Principles of a risk evaluation and mitigation strategy (REMS) for breast cancer patients receiving potentially cardiotoxic adjuvant treatments

The number of breast cancer long survivors has increased in the last few years. However, this increase in survival may be affected by the side effects of adjuvant breast cancer therapies. In this context cardiovascular toxicity is considered one of the most clinically important toxicities.In this work we review the published clinical trials of adjuvant treatment on breast cancer, focusing on the trials which accurately mentioned the cardiotoxicity of the adjuvant treatments and those which underwent long term follow up of cardiac function. This article tries to summarize and evaluate the risk of cardiac toxicities associated with different adjuvant treatments for breast cancer (chemotherapy, radiotherapy, endocrine therapy and trastuzumab).In our opinion, each individual breast cancer patient should be meticulously evaluated before starting adjuvant treatment in order to basically asses cardiac function and to manage any predisposing risk factor which may increase the probability of treatment induced cardiotoxicity. Rigorous and frequent reassessment of cardiac function along with providing different mitigation strategies that can prevent or decrease the risk of such cardiovascular toxicities are inevitable methods to protect the patient from cardiac events which can mask the survival benefit associated with different adjuvant treatments.