What is the recommended cardiac surveillance protocol for patients undergoing TCH (Taxane, Carboplatin, Trastuzumab) chemotherapy?

Cardiac Surveillance Protocol for TCH Chemotherapy

For patients undergoing TCH (Taxane, Carboplatin, Trastuzumab) chemotherapy, cardiac monitoring should be performed at baseline, 3,6, and 9 months during treatment, with additional monitoring based on cardiac risk factors and symptoms. 1

Baseline Cardiac Assessment

• LVEF measurement: Conduct thorough cardiac assessment before initiating TCH therapy 2

  • Echocardiography (preferred) or MUGA scan to determine baseline LVEF
  • All patients must have LVEF above the lower limit of normal (LLN) to start trastuzumab

• Additional baseline evaluations:

  • Complete cardiac history and risk factor assessment
  • 12-lead ECG
  • Consider cardiac biomarkers (troponin, BNP or NT-proBNP) for high-risk patients 1

Monitoring Schedule During Treatment

• Regular LVEF assessments:

  • Baseline (before starting TCH)
  • 3 months after starting treatment
  • 6 months after starting treatment
  • 9 months after starting treatment
  • At completion of trastuzumab therapy (if not coinciding with above timepoints) 1

• Additional monitoring for high-risk patients:

  • More frequent monitoring (every 4-8 weeks) for patients with:
    • Pre-existing cardiovascular disease
    • Hypertension
    • Diabetes
    • Previous cardiotoxic therapy
    • Age >60 years 1

Management Based on LVEF Changes

Traffic Light System for Cardiac Monitoring 1:

• Green (Continue trastuzumab):

  • LVEF above LLN
  • LVEF decrease <10% from baseline

• Amber (Continue trastuzumab but initiate ACE inhibitor):

  • LVEF below LLN but >40%
  • LVEF decrease <10% from baseline
  • Repeat LVEF assessment in 6-8 weeks

• Red (Stop trastuzumab):

  • LVEF ≤40%
  • Any symptomatic heart failure
  • Start ACE inhibitor and refer to cardiologist
  • Repeat LVEF in 6-8 weeks; may restart if LVEF recovers to above LLN

Intervention for Cardiac Dysfunction

• For LVEF decrease ≥16% from baseline or LVEF below institutional LLN with ≥10% absolute decrease:

  • Withhold trastuzumab 2
  • Initiate ACE inhibitor therapy
  • Refer to cardiologist
  • Reassess LVEF after 6-8 weeks

• For symptomatic heart failure:

  • Interrupt trastuzumab treatment
  • Start ACE inhibitor therapy
  • Urgent cardiology referral 1

Advanced Monitoring Techniques

• Consider strain imaging: Global longitudinal strain (GLS) by echocardiography may detect subclinical cardiac dysfunction earlier than LVEF changes 3

• Cardiac biomarkers: Elevated troponin may identify early cardiotoxicity before LVEF changes 4

Common Pitfalls and Caveats

• Underestimating cardiac risk: TCH regimen has lower cardiac toxicity than anthracycline-containing regimens but still requires vigilant monitoring 5

• Inadequate baseline assessment: Failure to obtain accurate baseline LVEF can lead to misinterpretation of subsequent changes

• Inconsistent imaging modality: Use the same imaging technique (echo or MUGA) throughout treatment to ensure consistent measurements 1

• Delayed recognition of cardiac dysfunction: Early detection and intervention for LVEF decline is critical to prevent irreversible cardiac damage 6

• QT interval monitoring: While trastuzumab with carboplatin and docetaxel has not shown clinically significant QT prolongation, ECG monitoring is still recommended, especially with concomitant QT-prolonging medications 7

The TCH regimen generally has a more favorable cardiac safety profile compared to anthracycline-containing regimens, with studies showing no patients developing grade 3-4 left ventricular systolic dysfunction in the neoadjuvant setting 5. However, diligent cardiac monitoring remains essential throughout the treatment course to ensure early detection and management of potential cardiotoxicity.