Electrocardiographic changes and their impact on psychological distress and sleep quality in breast cancer patients during anthracycline-based chemotherapy
Abstract
Background: Breast cancer is the most common malignant tumor in women. Anthracycline is an essential adjuvant chemotherapy drug. Due to its cardiotoxicity, anthracyclines may lead to abnormal electrocardiogram, which may induce anxiety, depression and sleep disorders. Current studies mainly focus on the changes of echocardiogram parameters and serum myocardial markers, and the dynamic evolution of electrocardiogram. However, the mechanism of its interaction with psycho-sleep are still unclear. Objective: To analyze the electrocardiogram results of breast cancer patients with anthracycline chemotherapy, and to analyze its correlation with psychological disorders and sleep quality. Methods: In this longitudinal observational study, 100 breast cancer patients receiving anthracycline-based chemotherapy underwent 12-lead electrocardiogram (ECG) monitoring at three time points: within 7 days before chemotherapy initiation (T0), 24 hours after the completion of the second chemotherapy cycle (T1), and 24 hours after the completion of the fourth cycle (T2). QTc intervals and ST-segment changes were recorded. Concurrent psychological and sleep status assessments were performed using the Hospital Anxiety and Depression Scale (HADS) and the Pittsburgh Sleep Quality Index (PSQI). Results: After the fourth cycle of chemotherapy (T2), 36 patients had abnormal electrocardiogram (ECG), and the overall abnormal rate increased from 3% to 36.0%, mainly manifested as QTc prolongation (16.0%), ST segment depression (11.0%) and T wave changes (17.0%). Patients with age ≥ 50, BMI ≥ 24kg/m2, postmenopausal, TNM stage III, cumulative drug dose ≥300 mg/m2, hypertension, hyperlipidemia and other characteristics have a higher probability of abnormal ECG after chemotherapy. Psychological assessment showed that HADS-A and HADS-D scores increased from 5.71 ± 2.24 and 5.06 ± 1.73 at T0 to 9.74 ± 3.11 and 9.15 ± 2.80 at T2, respectively (P < 0.001). The incidence of anxiety increased from 13% (T0) to 42% (T2), and the incidence of depression increased from 10% to 36% (P < 0.001). HADS-A and HADS-D in the abnormal ECG group were significantly higher than those in the normal ECG group. There were significant differences in the incidence of anxiety (69.4% vs. 26.6%) and depression (55.6% vs. 25%) between the two groups (P < 0.01). The total score of PSQI was 5.49 ± 2.35 at T0, 7.53 ± 2.84 at T1, and 10.60 ± 3.67 at T2. ECG abnormalities were positively correlated with HADS-A (r = 0.522, P < 0.01), HADS-D (r = 0.439, P < 0.01) and PSQI (r = 0.706, P < 0.01). HADS-A (r = 0.655, P < 0.01) and HADS-D (r = 0.547, P < 0.01) were positively correlated with PSQI. Conclusion: Breast cancer patients undergoing anthracycline-based chemotherapy frequently exhibit characteristic ECG changes, including QT interval prolongation and ST-T segment abnormalities. These ECG abnormalities are associated with anxiety and depressive symptoms during treatment, as well as significantly aggravated sleep disturbances, suggesting a potential bidirectional interaction between cardiac function and neuropsychological health throughout the chemotherapy process.
Copyright (c) 2026 WeiXing Zhang, Qiongmei Zang, Shuqing Lai
This work is licensed under a Creative Commons Attribution 4.0 International License.
References
1. Libson S, Lippman M. A review of clinical aspects of breast cancer. International Review of Psychiatry. 2014; 26(1): 4–15. doi: 10.3109/09540261.2013.852971
2. Bray F, Laversanne M, Sung H, et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: A Cancer Journal for Clinicians. 2024; 74(3): 229–263. doi: 10.3322/caac.21834
3. Sun K, Zhang B, Lei S, et al. Incidence, mortality, and disability-adjusted life years of female breast cancer in China, 2022. Chinese Medical Journal. 2024; 137(20): 2429–2436. doi: 10.1097/cm9.0000000000003278
4. Shah AN, Gradishar WJ. Adjuvant Anthracyclines in Breast Cancer: What Is Their Role? The Oncologist. 2018; 23(10): 1153–1161. doi: 10.1634/theoncologist.2017-0672
5. Costache II, Petriş A. Cardiotoxicity of anthracyclines. Revista de Medicină şi Chirurgie a Societăţii de Medici şi Naturalişti din Iaşi. 2011; 115(4): 1200–7.
