Introdução: O câncer de mama é o mais comum entre as mulheres em todo o mundo, representando quase 25% de todos os casos de câncer. Alguns fármacos possuem características peculiares relacionadas à cardiotoxicidade. Objetivo: Analisar a incidência, as características clínicas e os fatores de risco associados à ocorrência de cardiotoxicidade em pacientes submetidas ao protocolo doxorrubicina e ciclofosfamida seguido ou não de taxanos e naquelas que realizaram o mesmo protocolo associado ao trastuzumabe. Método: Trata-se de um estudo de coorte realizado em um hospital público do Rio de Janeiro. Foram incluídas 153 pacientes que iniciaram tratamento entre os meses de setembro e novembro de 2012. A cardiotoxicidade foi definida com base nos critérios do Cardiac Review and Evaluation Committee e da Sociedade Brasileira de Cardiologia. Foi calculado o risco relativo (RR), utilizando-se um intervalo de confiança (IC) de 95%. Resultados: A incidência de cardiotoxicidade foi de 17%. Observou-se queda da fração de ejeção do ventrículo esquerdo em 31,3% e 52,2% das pacientes nos grupos human epidermal growth factor receptor-type 2 (HER-2) negativo e positivo, respectivamente. Foram identificados três casos de insuficiência cardíaca, sendo dois em pacientes HER-2 positivas. As pacientes que utilizaram trastuzumabe apresentaram maior risco de desenvolver cardiotoxicidade (RR=3,53; IC 95%: 1,84-6,79) em comparação com as mulheres do grupo HER-2 negativo. Conclusão:Foi possível verificar a ocorrência de casos de cardiotoxicidade em ambos os grupos com maior incidência para o grupo HER-2 positivo.

Introduction: Breast cancer is the most common among women worldwide, accounting for almost 25% of all cancer cases. Some drugs have a peculiar characteristic related to cardiotoxicity. Objective: Analyze the incidence, clinical characteristics and risk factors associated with cardiotoxicity in patients undergoing protocol doxorubicin and cyclophosphamide followed or not by taxanes and in those who underwent the same protocol associated with trastuzumab. Method: Cohort study conducted in a public hospital in Rio de Janeiro. 153 patients were included between September and November 2012. Cardiotoxicity was defined based on the criteria of the Cardiac Review and Evaluation Committee and the Brazilian Society of Cardiology. The relative risk (RR) was calculated using a 95% confidence interval (CI). Results: The incidence of cardiotoxicity was 17%. Left ventricular ejection fraction decreased in 31.3% and 52.2% of the patients in the negative and positive human epidermal growth factor receptor-type 2 (HER-2) groups, respectively. Three cases of heart failure were identified, two in HER-2 positive patients. Patients using trastuzumab had a higher risk of developing cardiotoxicity (RR=3.53; CI 95%: 1.84-6.79) compared to women in the HER-2 negative group. Conclusion: It was possible to verify the occurrence of cases of cardiotoxicity in both groups with higher incidence for the HER-2 positive group.

Introducción: El cáncer de mama es el más común entre las mujeres en todo el mundo, y representa casi el 25% de todos los casos de cáncer. Algunos medicamentos tienen característica peculiar relacionada con la cardiotoxicidad. Objetivo: Analizar la incidencia, las características clínicas y los factores de riesgo asociados con la cardiotoxicidad en pacientes sometidos al protocolo doxorrubicina y ciclofosfamida seguidos o no por taxanos y en aquellos que se sometieron al mismo protocolo asociado con trastuzumab. Método: Este es un estudio de cohorte realizado en un hospital público en Río de Janeiro. Se incluyeron 153 pacientes que comenzaron el tratamiento entre septiembre y noviembre de 2012. La cardiotoxicidad se definió según los criterios del Comité de Revisión y Evaluación Cardíaca y la Sociedad Brasileña de Cardiología. El riesgo relativo (RR) se calculó utilizando un intervalo de confianza (IC) del 95%. Resultados: La incidencia de cardiotoxicidad fue del 17%. La fracción de eyección del ventrículo izquierdo disminuyó en el 31,3% y el 52,2% de los pacientes en los grupos human epidermal growth factor receptor-type 2 (HER-2) negativo y positivo, respectivamente. Se identificaron tres casos de insuficiencia cardíaca, dos en pacientes con HER-2 positivo. Los pacientes que usaban trastuzumab tenían un mayor riesgo de desarrollar cardiotoxicidad (RR=3,53; IC 95%: 1,84-6,79) en comparación con las mujeres en el grupo negativo HER-2. Conclusión: Fue posible verificar la aparición de casos de cardiotoxicidad en ambos grupos con mayor incidencia para el grupo HER-2 positivo.

