Thursday, June 7, 2012 - 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. Learn more about cancer treatments and the effect on heart disease by experts from Cleveland Clinic.
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Cleveland_Clinic_Host: Let's begin with the questions.
Symptoms of Heart Disease after Cancer Treatment
FranW: I have idiopathic ventricular tachycardia. I am taking Flecainide twice a day and Toprol once a day for that. I had breast cancer in 2009, a lumpectomy, chemo, and radiation. I am currently taking Femara - have been on it since 2009. I had a VT attack last May (2010). Dr. didn't know what brought it on, but he changed my medication to what I am taking now. (I had been on Flecainide once a day with Verapamil.) Still have some fainting feelings occasionally. My heart rate is rally low. Doc's say Femara is not conflicting with my heart meds, but I wonder. What do you think? Also, is there any update on VT treatment? I had an ablation in 2006 when it first showed up, but it was not successful, so am using medication. Cardiologist says I am not perfect, but doing OK for now. But, I can't "over do" anything without getting fainting feelings. Thanks! Fran
Dr__Plana: Having received chemotherapy and radiation, the questions I have for you is what your ejection fraction is, and do you have any blockages in the coronary arteries (arteries of the heart) - we would recommend a special type of echo that we offer here at the Cleveland Clinic as well as evaluation for coronary artery disease.
CarolynK: I have a friend who had chemotherapy for ovarian cancer. She is now having high heart rates and chest discomfort. Is it possible to treat this and will she need to be on heart meds for life.
Dr__Oliveira: Depending on the chemotherapy that your friend had, her high heart rates could be a sign of some cardiac toxicity. She should have an echocardiogram performed and the treatment would be based on the findings of the echocardiogram.
Gilles: What is best treatment for SVT? Is it Toprol, Digoxin, or ablation with "twilight sleep" anesthesia?
Dr__Oliveira: Although this is not a common side effect of cancer therapy, we do encounter it sometimes. The best treatment of your SVT depends on the type of SVT. This determination is best made by an electrophysiologist.
benlomondeast: I was treated for Hodgkin's in "82" with mediastinal RT. Subsequent valvular and myocardial damage have progressed to symptomatic heart disease, afib, and failure, what are my best options?
Dr__Oliveira: Your best option is to come in and see us. The reason for this is that there are many possible co-existing factors contributing to your current situation. Without a detailed cardiovascular evaluation, it is impossible to answer your question in a web chat.
Damage to the Heart after Cancer Treatment
MargeK: I had breast cancer, lumpectomy, chemo and radiation back in 2008. I have been doing very well. I read that chemo can cause heart failure and muscle damage even up to 10 years after treatment. Do you have statistics as to how often damage occurs?
Dr__Plana: The data that we now have is that LV dysfunction can occur in up to 32% of patients and heart failure in up to 7%. We recommend an echo using a special technology called strain echocardiogram. This new technology that we are pioneering here at the Cardio-Oncology Center allows for very early detection of toxicity.
DaleT: How does chemotherapy damage the myocardium? How do you prevent side effects of chemotherapy from damaging the heart?
Dr__Oliveira: The ways in which chemotherapy may damage the heart are many. The most common chemotherapeutic culprit has historically been the anthracyclines, of which, adriamycin is the best known. Adriamycin, as Dr. Plana has pointed out, causes death of the myocardial cells through mechanisms that have not been entirely clarified. The more adriamycin that is given, the more cells that die (dose dependent effect). Some of this cell death is caused by a mechanism called apoptosis. Because this process is insidious and occurs subclinically, this effect may be initially missed by conventional echocardiography using ejection fraction or other methods such as MUGA. At our Cardio-Oncology Center, the use of strain imaging echocardiography has allowed us to identify this toxicity at an earlier stage and initiate treatments sooner. As soon as we detect an abnormality in strain which we think signifies cardiotoxicity, we initiate treatment to minimize and counteract this process. The major form of therapy for this has been the use of a medicine carvedilol, which both clinically and experimentally has been shown to prevent myocardial cell death.
PemberKim59: Having had multiple chemotherapies over the last 12 years, I was diagnosed with LV dysfunction and heart muscle damage at your center. I have since been on medications and my strain echoes have been good since the medications have been initiated. How frequently is it recommended that the echo be repeated, since I am no longer on chemotherapy?
