Cardio-Oncology: How Can Cancer Treatment Affect My Heart (Drs Plana&James 10 17 13)
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. Plana and Dr. James answer your questions about cancer and the effect on the heart.
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Monitoring and Surveillance During Cancer Treatments
AnnS1961: I have a friend that recently had cancer treatment. She had echos during the treatment but not the special strain imaging you talk about on the website. Is that enough to monitor her for heart problems?
Juan_Carlos_Plana,_MD_: The use of imaging does not allow for recognition of subtle changes in left ventricular function. Therefore, we recommend strain imaging when available.
CynthisT: I have seen this information that has been on your blog and am currently undergoing treatment for breast cancer. Luckily, caught fairly early. The interesting thing is that my doctor has not really brought up these issues. Could it be that my treatment is not harmful - or - how do I bring these concerns up with him. What should I ask? What types of testing should I be having - and - what if you don't have that type of tests in your area? I am from a small town. Should I ask to go to another center for testing? Is it that important?
Juan_Carlos_Plana,_MD_: The discussion needs to be held with your doctor about the potential cardiotoxicity of the treatments. If your doctor considers that there is potential for heart damage, we recommend baseline echo and follow up echos; and - if the strain technology is not available, you can consider checking biomarkers (troponins).
Moderator: Why a Cardio-Oncology Center?
Juan_Carlos_Plana,_MD_: Recent data have raised concern about the true frequency of cardiac toxicity associated with these cancer treating medications. Today, the treatments for cancer are successful, and the cardiovascular complications of cardiotoxicity has become the number one reason for morbidity and mortality. As a result, along with other institutions in the US, we have decides to open up multi-disciplinary cardio-oncology centers dedicated to the care of patients who are undergoing - or have undergone cancer treatments.
HB422: What is cardio-oncology? Is it cancer of the heart?
Juan_Carlos_Plana,_MD_: Although there are cancers that can potentially go to the heart, the focus of our Center is to deal with the cardiovascular complications of cancer therapy (chemotherapy and radiation therapy). We also take care of common cardiovascular problems as patients undergo cancer treatment.
We are using new technology called strain imaging that allows for very subtle changes in cardiac function - giving us the ability to recognize it early and then treat it early. This strategy not only prevents the development of a drop in ejection function and heart failure syndrome - it also prevents unnecessary interruptions in their chemo treatments.
Moderator: What has your research shown?
Juan_Carlos_Plana,_MD_: Our research demonstrates the role of strain imaging in the evaluation of these patients. It allows us to identify the area of change in cardiac function due to toxicity and it allows us to initiate treatment early; preventing a reduction in ejection fraction and development of heart failure syndrome. We are anticipating that in the first semester of 2014, we will be publishing expert consensus that will guide the decisions as to how to take care of patients like you.
Breast Cancer Treatments
Venie: How will my heart & lungs be affected by radiation to metastatic breast cancer lesions on my thoracic spine? How can the risk be reduced?
Juan_Carlos_Plana,_MD_: As far as the heart goes, damage can occur to the pericardium, the arteries, the muscle itself or the valves. As far as the lungs go, the lung itself or the pleura can be affected. Right now there are modern techniques that try to reduce the amount of radiation or reduce the damage, especially to the heart.
MaryK: I have a friend who had breast cancer treatments 10 years ago and out of the blue this past week, she started having chest pains and shortness of breath with minimal activity. She is seeing a cardiologist next Monday. Her family doc thinks she may have heart damage from her chemo. Is it possible that she can be treated and get back to being an active person again. Right now she is very limited.
Juan_Carlos_Plana,_MD_: The knowledge that we have is that the condition could be successfully treated as long as it is recognized early. If many years have gone by, there is less likelihood she will come back to full recovery - that is why we encourage early screening and treatment.
Karen_James,_MD_: There may have been long standing damage, however, there are medications and therapies that can be used to help a patient reduce symptoms and improve heart function in that circumstance.
stuti: I often suffer from a bad pinching kind of pain at the mid left of my chest and this pain is accompanied by a backache, right behind the area of chest pain. and during this pain, it is even harder to breath as it hurts badly while exhaling. this pain is mostly followed by sneezes, etc. but not necessarily. I feel relieved after resting but shortness of breath is noticed by me...sometimes, I even undergo nausea kind of sort.........I have a doubt if it is due to low level of haemoglobin but not sure about it........please help!
Juan_Carlos_Plana,_MD_: Based upon the description - although - low hemoglobin can be a cause of your symptoms - we cannot exclude coronary artery disease. We recommend you be evaluated by a heart doctor.
Jennifer23: what is the relationship between arrhythmias and chemotherapy. I have had an irregular heart rhythm since my chemo - is that related?
