You may have seen all of the recent headlines about the decrease in cancer mortality.((https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2020/cancer-facts-and-figures-2020.pdf)) The breast cancer death rate alone has decreased by 40% since 1989. One big thing we have learned now that fewer people are dying from their initial cancer is that we need to have a better understanding of the effects of cancer treatment on the rest of the body, particularly the heart. Cardiovascular disease is responsible for the deaths of 1 in 10 cancer survivors((https://www.ajmc.com/focus-of-the-week/number-of-cardiovascular-deaths-rising-among-cancer-survivors-study-finds)), and this information has encouraged the formation of a new specialty: cardio-oncology.
Breast, prostate, and bladder cancer survivors make up the largest portion of deaths from cardiovascular disease in cancer survivors.(( https://www.ajmc.com/focus-of-the-week/number-of-cardiovascular-deaths-rising-among-cancer-survivors-study-finds)) For breast cancer survivors, some of this effect could be due to the frequency of the diagnosis (most commonly diagnosed cancer in women), but there are some aspects of breast cancer treatment specifically that can have a major impact on the heart.
The landmark drug for people with HER2+ breast cancer, trastuzumab (brand name Herceptin), which has drastically improved survival for people with this type of breast cancer, brings with it an increased risk of heart failure. If a breast cancer patient doesn’t have this type of breast cancer or even doesn’t have chemotherapy at all, they are still likely going to have radiation treatment. With radiation, particularly if the tumor is located in the left breast (the side where the heart is located), there is an increased chance of the survivor having a heart attack.
And very often after surgery, and possible chemotherapy and radiation, the breast cancer survivor is placed on tamoxifen and/or an aromatase inhibitor in order to shut down estrogen production and decrease the chance of recurrence. Unfortunately, those can all increase a breast cancer survivor’s chance of stroke and blood clots.(( https://www.cancernetwork.com/news/causes-death-after-breast-cancer-diagnosis-provide-insight-patient-counsel)) Risk of death from cardiovascular disease after breast cancer treatment is highest in the first year after diagnosis, but breast cancer survivors continue to have an elevated risk for the rest of their lives compared to the average population.((https://academic.oup.com/eurheartj/article/40/48/3889/5637730))
A special note for the younger survivors: the cardiovascular effect is greater for those diagnosed below the age of 35. Though breast cancer is much less frequently diagnosed in women under 50, we are learning more and more about the outsized effects of breast cancer on this population. For breast cancer survivors diagnosed under 35, there is an increased risk of stroke and death from cardiovascular disease.((https://www.ajmc.com/focus-of-the-week/number-of-cardiovascular-deaths-rising-among-cancer-survivors-study-finds)) Some of this increased risk can be explained by the fact that those who are younger generally, by definition, have a longer time left to live,((https://www.ajmc.com/focus-of-the-week/number-of-cardiovascular-deaths-rising-among-cancer-survivors-study-finds)) and therefore more time for the cardiovascular effects of treatment to show up.
So, where’s the good news?
A positive is that there are more people surviving their initial cancer, and some living a long time after diagnosis, and that’s how we are learning about these cardiovascular effects. This initial disease survival improvement offers survivors longer survival rates, and the doctors and researchers have more time to figure out what life looks like medically after cancer treatment. We are seeing the same thing in pediatric cancer; there are more survivors who are living longer so we are learning more about long term effects of treatment.
Another positive is that there is now more conversation happening around how dosages for medication are determined. Currently, the standard is based on the maximum tolerated dose, which is the highest dose of the medication possible with the least amount of side effects. The new conversation happening more and more is: what if more treatment isn’t necessarily better? Instead of asking what is the highest possible limit of medication we can give a patient, why aren’t we asking what is the lowest amount we can give a patient and still reap the maximum benefit of the treatment? Surgeries are moving in this direction with the shift away from complete mastectomies and towards lumpectomies (when possible), and there are some relatively new, smaller area, radiation techniques as well.(( https://www.cancer.org/cancer/breast-cancer/treatment/radiation-for-breast-cancer.html))
Important disclaimer here: we would not have seen these decreases in breast cancer deaths if we did not have these medications and treatments. Period. These medications and treatments are important and necessary, so even with the potentially harmful side effects, they are still worth doing if prescribed by your doctor. However, now that we have medications and treatments that work, why not find out if there are ways for them to work better for the patient’s quality of life and not just quantity of life.
If you are being treated for breast cancer or are a breast cancer survivor, what do you take away from this? The biggest thing is to talk to your oncologist about your personal and your family’s heart health history. Those who have the biggest negative cardiovascular effects already had some signs of cardiovascular disease,((https://www.ajmc.com/focus-of-the-week/number-of-cardiovascular-deaths-rising-among-cancer-survivors-study-finds)) so make sure you and your oncologist know what’s going on with your heart throughout your treatment. It is being recommended that cancer patients be followed by a cardiologist throughout their treatment as well, or if possible, a cardio-oncologist. Cardio-oncology is still a new specialty, and there aren’t a lot of them, but ask and find out if there is one in your area and if you would benefit from being under their care.
Lastly, it is important to know the signs and symptoms of a heart attack and stroke. Heart attack symptoms can be different in women. Yes, there is usually chest and arm pain, but also pay attention to shortness of breath, lightheadedness, nausea, and pain in the back or jaw. If you experience these symptoms and end up in the emergency room, do not let them ignore your heart just because you may not be showing classic symptoms! Be sure to share your cancer history and make sure they consider your heart.
When it comes to women and strokes, know to act F.A.S.T. You may have heard the acronym FAST before in regard to strokes, and the letters stand for Face (facial drooping), Arms (can’t raise one arm in front of you, or not as high as the other), Speech (slurring of speech or inability to talk or understand words), and Time (meaning the faster you get help, the more likely the person is to recover). Like with heart attack, there are signs that are more common in women.
How about a final piece of good news? A study examining over 1.5 million incidences of a patient’s first heart attack found that breast cancer survivors did better overall when compared to women who had not been diagnosed with breast cancer. The researchers concluded that this could be based on patients’ improved lifestyle choices: lowering their risk factors such as obesity, type 2 diabetes, and smoking, and perhaps improving their general health knowledge due to the fact that they had been through cancer.((https://www.ajmc.com/focus-of-the-week/number-of-cardiovascular-deaths-rising-among-cancer-survivors-study-finds))
Having more people survive breast cancer is always good news, now we just need to learn more about what it means medically to be a long-term breast cancer survivor. Do you have a heart health story to tell? Do you have any suggestions for policies that might help breast cancer survivors and their doctors take better care of their heart health? Let me know at erin@vbcf.org.
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One Response
Good informative article.