Cardiology Patient Page
Breast Cancer Chemotherapy and Your Heart Christine Unitt, BS; Kamaneh Montazeri, MD; Sara Tolaney, MD; Javid Moslehi, MD
B
reast cancer is the most commonly diagnosed cancer in women. One in 8 women is diagnosed with breast cancer. Over the past 2 decades, death from breast cancer has decreased. As a result, today there are ≈3 000 000 breast cancer survivors in the United States, a number that will increase in the coming years. Increased breast cancer survivorship has occurred in part as a result of improved breast cancer treatments. Breast cancer treatments include the following: 1. Chemotherapy involves drugs that are intended to kill the cancer cells or stop them from dividing. In many cases, chemotherapy includes a class of chemotherapies called anthracyclines. 2. Surgery involves removal of the breast tumor. How much of the breast is removed depends on the size of the tumor and location of tumor and other factors. 3. Radiation uses high-energy radioactive beams and often accompanies surgery to lower the chance cancer will recur in the breast or nearby lymph nodes. 4. Targeted therapies target specific receptors that are highly expressed on cancer cells. For
instance, some breast cancer types have a receptor called HER2. As a result, novel therapies have been developed that target HER2. One such example is trastuzumab (Herceptin). 5. Breast cancer treatments are often used in combination to provide the highest chance for a cure. Although these therapies have increased the survival of cancer patients, some may cause cardiotoxicity or damage to the heart. Cardiotoxicity can occur in various forms and can include damage to the heart muscle itself, the heart arteries, or the heart valves. If the heart muscle is damaged, the heart will pump less efficiently—a disease called cardiomyopathy, or heart failure. This Cardiology Patient Page will discuss heart failure that can arise from breast cancer therapy, especially from anthracyclines or trastuzumab. Anthracyclines are strong chemotherapy drugs that disrupt tumor growth. An example is doxorubicin (also known as Adriamycin). HER2 targeted therapies, for example trastuzumab (also called Herceptin), are often given in combination with other chemotherapies and
decrease the risk of cancer recurrence in a subset of patients. Both doxorubicin and trastuzumab can lead to heart failure—either during the duration of therapy or several years after the cancer has been in remission.
What Is Heart Failure? Heart failure or cardiomyopathy occurs when the heart is unable to pump as efficiently as it should. There are 2 types of heart failure—systolic and diastolic. Systolic heart failure occurs when the heart muscle becomes weak, and cannot push enough blood through circulation. In diastolic heart failure, the heart muscle stiffens and cannot relax to fill completely. In either case, the heart pump efficiency diminishes, and the heart fails to deliver adequate oxygenated blood to the rest of the body, especially during activity when the body demands more oxygen and nutrients. Heart failure can occur with or without symptoms (Table 1). The most common symptom associated with heart failure is shortness of breath. Shortness of breath can occur during exertion, when lying flat in bed, or at night when the patient tries to sleep.
The information contained in this Circulation Cardiology Patient Page is not a substitute for medical advice, and the American Heart Association recommends consultation with your doctor or healthcare professional. From the Cardio-Oncology Program (C.U., K.M., J.M.) and Medical Oncology (S.T., J.M.), Dana-Farber Cancer Institute, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (J.M.); and Cardio-Oncology Program, Vanderbilt School of Medicine, Nashville, TN (J.M.). Correspondence to Javid Moslehi, MD, Cardio-Oncology Program, Vanderbilt University Medical Center, 2220 Pierce Avenue, Nashville, TN 37232. E-mail [email protected] (Circulation. 2014;129:e680-e682.) © 2014 American Heart Association, Inc. Circulation is available at http://circ.ahajournals.org
DOI: 10.1161/CIRCULATIONAHA.113.007181
Downloaded from http://circ.ahajournals.org/ e680 at UNIV OF NORTH DAKOTA on May 31, 2015
Unitt et al Breast Cancer Chemotherapy and Your Heart e681
Because the heart pump is less efficient during heart failure, it can also lead to build-up of fluids behind the heart, causing edema or fluid build-up in the legs and the lungs, which can cause further shortness of breath.
What Tests Should the Doctor Order to Determine Heart Function? 1. Electrocardiogram, commonly referred to as an EKG or ECG, records the electric activity of the heart. It may show irregularity in the beats or damaged parts of the heart. 2. Echocardiogram or Echo, is an ultrasound of the heart. It is a painless procedure whereby a technician moves a device across your chest. Echocardiogram uses sound waves bouncing off your heart to create images of the heart that allow your doctor to see the Table 1. What Are the Symptoms of Heart Failure? 1. Are normal activities, such as getting dressed, difficult to complete? 2. Are you getting out of breath performing routine activities? 3. Are you coughing more than usual? 4. Have you experienced unusual tiredness or weakness? Dizziness? 5. Have you felt as if you might pass out? 6. Do you feel full, even before eating a meal, or you don’t want to eat much? Do your clothes around your waist feel tighter? 7. At rest, do you feel your heartbeats are irregular or fast? Can you feel your heart beats thumping? 8. Have your legs or ankles become swollen? Do your socks or shoes feel tighter? 9. Do you experience shortness of breath during exercise? Chest Pain? 10. How far can you walk before needing to rest? 11. Have you gained >2 pounds over 48 h, or 5 pounds over a week’s time when weighed in the morning before breakfast? 12. Do you wake in the middle of sleep, unable to catch your breath? Must you use more pillows to sleep at night? If you’ve answered yes to these questions, you should discuss with your physician, and if appropriate undergo evaluation of your heart.
size and shape of your heart, the heart valves, how well the heart fills with blood, and how well your heart pumps (measured as ejection fraction [EF]). A normal EF is between 55% and 70%; an EF ≤50% is indicative of heart failure. 3. MUGA, also known as RVG, is a procedure used to measure how well your heart squeezes during every beat by measuring the EF. It does use radiation, so in our practice we generally use an echocardiogram to assess heart function. As a general rule, we recommend that all patients being treated with either anthracyclines or Her2 targeted therapies undergo cardiac evaluation either during or after completion of breast cancer treatment. This should include an echocardiogram.
