The human heart is an amazing machine.
It beats about 100,000 times per day, about 35 million times in a year, and hopefully, if one watches one’s Ps and Qs, more than two billion in a lifetime.
It’s force in pumping blood out to the body is the equivalent of giving a tennis ball a good, hard squeeze.
It has the capacity to swell enormously with love and break with sadness.
It is our body’s most necessary organ, even more so than the brain. A heart can keep pumping without brain function, but not the reverse.
Now that National Heart Month has officially dawned, a great deal of attention will be focused on the importance of women taking care of their tickers. More of us die of heart disease than of all cancers combined. But rarely do we hear about the cancer-heart disease connection. It is the very reason cardiologists like Tochukwu Okwuosa, Ana Barac, Puja K. Mehta and Nausheen Akhter are pioneering a new field in medicine: cardio-oncology.
Dr. Okwuosa, who practices at Chicago’s Rush University Hospital, explains. “Cardiologists focus on heart issues. Oncologists focus on cancer. My practice creates a bridge between the two by asking what’s the best of both worlds? How can we stop the cancer and while protecting the heart to ensure optimum quality of life for the patient down the road?”
Quite a conundrum, and not a new one in the world of oncology. Doctors and researchers have long understood the maddening tightrope walk of treatment protocols. Err too far on the side of caution, and cancer clutches an ever more powerful grip on the patient. Err too far on the side of aggression, and the treatment’s collateral damage can cause severe patient debilitation.
But Dr. Okwuosa stresses a singularly important point. “I am not in the business of insisting that treatment be halted entirely. Rather, I want to work closely with oncologists, putting our heads together, weighing benefits against risks, and determining how best to protect the heart while killing the cancer.”
At the Barbra Streisand Women’s Heart Center at Cedars-Sinai Medical Center in Los Angeles, Dr. Mehta is focusing on patients with one thing in common: heart symptoms with no clogged vessels. It’s called microvascular disease.
“My patients are divided into two groups,” Dr. Mehta tells me. “Those who have already finished treatment and those about to start. We work to ensure that cardiac risk factors are assessed and addressed, with heart healthy lifestyle recommendations and careful use of medications. We also discuss stress because it has an effect on microvascular disease as well, which is my particular interest.”
Back in the Windy City, Dr. Akhter of Northwestern University makes a strong point. “The good news for survivors is that cancer becomes ancient history in their lives. They don’t think about what their past treatments might cause in the future. We call those ‘off-target’ effects, issues that arise in organs not targeted with whatever the treatment for cancer was.”
Dr. Barac, who practices within the MedStar system in the Washington D.C. area, had been intrigued by the apparent randomness of heart disease among survivors. “I began to look for predictors,” she says, “and I could find no pattern. Only some women exposed to drugs develop heart issues. I reached out to breast cancer oncologists as they offered such a large number of long term survivors.”
So what have they found from their studies?
The prime suspects among breast and gynecological cancer chemo drugs when it comes to post-treatment cardiac problems are Adriamycin, Herceptin and Cytoxan, given alone or in combination. Additionally, a class of drugs known as TKIs (used in uterine and ovarian cancers) can cause the heart muscles to weaken. They can also cause a buildup of fluid around the heart and swelling in legs. All of this can lead to heart failure, which, if severe enough, could end in a heart transplant. Hypertension (a.k.a. high blood pressure), the precursor of a stroke, is a major concern of these group of drugs.
That’s the bad news and admittedly doesn’t paint a very pretty picture. Or does it? The very fact that we’re recognizing the potential for these issues is very good news, right?
“Adriamycin was introduced in 1974. In the late 70’s a paper came out showing that cardiac issues was very dose dependent. The dose now given is well under what might cause heart damage,” Dr. Barac says.
That’s encouraging for those of us who happily lined up for those poisons in order to kill our cancers. Additionally, Dr. Mehta is doing pilot studies on the drugs, using cardiac MRIs before, during and after chemo. Perhaps beta-blockers at the onset of cardiac disease among Adriamycin recipients is the answer.
Radiation delivers another set of post-treatment challenges, particularly in breast cancer and lymphoma patients. “If radiation is directed over heart,” Dr. Akhter says, “valve issues, aorta issues, premature coronary artery disease can arise.” Yikes! But then come reassuring words: “But we’ve gotten far better in narrowing the radiation window in this century.”
Dr. Mehta concurs. “Older patients, who had radiation before we know what we know now, are more likely to have issues. Today’s radiation oncologists are aware of keeping vessels safe.”
“We know that the number one complication down the road after cancer treatment is recurrence or metastasis. That’s been the case for a long time. What we now know is that heart disease is the second complication we must watch for, whether it’s a new condition or exacerbation of pre-existing cardiac conditions.”
From the Patients’ Mouths
Thank God Carla Tinebro got the chicken pox at 26 years old. It was what lead to her diagnosis of stage 4B Hodgkin Lymphoma in 1990. Her medical team told her that the eight months of chemo (which included Adriamycin) followed by full body radiation and a bone marrow transplant might have down the road implications. But Carla’s cancer was aggressive and not following that aggressive treatment plan would surely end badly for her.
“I was like, why worry about down the road,” Carla says. If we don’t hit it hard I won’t have any ‘down the road!”
Eighteen years later, she developed congestive heart failure. The damage from her treatments, and perhaps the Graft vs. Host disease that followed her transplant, did damage to a heart valve. Her only alternative was to have a defibrillator implanted.
What Carla may lack in heart power, she makes up for in spirit. “You constantly need to reinvent yourself with anything life throws at you. If someone can learn from my journey, that’s great. I’m always on the look out for a special reason that things may have happened.”
Angela Flinn was diagnosed with Non-Hodgkin Lymphoma twice, once at age 20 and again in 2014 at 42. Her medical team told her after her first treatment that she’d be infertile. But that wasn’t something she was willing to settle for.
“We now have three beautiful children. My goal now is to make sure I’m there for them, to experience things with them.” Because of the Adriamycin in her treatment protocol, she was closely monitored by Dr. Okwuosa, and continues so today.
And then Angela voices the reality all survivors experience: “I felt strong during chemo. You feel as though you’re safe and beating the cancer. Once out of treatment, though, I got scared. Who was going to check on me when my next appointment was 12 weeks away? Then I realized, some days are easy. Others you just have to work a little harder for.”
“No one knows what tomorrow will bring, “Angela says. “Find the strength to enjoy each moment.” Amen, sister.
Patient Take Homes
So advice what would each of our cardio-oncologists tuck in a patient’s goody bag?
Give patients the education that will help them be a partner in their healthcare. If they have a history of heart issues, the beginning of cancer treatment is not the moment to be shy about sharing those issues. Furthermore, patients know their bodies better than their doctors ever could, Dr. Okwuosa says. If their legs begin inexplicably swelling, they need to know that and reach out to their physician.
Hospitals need to develop patient advocates in the field. But until then, communicate with patients that, after cancer treatment, they may be left with things they’re not equipped to deal with. Any side effects that impact quality of life shouldn’t be ignored; they must be shared with their medical teams.
My first recommendation to patients is always to treat the cancer, but optimally control the cardiac risk factors. Then, after treatment, monitor the risk factors, such as cholesterol, and include walking/physical activity daily.
Be pro-active: you know your body the best. Most of these occurrences are very rare. But your cancer and cancer treatment make you unique from everyone else. Consequently your symptoms should be taken seriously. Long term effects of agents shouldn’t be forgotten.
Happily for survivors, with the work of these brilliant doctors and the wisdom of their courageous patients, the beat goes on!