Cancer treatment and cardiac function

Recent articles in both the oncology and cardiology literature have called for increased collaboration between oncologists and cardiologists in the clinical care of cancer patients and additional research on the cardiac effects of various cancer treatments.

It is not news that radiation therapy to the chest and some chemotherapy agents can cause heart disease, either acutely or as a delayed effect. It is well-documented that adult survivors of pediatric cancers, especially those treated with anthracycline-based chemotherapies, have significantly higher rates of cardiovascular disease than matched controls, including siblings. As more people live longer and as more agents with known or potential cardiotoxicity come out of the pipeline and into the clinic, post-treatment cardiovascular disease has become a bigger problem for all age groups. Identifying which individuals and groups are at greatest risk may be difficult, but those with pre-existing risk factors should be screened. Even asymptomatic individuals for whom anthracyclines are indicated are routinely screened using MUGA scans or echocardiograms.

After decades of experience researchers have only recently begun to elucidate the pathophysiologic effects of chemotherapy agents that lead to dysrhythmias and heart failure. Not surprisingly, different agents have different effects based on their mechanism of action. For example, trastuzumab (Herceptin) is a monoclonal antibody that attaches to HER2 receptors that are expressed in some cancers, especially a subset of breast cancers. There are also HER2 receptors on cardiac muscle cells.

Heart failure can progress silently for months to years. Although evidence-based guidelines specific to cancer survivors are not yet in widespread use, screening for at-risk patients is essential. The most common manifestation of cardiotoxicity is asymptomatic decrease in left ventricular ejection fraction (LVEF). Oncologists, cardiologists, and primary care providers can partner in the early detection and even prevention of heart failure brought on by chemotherapy-induced left ventricular dysfunction. A recent European Society for Medical Oncology guideline recommends post-treatment screening for asymptomatic patients at 12 months, 4 years, and 10 years after anthracycline treatment. It has been recommended that the American College of Cardiology/American Heart Association guidelines be used in the treatment of patients with asymptomatic LVEF decrease. These include lifestyle interventions (i.e., optimizing nutrition and exercise) and pharmacologic interventions. A pilot study has suggested that cancer treatment-induced heart failure patients can benefit from directed exercise programs modeled after those designed for patients with non-cancer associated heart failure.

This year Smilow Cancer Hospital has added a Cardiotoxicity Program to help oncologists manage cancer in patients with cardiac co-morbidity as well as assessing at-risk patients for whom they are considering treatments with potential cardiotoxicity.  

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McGrath PJ. Science is not enough: the modern history of pediatric pain. Pain. 2011; Aug 29.

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