
==== Front
JACC CardioOncol
JACC CardioOncol
JACC: CardioOncology
2666-0873
Elsevier

S2666-0873(24)00204-7
10.1016/j.jaccao.2024.03.013
Letters
To the Editor
Assessing Neurohormonal Antagonist Withdrawal in HER2+ Breast Cancer Patients With CTRCD
Albulushi Arif MD dr.albulushi@gmail.com
∗
Al-Farhan Hatem MD
∗ Advanced Heart Failure and Transplant Cardiology, National Heart Center, The Royal Hospital, Muscat, Oman dr.albulushi@gmail.com
25 6 2024
8 2024
25 6 2024
6 4 625626
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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pmcWe read with interest the study by Yu et al1 examining the withdrawal of neurohormonal antagonists (NHAs) in breast cancer patients showing improved left ventricular function postcardiotoxicity. This research adds valuable insights into the management of cancer therapy–related cardiac dysfunction in a specific patient cohort (Table 1). However, we wish to raise some considerations and seek clarifications.Table 1 Comparative Characteristics and Outcomes of STOP and Control Groups in Breast Cancer Patients With CTRCD

	STOP Group (n = 10)	Control Group (n = 10)	
Age at cancer diagnosis, y	48 (43-52)	50 (40-59)	
Prevalence of hypertension	1/10	3/10	
Prevalence of diabetes	0/10	1/10	
Prevalence of obesity	3/10	1/10	
Smoking history	1/10	2/10	
Prevalence of dyslipidemia	0/10	2/10	
Doxorubicin equivalent dose, mg/m2	205 (200-208)	205 (203-207)	
Radiotherapy received, Gy	10/10 (50 [50-50])	9/10 (50 [44-50])	
Trastuzumab cycles completed	17 (except 1 with 14)	17	
Nadir 3D-LVEF at CTRCD, %	49 (47-49)	49 (48-51)	
BNP value at CTRCD diagnosis, pg/mL	Not applicable	71.9 (n = 1)	
NHA treatment duration, mo	32 (26-40)	Not applicable	
Follow-up duration, mo	29 (17-40)	27 (17-36)	
Final 3D-LVEF	Remained > baseline	Remained > baseline	
Final GLS	Remained > baseline	Remained > baseline	
Final BNP value, pg/mL	14.6 (12.4-18.0)	20.0 (7.7-23.7)	
Values are median (25th-75th percentiles), n/N, n/N (median [25th-75th percentiles]), or n.

3D-LVEF = 3-dimensional left ventricular ejection fraction; BNP = B-type natriuretic peptide; CTRCD = cancer therapy–related cardiac dysfunction; GLS = global longitudinal strain; NHA = neurohormonal antagonist.

First, the selection criteria for patients in the STOP group, particularly the reasons for NHA withdrawal, are subjective, potentially introducing bias. It is crucial to understand whether these reasons reflect a broader patient perspective or are isolated cases.

Second, although the study’s design is appropriate for its exploratory nature, the small sample size and lack of randomization limit the generalizability of the findings. Future studies would benefit from a randomized controlled design to mitigate bias and enhance the reliability of the conclusions drawn.

We also wonder how the findings of the TRED-HF study,2 which showed a 40% relapse in patients with dilated cardiomyopathy upon NHA withdrawal, might inform or contrast with the outcomes in this breast cancer cohort, considering the different pathophysiological mechanisms at play.

Lastly, we are curious about the authors’ perspectives on the potential long-term cardiac impacts of NHA withdrawal in this patient population, especially considering the chronic nature of cancer therapy–related cardiac dysfunction. In summary, the Yu et al1 study initiates an important conversation about NHA management in cancer survivors, setting the stage for further research.1

The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
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References

1 Yu C. Power C. Sooriyakanthan M. Withdrawal of neurohormonal antagonists in breast cancer patients with cardiotoxicity and improved left ventricular function J Am Coll Cardiol CardioOnc 6 2 2024 315 317
2 Halliday B.P. Wassall R. Lota A.S. Withdrawal of pharmacological treatment for heart failure in patients with recovered dilated cardiomyopathy (TRED-HF) Lancet 393 2019 61 73 30429050
