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Coronary Artery Disease After Radiation Therapy for Early Breast Cancer

Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

To the Editor:

We discussed in our journal club the article "Coronary Artery Findings After Left-Sided Compared With Right-Sided Radiation Treatment for Early-Stage Breast Cancer,"¹ published in your esteemed journal. We congratulate the authors on their persistent efforts in studying the long term radiation-induced coronary artery damage in left-sided breast cancer patients. The article evoked good discussion among all teachers and residents. However, we would like to make a few comments and request that the authors clarify certain points.

First, the study employed a large series of 1,171 patients, but we would like to know if there was any selection bias, given that only 961 patients were screened for coronary artery disease. What about rest of the patients?

Second, the protocol of using radiotherapy (RT) in breast conservation is not fully explained. Did you employ brachytherapy? If so, was there any difference in the incidence of severity of coronary artery disease (CAD) vis-à-vis external beam RT? If yes, it might indicate which one is safer (external beam RT or brachytherapy).

Third, the indication for irradiating internal mammary node fields in the six right-sided and six left-sided breast cancer patients is unclear.

Fourth, the study screened only symptomatic patients for CAD, but asymptomatic patients were excluded. If all patients had been screened, early changes indicating CAD occurring in the coronary artery vasculature could have been detected in some of the asymptomatic patients. Appropriate timely interventions (if indicated) in these group of asymptomatic patients might have led to decreased morbidity and mortality.

Fifth, supposing the information about existence of CAD was available preoperatively, what modification(s) in RT technique(s) might you have employed in this group of patients, and with what anticipated benefits?

Sixth, the 2006 Harris et al article² describes overall morbidity and mortality, whereas the article discussed here describes coronary artery changes in detail. We would like to know if there were any differences in the site-specific lesions in coronary vascular architecture (in sites other than the left anterior descending coronary artery), and if the techniques employed to deliver RT were different (brachytherapy-intraoperative wire implant/mold techniques and so on). This might shed some light on brachytherapy (technique-specific)–induced lesions (site-specific) in coronary artery vasculature. To the best of our knowledge, no such study has been reported in the literature until now. Though Hooning et al³ found statistically significant correlation between hypertension and left-sided breast irradiation in development of coronary artery disease, no significant trend for myocardial infarction and no correlation between RT and congestive heart failure/cardiac deaths could be established.

Seventh, is there sufficient data on a significant number of patients in whom partial breast irradiation was used so as to derive any conclusion of its superiority over conventional full breast irradiation?

Thank you,

AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The author(s) indicated no potential conflicts of interest.

REFERENCES

1. Correa CR, Litt H, Hwang WT, et al: Coronary artery findings after left-sided compared with right-sided radiation treatment for early-stage breast cancer. J Clin Oncol 25:3031-3037, 2007[Abstract/Free Full Text]

2. Harris ER, Correa CR, Hwang WT, et al: Late cardiac mortality and morbidity in early-stage breast cancer patients after breast-conservation treatment. J Clin Oncol 24:4100-4106, 2006[Abstract/Free Full Text]

3. Hooning MJ, Botma A, Aleman BMP, et al: Long term risk of cardiovascular disease in 10-year survivors of breast cancer. Breast Cancer Res Treat 94:S177, 2005 (suppl 1; abstr 4035)[CrossRef]

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