risk-guided cardioprotection with carvedilol in breast cancer patients treated with doxorubicin and/or trastuzumab

Conditions: Cardiotoxicity; Risk Factor, Cardiovascular; Toxicity Due to Chemotherapy; Breast Cancer; Cardiomyopathies; Heart Failure

Summary: investigators will evaluate the safety, tolerability, and feasibility of a risk-guided cardioprotective treatment strategy with carvedilol, as compared to usual care, in breast cancer patients undergoing treatment with doxorubicin, trastuzumab, or the combination.

this is a single-center, randomized clinical trial that seeks to determine if a risk guided treatment strategy that initiates carvedilol in high risk breast cancer patients prior to doxorubicin and/or trastuzumab is safe, tolerable, and feasible. subjects who are identified as having elevated ctx risk by an internally validated clinical risk score (exceeding a pre-specified risk threshold) will be randomized to individually-dosed, open-label carvedilol or usual care. investigators will use a stratified randomization according to trastuzumab therapy (yes/no) to ensure balance across treatment regimen. clinical, echocardiographic, and biomarker data will be collected on all patients at baseline and standardized time intervals during and after therapy at approximately 3, 6, 9, 12, and 24 months.

Eligibility criteria:
inclusion criteria: * females * at least 18 years old * diagnosed with stage i-iii breast cancer with treatment plan to include therapy with anthracyclines and/or trastuzumab in the adjuvant or neo-adjuvant setting * study team is able to obtain all necessary information for calculating cardiotoxicity risk score (including echocardiographic measurement of left ventricular ejection fraction) exclusion criteria: * pregnant or breast feeding. due to unknown risks and potential harm to the unborn fetus a negative pregnancy test within 10 days prior to enrollment is required in women with child-bearing potential. due to the potential nursing infant harm, women who are currently breast feeding are not eligible for this study. * contraindication to carvedilol * baseline systolic blood pressure \< 90mmhg (if multiple blood pressures are available in the medical record within 1 month prior to screening, the average sbp will be considered) * baseline heart rate \< 55 bpm consistent with severe bradycardia (if multiple resting heart rates are available in the medical record within 1 month prior to screening, the average heart rate will be considered) * allergy to carvedilol * history of bronchial asthma or related bronchospastic conditions * known history of sick sinus syndrome * severe hepatic impairment, defined as serum bilirubin \> 3.0x uln, ast or alt \> 5.0 uln within 28 days of enrollment * second- or third-degree av block, as determined by electrocardiogram * severe bradycardia (unless permanent pacemaker is in place) * patients in cardiogenic shock or decompensated heart failure requiring the use of iv inotropic therapy * current use of: bupropion (wellbutrin), fluoxetine (prozac), paroxetine (paxil), quinidine (quinidex), duloxetine (cymbalta), digoxin * current treatment with beta blocker * unable to provide consent

Keywords: risk-guided intervention carvedilol cardiotoxicity of chemotherapy cardio-oncology cardiomyopathy