6. Hu G, Wang D. Analysis of Cardiac Adverse Reactions Caused by Different Doses of Adriamycin Chemotherapy in Patients with Breast Cancer. M.A B, ed. Journal of Healthcare Engineering. 2022; 2022: 1-5. doi: 10.1155/2022/1642244
7. Von Hoff DD, Layard MW, Basa P, et al. Risk Factors for Doxorubicin-lnduced Congestive Heart Failure. Annals of Internal Medicine. 1979; 91(5): 710–717. doi: 10.7326/0003-4819-91-5-710
8. van der Pal HJ, van Dalen EC, Hauptmann M, et al. Cardiac Function in 5-Year Survivors of Childhood Cancer. Archives of Internal Medicine. 2010; 170(14). doi: 10.1001/archinternmed.2010.233
9. Studzian K, Kik K, Lukawska M, et al. Subcellular localization of anthracyclines in cultured rat cardiomyoblasts as possible predictors of cardiotoxicity. Investigational New Drugs. 2015; 33(5): 1032–1039. doi: 10.1007/s10637-015-0276-9
10. Yang Y, Sun H, Luo X, et al. Network connectivity between fear of cancer recurrence, anxiety, and depression in breast cancer patients. Journal of Affective Disorders. 2022; 309: 358–367. doi: 10.1016/j.jad.2022.04.119
11. Carreira H, Williams R, Müller M, et al. Associations Between Breast Cancer Survivorship and Adverse Mental Health Outcomes: A Systematic Review. Journal of the National Cancer Institute. 2018; 110(12): 1311–1327. doi: 10.1093/jnci/djy177
12. Li Q, Lin Y, Hu C, et al. The Chinese version of hospital anxiety and depression scale: Psychometric properties in Chinese cancer patients and their family caregivers. European Journal of Oncology Nursing. 2016; 25: 16–23. doi: 10.1016/j.ejon.2016.09.004
13. Buysse DJ, Reynolds CF 3rd, Monk TH, et al. The pittsburgh sleep quality Index: a new instrument for psychiatric practice and research. Psychiatry Research. 1989; 28(2): 193–213. doi: 10.1016/0165-1781(89)90047-4
14. Horacek JM, Jakl M, Horackova J, et al. Assessment of anthracycline-induced cardiotoxicity with electrocardiography. Experimental Hematology & Oncology. 2009; 31(2): 115-7. doi: nasplib.isofts.kiev.ua/handle/123456789/136213
15. Larsen RL, Jakacki RI, Vetter VL, et al. Electrocardiographic changes and arrhythmias after cancer therapy in children and young adults. American Journal of Cardiology. 1992; 70(1): 73–77. doi: 10.1016/0002-9149(92)91393-i
16. Carpenter A, Chambers OJ, El Harchi A, et al. COVID-19 Management and Arrhythmia: Risks and Challenges for Clinicians Treating Patients Affected by SARS-CoV-2. Frontiers in Cardiovascular Medicine. 2020; 7. doi: 10.3389/fcvm.2020.00085
17. Vicente J, Johannesen L, Hosseini M, et al. Electrocardiographic Biomarkers for Detection of Drug-Induced Late Sodium Current Block. Rasmusson RL, ed. PLOS ONE. 2016; 11(12): e0163619. doi: 10.1371/journal.pone.0163619
18. Tisdale JE. Drug-induced QT interval prolongation and torsades de pointes. Canadian Pharmacists Journal / Revue des Pharmaciens du Canada. 2016; 149(3): 139–152. doi: 10.1177/1715163516641136
19. Songbo M, Lang H, Xinyong C, et al. Oxidative stress injury in doxorubicin-induced cardiotoxicity. Toxicology Letters. 2019; 307: 41–48. doi: 10.1016/j.toxlet.2019.02.013
20. Grusdat NP, Stäuber A, Tolkmitt M, et al. Routine cancer treatments and their impact on physical function, symptoms of cancer-related fatigue, anxiety, and depression. Support Care Cancer. 2022; 30(5): 3733–3744. doi: 10.1007/s00520-021-06787-5
21. Hashemi SM, Rafiemanesh H, Aghamohammadi T, et al. Prevalence of anxiety among breast cancer patients: a systematic review and meta-analysis. Breast Cancer. 2019; 27(2): 166–178. doi: 10.1007/s12282-019-01031-9
22. Pilevarzadeh M, Amirshahi M, Afsargharehbagh R, et al. Global prevalence of depression among breast cancer patients: a systematic review and meta-analysis. Breast Cancer Research and Treatment. 2019; 176(3): 519–533. doi: 10.1007/s10549-019-05271-3
23. Lam WWT, Bonanno GA, Mancini AD, et al. Trajectories of psychological distress among Chinese women diagnosed with breast cancer. Psycho-Oncology. 2009; 19(10): 1044–1051. doi: 10.1002/pon.1658
24. Lv D, Lan B, Zhang L, et al. Association between depression and anxiety status of breast cancer patients before adjuvant chemotherapy and chemotherapy‐induced adverse events. Cancer Medicine. 2022; 12(4): 4794–4800. doi: 10.1002/cam4.5283
25. Rehman A, Drake CL, Shiramizu V, et al. Sleep reactivity predicts insomnia in patients diagnosed with breast cancer. Journal of Clinical Sleep Medicine. 2022; 18(11): 2597–2604. doi: 10.5664/jcsm.10170
26. Zhang H, Meng Y, Jiang R, et al. Effect of Multimodal Exercise on Cancer-Related Fatigue in Patients Undergoing Simultaneous Radiotherapy and Chemotherapy: A Randomized Trial in Patients with Breast Cancer. Alternative Therapies In Health And Medicine. 2023; 29(5): 233–237.
27. Aung O, Amorim MR, Mendelowitz D, et al. Revisiting the Role of Serotonin in Sleep-Disordered Breathing. International Journal of Molecular Sciences. 2024; 25(3): 1483. doi: 10.3390/ijms25031483
28. Kumar R, Rizvi MR, Saraswat S. Obesity and stress: a contingent paralysis. International Journal of Preventive Medicine. 2022; 13: 95. doi: 10.4103/ijpvm.IJPVM_427_20
29. Ratcliff CG, Lam CY, Arun B, et al. Ecological momentary assessment of sleep, symptoms, and mood during chemotherapy for breast cancer. Psycho-Oncology. 2014; 23(11): 1220–1228. doi: 10.1002/pon.3525
