Heart & Vascular Institute Physician eNewsletter - Summer 2012
Patients with breast cancer, once cured, do not die from recurrence of their cancer according to Juan Carlos Plana, MD, co-director of Cleveland Clinic’s new Cardio-Oncology Center. "They die from heart failure."
The good news is that cancer therapy today is so effective that there are more survivors than ever before. Despite this encouraging trend, cancer patients have another challenge to beat: the chemotherapies used to treat cancer are damaging to the heart.
"In the past, the cardiac complications of cancer treatments were not really a concern," says Dr. Plana. The Center is focused on early detection and treatment of heart issues stemming from cancer treatment. "Today, we are delivering very successful therapies for cancer, and patients are surviving," Dr. Plana says. "And as a result, they live long enough to experience the cardiac complications of cancer therapy."
After patients are cured from cancer, cardiac complications are a silent culprit for declining quality of life and risk of mortality. In fact, the American Heart Association and the American College of Cardiology consider a patient who has received a cardiotoxic treatment already a patient with "Stage A" heart failure, Dr. Plana points out.
"These patients need close follow-up and surveillance," he continues. "It’s not O.K. to cut these patients loose and never see them again."
Early detection and treatment are critical for identifying and managing cardiac issues associated with cancer therapy; however, the field of cardio-oncology is still young. Plana is working with an international team to develop the first set of guidelines as to how to effectively evaluate and risk-stratify these patients.
Cleveland Clinic’s Cardio-Oncology Center is a multi-disciplinary collaboration between the Miller Heart & Vascular Institute and the Taussig Cancer Institute, with Thomas Budd, MD, serving as co-director alongside Dr. Plana. The Cardio-Oncology Center works with referring physicians to coordinate therapy for cancer patients.
That includes using a sensitive new technology called strain imaging. With this echocardiographic diagnostic test, tissue deformation in the heart can be calculated. In a small study, strain predicted cardiac issues up to three months earlier than monitoring with ejection fraction alone.
2-D strain imaging of an apical three-chamber-view of a patient with herceptin-induced cardiomyopathy. The global longitudinal strain is reduced (-13.7% , normal being -18.6%). The inferolateral wall of the heart looks pink instead of the normal red.
"Strain imaging doesn’t take a lot of time, and it allows us an opportunity to gauge the health of the heart," Dr. Plana says. This new technology can give peace of mind to cancer patients who learn from strain imaging that their heart is in good shape or if issues are detected, intervention can be staged to protect the heart.
"Once we identify the problem, we want to treat these patients aggressively and in a timely fashion because that can make a difference in their prognosis," Dr. Plana says.
Heart issues are the cause for stopping cancer therapy in up to 17 percent of patients being treated for the most aggressive form of breast cancer. By using strain imaging, any heart issues can be identified early and addressed. That way, heart failure is not a barrier to cancer treatment.
"We want to follow patients who are in treatment for breast cancer, leukemia, sarcoma and renal cancer that require medications that are known to be toxic, so we can apply this very sensitive technology," Dr. Plana says.
Cleveland Clinic recommends that patients with the above diagnosis who are receiving cardiotoxic regimens or who have undergone chemotherapy or radiation in the past and present with symptoms including weakness and fatigue, shortness of breath, swollen feet, chest pain or arrhythmia be evaluated at the center. Cancer patients with heart disease or risk factors would also benefit from a screening at Cleveland Clinic Cardio-Oncology Center prior to the initiation of their treatments.
"Patients who have received cardio-toxic medications are at risk for heart issues, so the first step is for physicians to be aware of the chemotherapies that are toxic to the heart, and to recognize patients that are going through therapy with those regimens," Dr. Plana says. "The Cardio-Oncology Center has the capacity to accommodate these patients, and if their hearts are in trouble, we can coordinate therapy."
Red Flag: Cardiotoxic Cancer Drugs
Following are the most common heart side effects caused by the most common chemotherapeutic agents.
- LV Dysfunction: Anthracyclines, Cyclophosphamide and Trastuzumab
- Ischemia: Fluorouracil
- Hypertension: Bevacizumab, Sorafenib and Sunitinib
- Venous thromboembolism: Lenalidomide and Thalidomide
- Bradycardia: Thalidomide and Paclitaxel
- QT prolongation: Arsenic trioxide