A Importância do Monitoramento e da Identificação Precoce de Cardiotoxicidade do Tratamento com Trastuzumabe no Câncer de Mama: Relato de Caso / The Importance of Early Monitoring and Identification of Cardiotoxicity of Trastuzumab Treatment in Breast Cancer: Case Report / La Importancia del Monitoreo y de la Identificación Temprano de la Cardiotoxicidad del Tratamiento con Trastuzumab en el Cáncer de Mama: Informe de Caso

Introdução: O câncer de mama representa a neoplasia mais frequente entre as mulheres, com elevada morbimortalidade. Com o advento de novos medicamentos, houve um aumento na sobrevida global; entretanto, o trastuzumabe, um anticorpo monoclonal utilizado no tratamento, pode promover cardiotoxicidade, que deve ser avaliada e monitorada durante o tratamento. O objetivo deste artigo é descrever um relato de caso de paciente que apresentou cardiotoxicidade associada ao uso de trastuzumabe e a importância do monitoramento e da identificação precoce da cardiotoxicidade por meio do monitoramento pelo ecocardiograma (ECO). Relato do caso: Paciente, sexo feminino, 63 anos, hipertensa, obesa, com câncer de mama, apresentou cardiotoxicidade associada ao uso de trastuzumabe, com redução da fração de ejeção do ventrículo esquerdo (FEVE) e desenvolveu diabetes após o tratamento. A paciente fez acompanhamento regular pelo ECO durante o tratamento, tendo sido esse processo fundamental para a detecção precoce e o manejo adequado da cardiotoxicidade associada ao uso do trastuzumabe. Foi utilizado um algoritmo na determinação da causalidade. Conclusão: Este estudo mostra a importância do acompanhamento da FEVE pelo ECO em pacientes submetidas à quimioterapia cardiotóxica e do monitoramento de possíveis alterações metabólicas após o tratamento oncológico.

Introduction: Breast cancer represents the most common neoplasm among women, with elevated morbimortality. With the appearance of new drugs, there has been an increase of global survival; however, trastuzumab, a monoclonal antibody used in the treatment, may promote cardiotoxicity that should be evaluated and monitored during treatment. The aim of this article is to describe a case report of a patient presenting trastuzumab-associated cardiotoxicity and the importance of monitoring and early identification of cardiotoxicity through echocardiography (ECHO). Case report: A 63-year-old female patient, hypertensive, obese, with breast cancer, presented trastuzumab-associated cardiotoxicity, reduced left ventricular ejection fraction (LVEF), who developed diabetes after the treatment. The patient underwent regular echocardiography follow-up during treatment and this process was essential for early detection and appropriate management of trastuzumab-associated cardiotoxicity. An algorithm was used to determine the causality. Conclusion: This study shows the importance of LVEF follow-up with ECHO in patients undergoing cardiotoxic chemotherapy, and the monitoring of possible metabolic changes after oncologic treatment.

Introducción: El cáncer de mama representa el cáncer más común entre las mujeres, con alta morbilidad y mortalidad. Con el advenimiento de nuevos medicamentos, ha habido un aumento en la supervivencia general, sin embargo, trastuzumab, un anticuerpo monoclonal utilizado en el tratamiento, puede promover la cardiotoxicidad, que debe evaluarse y monitorearse durante el tratamiento. El objetivo de este trabajo es describir un informe de caso de un paciente que presenta cardiotoxicidad asociada con el uso de trastuzumab y la importancia del monitoreo y la identificación temprana de la cardiotoxicidad a través del monitoreo ecocardiográfico (ECHO). Relato del caso: Una paciente de 63 años, hipertensa, obesa, con cáncer de mama, tenía cardiotoxicidad asociada con trastuzumab, fracción de eyección ventricular izquierda (FEVI) reducida y diabetes después del tratamiento. El paciente se sometió a un seguimiento ecocardiográfico regular durante el tratamiento y fue el proceso fundamental para la detección temprana y el manejo adecuado de la cardiotoxicidad asociada con el uso de trastuzumab. Se utilizó un algoritmo para determinar la causalidad. Conclusión: Este estudio muestra la importancia del seguimiento ECHO de la FEVI en pacientes sometidos a quimioterapia cardiotóxica, y el monitoreo de posibles cambios metabólicos después del tratamiento del cáncer.

