Heart dis­ease stalks breast can­cer sur­vivors

Sur­vivors of breast can­cer are liv­ing so long that they face an­other risk — heart dis­ease, and it’s be­ing brought on by the drug treat­ments that saved their lives

The Weekend Australian - Travel - - Health -

WHEN Susan Heun showed up at Froedtert Hospi­tal, in Wauwatosa, Wis­con­sin, last month, all she wanted was a sec­ond opin­ion on her breast can­cer. She wasn’t ex­pect­ing that heart doc­tors would get in­volved in her treat­ment.

Heun, 58, col­lapsed and went into car­diac ar­rest at the hospi­tal while await­ing rou­tine tests. She was re­vived, only to get dis­turb­ing news: her heart was not pump­ing as well as it should, which might have been the re­sult of the breast can­cer treat­ments she re­ceived a cou­ple of years ear­lier.

‘‘ Now I’m go­ing home with heart med­i­ca­tion,’’ Heun said while ly­ing in her bed at the hospi­tal, with her hus­band, Tom, sit­ting next to her. ‘‘ I didn’t come in with heart med­i­ca­tion. Now we’ve got two prob­lems.’’

For years, physi­cians have known that some chemo­ther­apy drugs and ra­di­a­tion can dam­age the heart. But doc­tors and pa­tients have ratch­eted up their con­cern as can­cer pa­tients live longer and as al­ter­na­tive ther­a­pies less toxic to the heart have be­come avail­able.

‘‘ In the old days, car­diac death (for can­cer pa­tients) was a bless­ing,’’ said Byung-il William Choi, a Froedtert car­di­ol­o­gist. ‘‘ No more.’’

Re­cent re­search pub­lished in the Jour­nalof theAmer­i­canCol­le­ge­ofCar­di­ol­ogy sug­gested that breast can­cer pa­tients might be at even higher risk be­cause of what’s known as the ‘‘ mul­ti­ple-hit’’ hy­poth­e­sis.

The au­thors noted that phys­i­cal in­ac­tiv­ity and obe­sity — two in­de­pen­dent risk fac­tors for breast can­cer and heart dis­ease — are more com­mon in breast can­cer pa­tients. Then, add in the var­i­ous ther­a­pies breast can­cer pa­tients must go through. The re­sult is a se­ries of ‘‘ car­dio­vas­cu­lar in­sults’’, the au­thors wrote.

The in­sults, or dam­ag­ing ef­fects, make the heart even more sus­cep­ti­ble to in­jury and the pa­tient more at risk of dy­ing pre­ma­turely.

Heun’s sit­u­a­tion is com­pli­cated. Froedtert doc­tors say they do not think her can­cer treat­ments led to the ar­rhyth­mia that caused her heart to stop. How­ever, they found an­other prob­lem with her heart that they do be­lieve was caused by the can­cer treat­ments: her heart wasn’t pump­ing ef­fi­ciently.

Car­di­ol­o­gists use a mea­sure known as ejec­tion frac­tion to de­scribe how much blood is pumped out of the left ven­tri­cle, the heart’s main pump­ing cham­ber, with each beat. A nor­mal ejec­tion frac­tion is 55 per cent to 75 per cent. Heun’s ejec­tion frac­tion is 35 per cent, in­di­cat­ing dam­age to the heart mus­cle and a con­di­tion known as heart fail­ure.

‘‘ I knew that the chemo­ther­apy and the ra­di­a­tion had some­thing to do with this,’’ said car­di­ol­o­gist Choi.

Twenty-five years ago, Choi co-wrote a pa­per in the Amer­i­can Heart Jour­nal high­light­ing the car­dio­vas­cu­lar con­cerns of a par­tic­u­lar can­cer drug and of­fer­ing rec­om­men­da­tions on how and when it should be used to limit heart dam­age.

To­day, with 2.3 mil­lion Amer­i­can women liv­ing with a his­tory of breast can­cer and a 24 per cent drop in the breast can­cer death rate alone from 1990 to 2000, the con­cern is even more mag­ni­fied.

More and more doc­tors are look­ing to re­place old-line can­cer drugs that have known toxic heart ef­fects with ones that might work as well but with­out the heart prob­lems, said Jim Ste­wart, an on­col­o­gist at the Univer­sity of Wis­con­sin Hospi­tal and Clin­ics in Madi­son.

‘‘ We have to as­sume that a wo­man with breast can­cer will be alive 20 or 30 years later,’’ said Ste­wart.

In­deed, since age­ing is an in­de­pen­dent risk fac­tor for heart dis­ease, longer sur­vival for breast can­cer pa­tients who also might have been ex­posed to heart-dam­ag­ing drugs is likely to mean more cases of car­dio­vas­cu­lar dis­ease in the years to come.

‘‘ It’s a re­flec­tion of suc­cess,’’ Ste­wart said. ‘‘ They are sur­viv­ing long enough to be at risk.’’

In Septem­ber, a study of 43,338 older women treated for breast can­cer be­tween 1992 and 2002 found a 26 per cent higher rate of sub­se­quent heart fail­ure in those treated with an­thra­cy­cline can­cer drugs com­pared with non-an­thra­cy­cline drugs. An­thra­cy­clines are a class of drugs used on a variety of can­cers and still are a main­stay in breast can­cer treat­ment. The re­search was pub­lished in the Jour­nal of Clin­i­cal On­col­ogy .

Al­though an­thra­cy­cline drugs are of more con­cern, most of the drugs used to treat breast can­cer pose some short-term and long-term po­ten­tial for heart com­pli­ca­tions, doc­tors say.

In March, a study in the Jour­nal of the Na­tional Can­cer In­sti­tute raised con­cerns about ra­di­a­tion ther­apy.

