Here's what those who have had cancer—and their employers—can do to avoid heart complications.
It's a quintessential good news/bad news scenario. Thanks to earlier detection and better treatment options, women diagnosed with breast cancer are living longer.
The flip side is that they are experiencing more cardiovascular complications as a result. Breast cancer survivors, especially women over 65, are more likely to die from cardiovascular disease than breast cancer, according to a scientific statement released by the American Heart Association earlier this year. That underscores the need for managing heart disease risk during and after cancer treatment, the AHA says.
To some degree, the increase in cardiovascular problems isn't surprising, local experts say. “Approximately 90 percent of breast cancer survivors are alive five years after diagnosis,” says Dr. Anne Albers, a cardiologist with OhioHealth Heart & Vascular Physicians. “Age is a risk factor for cardiovascular disease, so a longer [cancer] survival rate will increase your risk for heart and vascular disease.”
That said, both chemotherapy and radiation exert stress on a woman's heart and vascular system in a variety of ways:Some drugs, such as anthracycline, can result in abnormal heart rhythms that may be life-threatening in some cases. HER2-targeted therapies, such as Herceptin, can cause weakening of the heart muscle, or heart failure, which occurs when the heart loses its ability to contract normally. Herceptin and other targeted immunotherapies treat so-called HER2-positive breast cancers, which contain abnormally high levels of a protein that stimulates cancer cell growth. Anti-metabolites can cause spasms in the heart's arteries that cause chest pain but could lead to heart attacks as well. Radiation creates collateral damage to surrounding tissue, which can lead to narrowing of the arteries and other problems.
Dr. Laxmi Mehta, director of the Women's Cardiovascular Health Program at the Ohio State University Wexner Medical Center, was one of the authors of the AHA paper. “Patients are overwhelmed when they're diagnosed with two serious conditions. … There has to be a focus on the heart both during and after cancer treatment,” she says. “It's imperative to carefully monitor heart functions.”
However, she cautions, “We don't want to raise hysteria. We definitely don't want patients stopping their treatment.”
Physicians say the medical community is increasingly aware and vigilant when it comes to monitoring a breast cancer patient's cardiovascular status and adjusting treatment accordingly. “We aggressively monitor patients while they are receiving [potentially toxic] medications to minimize these toxicities when possible,” says Dr. Raquel Reinbolt, breast medical oncologist with the Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute.
Patients should be reassured that, “When we recommend a treatment for a patient, we really believe the benefits outweigh the risks,” says Dr. Jeanna Knoble, a medical oncologist with Zangmeister Cancer Center and co-medical director of the breast cancer program at Mount Carmel Health System.
Reinbolt says “multiple efforts” are under way to prevent, reduce or eliminate heart-related complications. In some cases, physicians can try different medications or administer them differently to try to mitigate serious side effects.
For example, studies have shown that when the drug doxorubicin is infused slowly, rather than all at once, patients may have a lower risk of heart failure. Prone radiation, in which a woman lies stomach-down on the treatment table, delivers a far more targeted dose of radiation, sparing nearby tissue.
Women also may receive so-called “cardio-protective” agents, such as beta blockers or cholesterol-lowering statins, if they are at risk for developing heart and vascular complications.
Because no two women share the same risk factors, or cancer, it's essential to think ahead when planning treatment.
Local physicians stress the importance of communication and collaboration between oncologists and heart specialists in higher-risk patients. “There is much more awareness of the link between cancer treatment and heart disease, and we're seeing a more multidisciplinary approach,” says Dr. Laura Gravelin, a cardiac electrophysiologist at Mount Carmel. The growing field of cardio-oncology is evidence of that, she says.
“Cardio-oncology is a conversation” between specialties, says Albers, who notes that in her experience, oncologists have been diligent about ordering echocardiograms and other tests to monitor effects on the heart. “If we see something abnormal, maybe we take a break or consider changing medication or adding medication,” she says.
Mehta says specialists are working to develop guidelines to determine which patients would most benefit from testing and ongoing surveillance. “Not all treatments result in cardiovascular complications,” she notes.
Reinbolt says physicians and researchers also are trying to better understand why some cancer drugs cause heart issues in certain breast cancer survivors. For example, researchers at OSU are trying to identify a genetic “signature” that may signal that a woman is at higher risk. “We've also evaluated if we can use cardiac imaging, like cardiac MRI, to detect heart toxicities earlier on.”
Another key message contained in the AHA scientific statement was that of shared risk factors for both breast cancer and cardiovascular disease, namely: age, obesity, physical inactivity, smoking, poor diet and family history. Another overlapping risk factor is being post-menopausal. Some cancer therapies can trigger premature or early menopause, Reinbolt notes.
She and others say lifestyle changes can have an impact on the risk for breast cancer recurrence as well as cardiovascular disease.
The American Heart Association says adherence to its Life's Simple 7 program is associated with a trend toward lower incidence of breast cancer. It includes:Being physically active (at least 150 minutes of moderate to vigorous physical activity a week) Achieving and maintaining an ideal body weight Eating a healthy diet, with an emphasis on plant-based foods Avoiding tobacco use Maintaining healthy levels of blood pressure, cholesterol and blood sugar
Albers says it's important for women to know that when it comes to the physical activity, exercise can be spaced out in three, 10-minute intervals a day.
“If you can adhere to these seven things, you really can put yourself in a better position” both in terms of cancer and cardiovascular disease, she adds.
The business sector has a role to play as well, physicians say. Albers says businesses both large and small can make a difference by offering incentives for tracking steps and supporting lifestyle choices such as mindfulness and stress reduction, for example.
Gravelin says companies also can establish lunchtime walking programs, offer healthier choices in cafeterias and vending machines, and partner with gyms to offer discounted memberships. She says she plans to ask her patients about what their employers area doing to support health and wellness.
Women need to be as concerned about their cardiovascular well-being as they are about their breast health, Gravelin believes. “Women are much more afraid of breast cancer, yet heart disease is the number one killer of women, causing one in three deaths.”
Laurie Allen is a freelance writer.