Características clínicas y pronóstico de pacientes con cáncer de mama HER2 positivo avanzado, en la era antes y después de terapias anti-HER2 / Survival of patients with advanced HER2+ breast cancer. Analysis of a cancer center database

Background: HER2+ breast cancer (BC) subtype overexpresses the Human Epidermal growth factor Receptor type-2 (HER2) and is characterized by its aggressiveness and its high sensitivity to monoclonal antibody-based HER2-targeted therapies. Aim: To assess the prognosis and evaluate the impact of novel anti-HER2 therapies on advanced HER2+ BC patients treated at our institution over the last decades. Material and Methods: Analysis of the patient database at a cancer center of a university hospital. Information about the subtype of cancer was obtained in 2,149 of 2,724 patients in the database. Eighteen percent of the latter were HER2+. We analyzed data of 83 of these patients with advanced disease. Results: Median overall survival (OS) was 24 months. For patients treated between 1997-2006 median OS was 17 months and for those treated in the period 2007-2017 median OS was 32 months (p = 0.09). Conclusions: A non-significant trend towards better survival in the last decade was observed. HER2+ BC overall survival has improved in our center. This can be probably attributed to the use of novel more effective anti-HER2 therapies.

Modelo de impacto orçamentario do trastuzumabe subcutâneo comparado com o intravenoso no tratamento de câncer de mama HER-2 positivo no Sistema de Saúde Suplementar brasileiro / Budget impact model of subcutaneous compared with intravenous trastuzumab in the treatment of HER-2 positive breast cancer in the Brazilian Private Healthcare System

OBJETIVO: Estimar o impacto orçamentário do trastuzumabe subcutâneo, comparado com o in-travenoso, no Sistema de Saúde Suplementar (SSS) para o tratamento do câncer de mama inicial e metastático HER-2 positivo. MÉTODOS: Foi realizada uma análise de impacto orçamentário na perspectiva do SSS. Os tratamentos de câncer de mama inicial foram trastuzumabe em monoterapia e trastuzumabe com paclitaxel ou docetaxel. No câncer de mama metastático, considerou-se trastu-zumabe associado com docetaxel ou paclitaxel na primeira linha e em monoterapia na segunda linha. Para ambos, comparou-se a substituição do trastuzumabe intravenoso pelo subcutâneo. Uma pesquisa com 28 operadoras mapeou taxas, preços e tabelas de referência usadas para o reembolso de medicamentos, materiais e procedimentos. Uma equipe multidisciplinar estimou o uso de recur-sos. Custos médicos diretos foram incluídos e os preços foram obtidos de fontes públicas. O horizon-te temporal foi cinco anos e considerou-se a incorporação progressiva de trastuzumabe subcutâneo com 20% no primeiro ano até atingir 100%. RESULTADOS: Estimaram-se 31.589 pacientes com câncer de mama no SSS em cinco anos. O uso progressivo de trastuzumabe subcutâneo em comparação com o intravenoso levou a uma economia de 962,7 mBRL, 14,5 mBRL, 1,5 mBRL e 0,2 mBRL no SSS, para operadoras de saúde de grande, médio e pequeno porte, respectivamente. Materiais e procedimentos de suporte com taxas médicas foram os parâmetros mais sensíveis. CONCLUSÃO: O trastuzumabe subcutâneo em comparação com o intravenoso pode levar a uma economia de até 962,7 mBRL no tratamento do câncer de mama no SSS.

Objective: To estimate the budgetary impact of subcutaneous trastuzumab, compared with intravenous trastuzumab, in the Brazilian Private Healthcare System (PHS), to treat early and metastatic HER-2 positive breast cancer. Methods: Budgetary impact analysis was performed in PHS perspective. For early breast cancer, treatment options were trastuzumab monotherapy, and trastuzumab plus paclitaxel or docetaxel, after adjuvant chemotherapy. For metastatic breast cancer, trastuzumab was combined with docetaxel or paclitaxel in the first line, and it was given in monotherapy in the second line. For both, a comparison of switching from intravenous to subcutaneous therapy was made. A survey was performed with 28 health maintenance organizations to map fees and sources used for reimbursement of drugs, materials and procedures. Direct medical costs were included. Time horizon was 5 years and market share of subcutaneous trastuzumab vary from 20% to 100%. Results were presented according to size of health maintenance organizations and a deterministic sensitivity analysis was conducted to analyze model robustness. Results: In 5 years, 31,589 breast cancer patients were estimated for the PHS, 284 patients for big, 30 patients for medium, and 6 patients for small HMOs. The progressive uptake of subcutaneous trastuzumab, compared with in-travenous formulation, can save up to 962,7 mBRL, 14,5 mBRL, 1,5 mBRL and 0,2 mBRL, respectively. Materials and support procedures along with medical fees were the most sensitive parameters. Con-clusion: Compared with the intravenous administration, subcutaneous trastuzumab can save up to 962,7 mBRL costs in the breast cancer treatment in the Brazilian PHS

Características y supervivencia de pacientes con cáncer de seno metastásico HER2-positivo en la era post-trastuzumab / Characteristics and survival of patients with HER2-positive metastatic breast cancer in the post-trastuzumab era

Resumen Introducción: Existen múltiples factores pronóstico de la supervivencia en el cáncer de mama metastásico (CMM). Los dos factores mejor estudiados son la expresión de receptores hormonales (RH) y el estatus HER2, por lo que su determinación es obligada en toda paciente con diagnóstico de CMM. El 80% de los tumores expresan RH y el 20% son HER2-positivo. El objetivo de este estudio es determinar los factores pronóstico de la supervivencia global (SG) de pacientes con diagnóstico de CMM HER2-positivo atendidos entre 2009 y 2015 en el Instituto de Cancerología de Medellín (Colombia). Métodos: Estudio observacional retrospectivo. Se realizaron las curvas de supervivencia mediante el método de Kaplan-Meier comparadas con Log-Rank test y se analizaron los factores que influyeron en la supervivencia mediante la regresión de Cox. Resultados: Se incluyeron 101 pacientes. La mediana de seguimiento fue 46,6 meses (rango 13-155 meses), la SG a cinco años fue 41% (IC95%: 31%-50%) y a diez años 13% (IC95%: 4%-30%). Tuvieron mayor SG pacientes con enfermedad en recaída, con estadios I y II, las mayores de 40 años, menopáusicas, con tumores con grado histológico bajo y co-expresión de receptores hormonales. Las pacientes que recayeron tuvieron mayor SG que las que hicieron metástasis de novo (HR: 0,47, IC95%: 0,27-0,81) ajustado por las otras variables. Conclusiones: La supervivencia de estas pacientes fue semejante al de otros países, al igual que las líneas de tratamiento y la terapia recibida.

Abstract Introduction: There are multiple risk factors associated with the prognosis of survival of metastatic breast cancer (MBC). The two major risk factors are the expression of hormonal receptors (HR) and HER 2 neu, and the reason why they are requested in every MBC patient. The large majority (80%) of breast tumors are HR positive, and 20% are HER 2 positive. The aim of this study was to determine the prognostic factors associated with the overall survival (OS) of patients diagnosed with HER 2 positive MBC seen between January 2009 and December 2015 in the Instituto de Cancerología (Medellín-Colombia). Methods: A retrospective observational study was conducted, with survival analysis using the Kaplan-Meier method. The survival curves were compared using the Log-Rank Test, and factors associated with survival were analyzed using the Cox regression. Results: 101 patients were included in the study. The median survival time was 46.6 months (Range 13-155 months), the 5-year OS was 41% (95% CI; 31%-50%) and the 10-year OS 13% (95% CI; 4%-30%). Higher overall survival was found for patients with relapsed disease, those with stages I and II, patients older than 40 years, postmenopausal, tumors with low histological grade and with co-expression of hormonal receptors. The patients with relapse of disease had a higher OS than the de novo patients after being adjusted for the other factors (HR: 0.47, 95% CI; 0.27-0.1). Discussion: The overall survival time is similar to that of other countries, as well as the lines of treatment and therapy received.

Global Longitudinal Strain Accuracy for Cardiotoxicity Prediction in a Cohort of Breast Cancer Patients During Anthracycline and/or Trastuzumab Treatment / Acurácia do Strain Longitudinal Global na Predição de Cardiotoxicidade em uma Coorte de Pacientes com Câncer de Mama em Tratamento com Antracíclicos e/ou Trastuzumab

Abstract Background: The high cardiotoxicity morbidity and mortality rates associated with the antineoplastic therapy for breast cancer could be reduced with the early use of cardioprotective drugs. However, the low sensitivity of left ventricular ejection fraction limits its use in that preventive strategy. New parameters, such as global longitudinal strain, are being used in the early detection of contractile function changes. Objectives: To assess the incidence of cardiotoxicity in patients treated for breast cancer, the independent factors associated with that event, and the ability of strain to identify it early. Methods: Prospective observational study of consecutive outpatients diagnosed with breast cancer, with no previous antineoplastic treatment and no ventricular dysfunction, who underwent anthracycline and/or trastuzumab therapy. The patients were quarterly evaluated on a 6- to 12-month follow-up by an observer blind to therapy. Cox regression was used to evaluate the association of cardiotoxicity with clinical, therapeutic and echocardiographic variables. A ROC curve was built to identify the strain cutoff point on the third month that could predict the ejection fraction reduction on the sixth month. For all tests, the statistical significance level adopted was p ≤ 0.05. Results: Of 49 women (mean age, 49.7 ± 12.2 years), cardiotoxicity was identified in 5 (10%) on the third (n = 2) and sixth (n = 3) months of follow-up. Strain was independently associated with the event (p = 0.004; HR = 2.77; 95%CI: 1.39-5.54), with a cutoff point for absolute value of -16.6 (AUC = 0.95; 95%CI: 0.87-1.0) or a cutoff point for percentage reduction of 14% (AUC = 0.97; 95%CI: 0.9-1.0). Conclusion: The 14% reduction in strain (absolute value of -16.6) allowed the early identification of patients who could develop anthracycline and/or trastuzumab-induced cardiotoxicity.

Resumo Fundamentos: A elevada morbimortalidade da cardiotoxicidade associada à terapia antineoplásica para o câncer de mama poderia ser reduzida com uso precoce de drogas cardioprotetoras. No entanto, a baixa sensibilidade da fração de ejeção limita sua utilização nessa estratégia preventiva. Novos parâmetros, como o strain longitudinal global, estão sendo utilizados na detecção precoce das alterações da função contrátil. Objetivos: Avaliar a incidência de cardiotoxicidade entre pacientes tratados para câncer de mama, os fatores independentes associados a esse evento e a capacidade do strain em identificá-la precocemente. Métodos: Estudo prospectivo observacional de pacientes ambulatoriais consecutivos com diagnóstico de câncer de mama, sem tratamento antineoplásico prévio, sem disfunção ventricular, submetidos ao uso de antracíclicos e/ou trastuzumab, avaliados trimestralmente de forma cega em relação à terapia, seguidos por 6 a 12 meses. Regressão de Cox foi utilizada para avaliar a associação de variáveis clínicas, terapêuticas e ecocardiográficas com cardiotoxicidade. Curva ROC foi construída para identificar o ponto de corte do strain capaz de prever redução da fração de ejeção. Para todos os testes, o nível de significância estatística foi definido com p ≤ 0,05. Resultados: Dentre 49 mulheres com idade média de 49,7 ± 12,2 anos, identificamos 5 casos de cardiotoxicidade (10%), aos 3 (n = 2) e 6 (n = 3) meses de seguimento. Strain foi associado de forma independente ao evento (p = 0,004; HR = 2,77; IC95%: 1,39-5,54), tendo como ponto de corte o valor absoluto de -16,6 (ASC = 0,95; IC95%: 0,87-1,0) ou redução de 14% (ASC = 0,97; IC95%: 0,9-1,0). Conclusão: A redução de 14% do strain (ou valor absoluto de -16,6) foi capaz de identificar precocemente pacientes que podem evoluir com cardiotoxicidade associada ao antracíclico e/ou trastuzumab.