Juan_Carlos_Plana,_MD_: There are two potential mechanisms for irregular heart rhythm in the setting of chemotherapy. One - the medication can induce irregular heart beat or the second one - the medications can produce weakness of the heart that can be manifested as irregular heart beat. Check with your doctor and be thoroughly evaluated for this.
Heart Failure and Cancer Treatments
JackNC: My dad has heart failure. He has a pacemaker-defibrillator, and last week they found a spot on his lung. He is being worked up now. With heart failure and arrhythmias already, I am very worried about what treatments would make his heart condition worse. Should we be more cautious about certain types of treatments with poor heart function?
Karen_James,_MD_: Certain types of chemotherapies can have an impact on heart failure. Your dad's oncologist should be aware of the prior diagnosis of heart failure. If your father does experience side effects of the chemo - these can be treated in conjunction with the chemotherapy by adjusting medications with the cardiologist.
Jack 45: What kind of advanced treatment options are available if a patient develops heart failure later on after chemotherapy?
Karen_James,_MD_: Patients who develop advanced heart failure in spite of precautions, may still benefit from medication used to treat heart failure and device therapy. For the small subset who have difficulty in spite of these measures, they should be referred to advanced centers who offer therapies such as heart transplant and left ventricular assist device therapy.
Oral Cancer Treatment
kelseyann: In 2000, I was diagnosed with oral cancer (which had spread to my right lymph nodes. I wasn't a smoker) and was treated with surgery and 40 radiation sessions to my throat and neck. After awhile things seemed to be back to normal--I had lots of energy, regained my active lifestyle, etc. Several years ago I realized that I was getting winded more and more easily. Even a slight walk uphill would have me gasping for air and my heart felt like it was going to beat out of my chest. About a year ago I thought I was having a heart attack and wound up in the ER. The doctors said I had constrictive pericarditis due to the radiation treatment. Both of my lungs were also hardened for the same reason. Since my ability to do simple exercise has become increasingly difficult, I am wondering if there is a point when I can expect the progression of the hardening to stop, or is it more likely that it will continue to worsen. Is exercising putting me at risk? I have no insurance or doctor. General info would help.
Juan_Carlos_Plana,_MD_: Unfortunately, constrictive pericarditis is a condition that is progressive. Available management is surgery - removal of pericardial sac. Exercise does not help. You should speak to a specialist and if insurance is a concern, a financial counselor at your hospital.
Karen_James,_MD_: Coronary artery disease can also be associated and should be part of the evaluation.
Chemo and Radiation
chopper256: Can the heart be affected by chemo as well as radiation during therapy for lung cancer?
Juan_Carlos_Plana,_MD_: It is more frequently affected by radiation therapy - but you need to check with your doctor about the type of chemotherapy you are receiving and the amount of potential cardio-toxicity.
Specific Medications for Cancer Treatment
mscadi1: Twenty years ago I had CMF adjuvant chemotherapy for node-negative, estrogen negative, progesterone positive breast cancer. Now in 2013, I have developed left ventricular dysfunction and tach-brady syndrome/sinus node dysfunction. Recently, I was also diagnosed with follicular B-cell lymphoma which has not been staged yet. Is there any possible connection between the chemotherapy and the heart problems and lymphoma. I have no risk factors for heart disease (retired cardiac rehab RN). My maternal and paternal families have lived long lives (80,s & 90,s) for many generations.
Juan_Carlos_Plana,_MD_: Although the regimens you obtained, do not frequently cause cardiomyopathy, it is possible that it could be the result of the chemotherapy that was used. We would recommend a work up with any patient with systolic dysfunction to rule out any other reasons such as coronary artery disease.
mscadi1: I am scheduled for ablation of atrial fibrillation in two weeks. As mentioned before, I have these arrhythmias as well as left ventricular diastolic dysfunction. Is there any contraindication for ablation if there exists already a possibility of damage from previous chemotherapy?
Juan_Carlos_Plana,_MD_: No - there is no contraindication.
pennsylvania man: Dear Sir.....I am currently receiving Hormone (oral and injections) treatments in order to reduce the size of my prostate, keeping the cancer from spreading, and preparing the prostate for future radiation treatments. My Urologist recommended that I stay on Hormone treatments for approximately 2 years or more in order to achieve the above. I am concerned that prolonged Hormone treatments are hard on your heart. Would it be possible to reduce the number of years on Hormone treatments and start the radiation treatments earlier than 2 years , with the same results as if I would have stayed on Hormone treatments longer. Thank You.
Juan_Carlos_Plana,_MD_: I would recommend to continue the regimen that was prescribed to you by your doctor.
Venie: Does Faslodex affect the heart? Afinitor? Xgeva?
Juan_Carlos_Plana,_MD_: I am not aware that they have major cardio-toxicity.
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