Dr__Plana: It is great to know that your strain values have been stable while on therapy. I would follow the advice of your treating physician as to the adequate interval for follow-up testing.
Prevention of Heart Problems with Cancer Treatment
Lara1974: If one is diagnosed with breast cancer and looking into different possibilities for treatment and has a strong family history of heart disease, what is the best way to go for treatment? What should I be looking for?
Dr__Oliveira: First of all, I would be careful with "different possibilities" for treatment of breast cancer. Specifically, I would not recommend alternative cancer treatments, because there are plenty of data supporting our current and established medical treatment for breast cancer.
Having said that, within the conventional treatments of breast cancer, there are different options. For someone with a family history of heart disease, it would be important to be evaluated by a cardiologist with experience in cancer treatment so that he, in conjunction with the oncologist, can arrive at the safest and most efficacious treatment plan for you.
JennyP: What is the risk to my heart with being treated with adriamycin for breast cancer? Is radiation worse or chemo worse for the heart? Does it make a difference if I am diabetic?
Dr__Plana: The risk of heart failure for a patient receiving adriamycin only is 5%. It goes up if used in combination with other chemotherapeutic agents. The risk of heart failure associated with adriamycin is dose dependent. Chemotherapy and radiation can cause heart toxicity and the fact that you are a diabetic increases the risk for both. I will recommend a thorough evaluation of both your heart function and the status of your heart arteries before initiation of treatment.
shaneme123: Hello: treated for Hodgkins IV with 6 cycles of ABVD two years ago (46 years old); last year valve aortic replacement. What have studies stated about longevity? I had a MUGA (sorry for spelling) test done prior to ABVD treatment; at end had another. No issues found but is the MUGA test accurate/reliable? are there any supplements/drugs that can help the heart and vascular functions after ABVD 6 cycles of treatment?
Dr__Plana: You received adriamycin as part of your chemotherapy. Your longevity will be determined by whether your heart muscle had toxicity secondary to the adriamycin and if the cancer recurs. Although your MUGA scan did not reveal the presence of issues, I will recommend that your heart gets tested with the state of the art technology (strain echocardiogram). If LV dysfunction is encountered, cardioprotective medications can be initiated.
Cleveland_Clinic_Host: Can you please tell us a little more about your program and some new research that has been coming out about the effects of chemotherapy on the heart?
Dr__Plana: We have put together a multidisciplinary center to address the cardiac complications of cancer therapy. The center includes cancer radiotherapy, heart failure and cardiac imaging experts. The goal of the center is to allow the patients to complete their cancer treatments minimizing the cardiac complications.
For patients that have received cardiotoxic chemotherapy and radiation, we offer new technology to detect toxicity that will allow us to initiate treatment and to prevent the development of heart failure.
Dr__Oliveira: Our Cardio-Oncology Center, while devoted to preventing and minimizing cardiotoxicity and facilitating successful cancer therapy, is also prepared to offer life-saving advanced therapies for those whose hearts have already been inexorably damaged. As such, we offer heart transplantations, as well as mechanical assist devices for patients with end stage heart failure induced by chemotherapy. Our recent research has shown that patients with chemotherapy induced cardiomyopathy that receive either heart transplantation or heart pumps do as well as any other type of heart failure patients.
Dr__Plana: The state-of-the-art echo that we offer at the Cardio-Oncology Center includes 3D (three dimensional) calculation of ejection fraction after the administration of echo-contrast (not toxic to the kidneys). It also includes strain imaging. Strain imaging allows an accurate characterization of the function of each individual segments of the heart. When comparing the images obtained during treatment with the ones obtained at baseline, we can identify cardiac toxicity at very early stages.
MH6874: For primary heart cancer – is transplant an option?
Dr__Oliveira: Maybe. Most often patients with active cancer are not a candidate for heart transplantation. However, patients with primary cancers isolated to the heart can sometimes be offered auto-transplantation. Auto-transplantation is a surgical procedure offered at the Cleveland Clinic where the heart is taken out of the chest, the tumor is extracted, and the heart is sewn back in.
This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician's independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians.