Friday, October 14, 2011 - Noon
Current treatments for cancer are saving lives and have been one of the greatest achievements in modern medicine. However, many of the life saving cancer therapies can have significant and serious cardiovascular side effects, such as heart failure, thromboembolism, severe hypertension and lethal arrhythmia. Dr. Juan Carlos Plana will answer your questions about cancer and the effect on heart disease.
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Cleveland_Clinic_Host: Welcome to our "Cancer and Heart Disease" online health chat with Juan Carlos Plana, MD. He will be answering a variety of questions on the topic. We are very excited to have him here today! Thank you for joining us, let's begin with the questions.
Dr__Plana: Let's start.
Cleveland_Clinic_Host: Dr. Plana, you come from an interesting background. What made you become interested in this particular area.
Dr__Plana: We are witnessing a change in the history of cancer treatment where medications are actually working and where patients are going to have survival whereby they can experience the side effects of the treatment or medications used for their cancer. If we think about breast cancer by itself, there are 2.2 Americans that have enough survival where they can face the side effects secondary to the chemotherapy. These patients once cured for breast cancer will not die from breast cancer - they will die from heart disease. So, the idea is to stop this from occurring. The idea will be to develop technologies that will allow for early recognition of the damage and allow these patients to receive early treatment. Allowing them to be cured from the cancer and prevent heart disease once they have survived it.
PemberKim59: I believe I was one of the first test patient's of Dr. Plana and I can attest to the excellent results I have had from the study!
Dr__Plana: That is absolutely true and I am so happy to see you in the web chat.
Chemotherapy and Risk of Heart Disease
Melissa: What are the types of chemotherapy that puts you at increased risk?
Dr__Plana: There are 7 types of chemotherapy that cause cardiac disease. The most frequent ones are two groups. One is anthracyclines and the second one is tyosine kinase inhibitors. This type of chemotherapy is used in treatment of breast cancer, leukemias, lymphomas, sarcomas, and more recently kidney tumors, among others.
SaraP: What if you had a toxic drug and thankfully I am cancer free now - but what should I do? Should I see a cardiologist? Can I prevent damage to my heart?
Dr__Plana: I would recommend that you see a cardiologist and get an echo with strain imaging to see how much damage you have secondary to the chemo that you had.
In the setting of chemo, what you can do is prevent further damage. But - the damage that is secondary to the chemotherapy can only be prevented if it is detected early. This is an important point - early detection is very important.
Chuck19624: What if you developed CAD which required CABG several years after a rigorous chemo regimen. How do you prevent future disease if all other traditional risk factors are minimized?
Dr__Plana: What is important once you have received chemotherapy, once all risk factors are controlled, is to make sure blood pressure is well controlled and also to recognize the damage that has occurred secondary to the chemotherapy. This will help us determine how aggressive to be with medical management.
PemberKim59: What about with the use of Herceptin?
Dr__Plana: Herceptin by itself can cause heart trouble but the most common cause of trouble that patients who receive Herceptin is if they have been previously treated with anthracyclines, where the rate of toxicity can be as high as 40% from our data from the Cleveland Clinic.
Before You Start Chemotherapy
vickiH: My mother is starting chemotherapy for breast cancer. We do have a family history of heart disease as my grandfather died from a heart attack. What should she ask her doctor?
Dr__Plana: She should ask for a special type of echo called echo with strain imaging. This is a new technology that allows some recognition of a slight dysfunction of the heart. In addition, she should have a formal evaluation of coronary artery disease with a stress test.
Cleveland_Clinic_Host: Dr. Plana, would you be able to explain strain imaging?
Dr__Plana: A Strain imaging test is a new type of technology that is used to analyze the images that are traditionally obtained. We can define the function with precision of each of the segments of the heart.
JonPTD: Would you recommend that patients see a cardiologist prior to beginning any chemotherapy regimen?
Dr__Plana: I would not say any chemo regimen - I would say that patients should see a cardiologist if they have risk factors for heart disease and receive a cardio-toxic chemotherapy regimen. If you are going to receive a cardio-toxic regimen AND if you have risk factors for heart disease - that is the most important.
nancyh: since so many oncology drugs can cause heart damage and immunosupression would a good approach be to consult a cardiologis/onconogy specialist as well as an infectious disease specialist ?
