Breast cancer treatments linked with heart failure, AHA warns

Read Advisory Board's take on this story.

For the first time, the American Heart Association (AHA) is warning that breast cancer patients who have received chemotherapy or radiation are at an increased risk of heart failure and other types of heart disease—although the overall risk remains low.

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According to the Washington Post's "To Your Health," oncologists are largely familiar with the cardiac risks of cancer treatment. However, the statement published Thursday in the journal Circulation, marks the first time AHA has issued a comprehensive scientific announcement on the link between breast cancer and heart disease—and it could serve as helpful reference for patients and other providers, such as ED doctors and primary care physicians, who treat women with breast cancer, "To Your Health" reports.

Background

Women who have breast cancer typically undergo surgery, chemotherapy, radiation, or a combination of those procedures, according to "To Your Health." However, research shows that many common chemotherapy drugs can strain the heart, STAT News reports.

For instance, the class of drugs called anthracyclines—including the common treatment doxorubicin—can kill cardiomyocytes, which make up the heart muscle. Another class of drugs, called taxanes, can slow heart rhythm; certain hormone drugs can cause potentially fatal blood clots; anastrozole, an aromatase inhibitor, is associated with cardiovascular events, such as heart attacks; and trastuzumab can cause heart failure, according to STAT News.

Statement details

The statement does not suggest that providers and patients avoid cancer treatment, STAT News reports. Rather, it recommends that they aim to minimize or avoid cardiac risks, emphasizing that breast cancer survivors can boost their chance of a healthy life with regular exercise and a healthy diet.

According to the report, the largest cardiac risk was from doxorubicin, and the risk increases with every treatment. While eight treatments with the typical dose for doxorubicin comes with a 5% risk of heart failure, 11 treatments is associated with a 26% risk—and more than 14 treatments is associated with a 48% risk. That said, the report also cited research showing that administering a dose of doxorubicin slowly, rather than at one time, could curb the risk of heart damage, as could use of a drug called dexrazoxane.

Overall, the report noted that while 3.3 million U.S. women have breast cancer, nearly 48 million have some kind of cardiovascular disease. In fact, according to the report, cardiovascular problems pose a greater mortality risk to older women than breast cancer.

That said, the overall risk posed by chemotherapy drugs remains low, according to the statement. Laxmi Mehta, a cardiologist at Ohio State University who led the report, said, "The intent of the paper is certainly not to say don't treat breast cancer. We want patients to undergo the best treatments available. But we also want patients and their doctors to be aware" of the risks breast cancer drugs pose to patients' hearts.

Comments

Several stakeholder praised the report, particularly for its potential to remind a woman's other, non-oncologist physicians about the connection between heart disease and breast cancer. 

For instance, Neelima Denduluri, a breast oncologist in Virginia who was not involved in the report, said she believes "the general oncologist absolutely knows the side effects of cardiotoxic drugs such as anthracyclines and Her2 targeted therapies," but the report is good as a reminder for the "busy general practitioner and the medical oncologist that they need to pull the cardiologist in."

Otis Brawley, the CMO of the American Cancer Society, said the report is an important reminder of the side effects of cancer treatments, particularly if women present with heart disease symptoms years after their breast cancer treatment. According to Brawley, doctors treating breast cancer survivors who later experience congestive heart failure symptoms, often look for signs of a heart attack or pulmonary embolism instead of the patient's history of breast cancer treatment—which could lead to incorrect treatment. Brawley said heart failure stemming from a chemotherapy drug should be treated differently than one caused by a heart attack.

Other experts voiced concerns, however. Deanna Attai, a breast surgeon at the University of California, Los Angeles, was worried about the effects of the report on patients, saying it might cause women not to seek aggressive treatment for cancer when they need it. "I don't want those patients to think they should not do chemo, because then they will be more likely to die of disease," she said (Begley, STAT News, 2/1; McGinley, "To Your Health," Washington Post, "2/1).

Advisory Board's take

Megan Tooley

Megan Tooley, Practice Manager, Cardiovascular Roundatble

The connection between cancer treatments and increased risk of cardiovascular disease is by no means a new revelation. In recent years, we've received a growing number of requests from members looking to hardwire early identification and management of cancer patients at increased risk of cardiovascular disease. The fact that the AHA is issuing this warning now indicates that there is still a great need for education of physicians and patients alike on this connection.

In order to improve patient care, we have seen more institutions develop formal cardio-oncology programs. An essential first step is simply building collaboration between cardiologists and oncologists—some programs have even created a cardio-oncology steering committee with equal representation from both specialties. From there, specialists can implement tactics such as EHR alerts that flag when an oncologist prescribes a potentially cardiotoxic drug to a cancer patient. The goal is not to prevent treatment, but to ensure they're fully evaluating the patients' risk of cardiovascular disease, and bringing in a cardiologist consult as needed.

At our current Cardiovascular Roundtable national meeting series, we explore this and other examples of cross service line collaboration to make sure CV patients don't slip through the cracks. It's best for the patient, and it's best for the program.

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