The study noted that doc­tors have mod­i­fied ra­di­a­tion ther­apy since the 1970s so that it is less harm­ful to the heart. How­ever, it still can have an ad­verse ef­fect on the heart, ac­cord­ing to the study.

The study in­volved 1979 women who un­der­went ra­di­a­tion ther­apy of the in­ter­nal mam­mary chain lymph nodes. They had higher rates of heart fail­ure and heart valve dys­func­tion than those who re­ceived only breast ir­ra­di­a­tion. And women who re­ceived ra­di­a­tion ther­apy and who smoked were three times more likely to have a heart at­tack.

At some hos­pi­tals, on­col­o­gists now are us­ing non-an­thra­cy­cline drugs in se­lected breast can­cer pa­tients who al­ready have heart prob­lems that might be wors­ened by the drugs.

John Charl­son, an on­col­o­gist at Froedtert, pointed to re­cent pre­lim­i­nary re­search sug­gest­ing that an­other class of can­cer drugs called tax­anes might be less toxic to the heart than an­thra­cy­clines. As a re­sult of that re­search, about 10 per cent of breast can­cer pa­tients at Froedtert were now treated with the new drugs while doc­tors waited for more re­search to see if the drugs could be used in larger groups of breast can­cer pa­tients, he said.

Al­ready, some in­ter­net-savvy pa­tients were ask­ing about other drug op­tions be­cause of con­cerns about heart dam­age, he said.

The other good news was that by lifestyle changes and con­trol­ling other car­dio­vas­cu­lar risk fac­tors, can­cer pa­tients might be able to re­duce their heart risk sig­nif­i­cantly, said Pamela Douglas, co-au­thor of the pa­per last month in the Jour­naloftheAmer­i­canCol­lege of Car­di­ol­ogy .

That in­cluded main­tain­ing a healthy weight, ex­er­cis­ing and be­ing vig­i­lant about con­trol­ling their blood pres­sure and choles­terol, said Douglas, a pro­fes­sor of car­di­ol­ogy at Duke Univer­sity Med­i­cal Cen­ter in Durham, North Carolina. In­deed, she said the suc­cess of breast can­cer treat­ment means doc­tors in­creas­ingly are telling pa­tients two things: ‘‘ Con­grat­u­la­tions, you’ve been cured of can­cer. Since you’ve been given a sec­ond chance at life, here’s what you need to do to op­ti­mise it.’’

In ad­di­tion to ra­di­a­tion ther­apy and an­thra­cy­cline drugs, the jour­nal ar­ti­cle noted other heart con­cerns as­so­ci­ated with breast can­cer treat­ment.

An­other com­mon breast can­cer drug, Her­ceptin, is as­so­ci­ated with a 2 per cent to 4.1 per cent in­creased in­ci­dence of heart fail­ure.

Al­though en­docrine ther­apy drugs such as ta­mox­ifen are not known to be dam­ag­ing to the heart (and might ac­tu­ally be ben­e­fi­cial for the heart), those drugs cause a small in­crease in for­ma­tion of clots.

Promis­ing new drugs that in­ter­fere with the blood sup­ply to tu­mours might also in­crease the risk of clots, re­duce the pump­ing abil­ity of the heart and worsen high blood pres­sure.

At the same time, phys­i­cal in­ac­tiv­ity and weight gain can worsen heart prob­lems for can­cer pa­tients. Some re­search in­di­cates that breast can­cer pa­tients de­crease their phys­i­cal ac­tiv­ity by two hours a week. An­other study found that more than 70 per cent of pa­tients in­creased their body weight by 2kg to 6kg.

It’s not just breast can­cer pa­tients who are at risk.

In 1999, Sue Northey un­der­went ex­ten­sive ra­di­a­tion ther­apy for Hodgkin’s dis­ease, treat­ment that would dam­age her heart a few years later.

Northey, 49, said she didn’t re­mem­ber be­ing told about the po­ten­tial for heart prob­lems, al­though things were such a blur and she was so wor­ried about the can­cer that any warn­ings might have slipped her mind.

‘‘ How would I have made a dif­fer­ent de­ci­sion?’’ she added. ‘‘ It was choos­ing be­tween life and death, and I chose life.’’

Her can­cer has been in com­plete re­mis­sion since 1999, but a few years ago the first signs of other prob­lems started crop­ping up. She be­gan feel­ing short of breath in 2004. ‘‘ By the end I couldn’t even walk up a flight of stairs,’’ said Northey, an ad­ver­tis­ing ex­ec­u­tive. ‘‘ I just didn’t have any life any more.’’

Tests showed she had a con­di­tion known as con­stric­tive peri­cardi­tis, a con­di­tion in which the peri­cardium, the sac around the heart, be­comes in­flamed, cal­ci­fied and thick. A nor­mal peri­cardium is about 1 to 3mm thick; Northey’s was be­tween 5 and 8mm.

In July, Northey un­der­went a five-hour heart op­er­a­tion at Froedtert to re­move scar tis­sue and part of the peri­cardium.

Her short­ness of breath has gone away, and she eas­ily can walk for a half-hour on the tread­mill. ‘‘ I have a new lease on life,’’ she said. ‘‘ I feel the best I’ve felt in a decade.’’

Her case, though, was an ex­am­ple of how can­cer pa­tients should be es­pe­cially vig­i­lant about tak­ing care of their hearts be­cause of the prob­lems that could oc­cur long af­ter treat­ment, said Northey’s doc­tor, Lee Bi­blo, a car­di­ol­o­gist at Froedtert.

‘‘ It’s like a chess game where you’re try­ing to stay five or 10 years ahead,’’ said Bi­blo, vicechair­man of medicine at the Med­i­cal Col­lege.

‘‘ In women, heart dis­ease is still the num­ber one killer.’’ AP

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