Dr__Plana: What they usually do right now - is for certain types of cancers is to give antibiotics in advance or the idea would be to consult an infectious disease physician if there are symptoms, but not for everybody.
franke: I have recently been diagnosed with Breast Cancer - - Stage II. Had surgery and now on chemotherapy. My oncologist never mentioned the potential side-effects to the heart, and in all my research I never came across info on the connection? Why is this? Why does this not get more attention?
Dr__Plana: We need to first establish if you received a combination that is toxic to the heart. That is the whole reason for this web chat. This is a new area of interest and we hope to get the word out to patients and physicians.
nancyhanks: Once damage is assessed what can one do to prevent or at least help with failure on home monitoring devices?
Dr__Plana: The first thing would be to be evaluated by a team that has experience with these types of issues. The idea is to optimize medical management with the right type of medications to make it as easy as possible for the heart to beat. Once the patient has been started on these medications, home monitoring devices can make sure that the heart rate and blood pressure are optimized.
Radiation and Heart Disease
Allison1977: How does prior chest radiation impact the heart? Do both radiation and chemotherapy cause later heart problems? If so, how?
Dr__Plana: Radiation can cause damage to the pericardium (the covering of the heart), the muscle itself and also to the valves. Patients can present with any of these three conditions:
- Constrictive pericarditis
- Heart failure
- Narrowing of the cardiac valves
Radiation can also put patients at risk for coronary artery disease, blockages in the arteries of the heart.
Chemo therapy can cause problems in the muscles, the electrical system and also in the vessels. The most common side effect is heart failure.
marilynm: I had a lumpectomy and radiation on my left breast. Should I be concerned about the possible effect of radiation to my heart?
Dr__Plana: The answer is yes. I would recommend that you get evaluated using our new technology called strain imaging, where we can define the extent of damage that your heart suffered secondary to the radiation therapy. I would like to mention that this is a very new area - it is so new that there are actually no guidelines.
We are partnering with the European Association of Echocardiography to put together the first set of guidelines that will be available in 2012, whereby clinicians will know from the imaging stand point what are the imaging guidelines for these patients.
marilynm: OK, I live in Maryland but I could come to the Clinic to get that done.
Dr__Plana: We would be happy to see you at Cleveland Clinic in the new Cardio-oncology Center that has the imaging studies that are necessary to assess your condition. Please contact my office and we would be happy to help you.
LibbiT: Is wound healing poor for patients with prior chest radiation – if so, why?
Dr__Plana: Yes - because when radiation is given, the idea is to kill the tumor cells but it also damages the tissue around the cells, which includes the vessels - this area will look more like a scar with compromised perfusion to the tissue.
Cleveland_Clinic_Host: Dr. Plana, how far out after cancer treatment could someone expect to experience heart problems?
Dr__Plana: In the setting of radiation, usually these patients can present somewhere between 15 - 20 years later with problems with the pericardium, valves, or arteries of the heart. Some of them require surgery.
Cleveland_Clinic_Host: Is there a particular group that should be concerned more than others?
Dr__Plana: The patients that usually get into trouble are most often the patients that were treated for Hodgkins Disease in which they radiate the chest.
nancyhanks: would better shielding prevent this?
Dr__Plana: Shielding has evolved over the years although with some tumors, due to their location, it is literally impossible to spare the heart.
Cleveland_Clinic_Host: Dr. Plana, is there any new research coming out on the topic?
Dr__Plana: We have recognized the importance of these issues and we have put together a new Cardio-oncology Center which will be devoted to addressing the needs of these patients. This will be a joint effort between cardiologists and oncologists. We have recently published a new study demonstrating that strain imaging can be used to detect the damage due to chemotherapy very early - when it is reversible with the use of heart failure medications.
nancyhanks: name of this study?
Dr__Plana: Our paper was published in the American Journal of Cardiology.
In terms of research, we have also taken a look at our data from Cleveland Clinic. Patients who went into chemotherapy and received cardio-protective medications for other reasons - they were protected also in terms of their cardio-toxicity, those that were receiving beta blockers.
nancyhanks: cardio protective drugs?
Dr__Plana: the strategy we have right now in our center is to identify the patients who have the earliest signs of toxicity and intervene on them. In light of the recent retrospective review we think that beta blockers may be the best choice for these patients.
nancyhanks: Major medical institutions adding to this study?
Dr__Plana: We are in the process of setting up agreements with major institutions inside and outside the United States to begin a large multi-center trial.
Cleveland_Clinic_Host: I'm sorry to say that our time is now over. Thank you again for taking the time to answer our questions about cancer and heart disease.
Dr__Plana: Thank you for having me today.
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