How to Manage and Treat Heart Failure? Heart failure is a disease that can increase the risk of other diseases or the risk of death if it is not detected early and treated effectively. To keep the same amount of blood flowing as with a healthy heart, the diseased heart compensates by increasing the size of its chambers to hold more blood. Over time, as the heart stretches and enlarges, the walls of the heart thicken, further decreasing the amount of blood being pumped through the body. There are several medications that protect the heart and help alleviate the stress that the heart endures during heart failure. β-Blockers (for example metoprolol [Toprol] or carvedilol [Coreg]) or angiotensin-converting enzyme inhibitors (eg, lisinopril) are 2 classes of medications that help protect the heart. Both classes of medications do this, in part, by decreasing the blood pressure thus decreasing the workload of the heart. If heart failure as a result of breast cancer therapy is suspected, your oncologist should refer you to a cardio-oncologist, or a cardiologist who
specializes in the care of the heart for cancer patients.
What Are My Risks of Developing Heart Failure? The chance of developing heart failure varies depending on the cumulative dose of doxorubicin. The frequency of developing heart failure due to doxorubicin is 1% to 2% at a cumulative dose of 300 mg/m2, in contrast to a 30% rate with a cumulative dose of >500 mg/m2. Risk factors include female sex, young or old age, underlying cardiovascular disease, or concurrent treatment with other chemotherapy or radiation. The incidence of trastuzumabrelated heart failure is 2% to 7% and increases with patients aged ≥50 years, borderline heart function before treatment, and a history of cardiovascular disease (such as hypertension). Heart failure may be “silent” and not present with any symptoms; therefore, have your heart function monitored periodically during and after doxorubicin or trastuzumab therapy. If heart failure symptoms occur, immediately consult your doctor.
What Can You Do (as the Patient) to Monitor Your Progress and Prevent Your Heart From Getting Worse? 1. Record your blood pressure at home. 2. Weigh yourself periodically. 3. Take your medications to manage heart failure symptoms 4. Lifestyle changes: - limit salt/liquids - decrease alcohol - cease smoking - stay active every day - eat a balanced, healthy diet - get adequate sleep/rest As a patient, you play an important role in managing your health in partnership with your doctor, especially after your cancer is in remission (Table 2). By recognizing symptoms of heart failure, ensuring that your hear is monitored if necessary, and maintaining appropriate
Downloaded from http://circ.ahajournals.org/ at UNIV OF NORTH DAKOTA on May 31, 2015
e682 Circulation June 24, 2014
Table 2. How to Monitor Heart Function Before, During, and After Chemotherapy Before • Baseline ECG and Echo to assess heart function
During
After
• Echocardiogram every 3 months for patients receiving trastuzumab • Cardiac evaluation if patient has symptoms of heart failure
• At the end of therapy with chemotherapy especially if this includes anthracycline, patients should have a cardiac evaluation, which may include an echocardiogram
lifestyle changes, breast cancer patients undergoing chemotherapy can feel better and enjoy life more without the risk of heart disease.
Additional Resources Brigham and Women’s Hospital. Understanding and Treating Heart Failure: A Guide for Patients and
Families. Boston: Brigham and Women’s Hospital, n.d. Print. Moslehi, Javid. “The Cardiovascular Perils of Cancer Survivorship.” New England Journal of Medicine. 2013. http://www.cardio-onc.org (This Web site lists some of the specifics of the cardiovascular care of cancer patients and cancer survivors and is both a reference for patients as well as physicians.)
Disclosures None.
Downloaded from http://circ.ahajournals.org/ at UNIV OF NORTH DAKOTA on May 31, 2015
Breast Cancer Chemotherapy and Your Heart Christine Unitt, Kamaneh Montazeri, Sara Tolaney and Javid Moslehi Circulation. 2014;129:e680-e682 doi: 10.1161/CIRCULATIONAHA.113.007181 Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2014 American Heart Association, Inc. All rights reserved. Print ISSN: 0009-7322. Online ISSN: 1524-4539
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://circ.ahajournals.org/content/129/25/e680
Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in Circulation can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Once the online version of the published article for which permission is being requested is located, click Request Permissions in the middle column of the Web page under Services. Further information about this process is available in the Permissions and Rights Question and Answer document. Reprints: Information about reprints can be found online at: http://www.lww.com/reprints Subscriptions: Information about subscribing to Circulation is online at: http://circ.ahajournals.org//subscriptions/
Downloaded from http://circ.ahajournals.org/ at UNIV OF NORTH DAKOTA on May 31, 2015
Breast Cancer Chemotherapy and Your Heart Christine Unitt, BS; Kamaneh Montazeri, MD; Sara Tolaney, MD; Javid Moslehi, MD
B
reast cancer is the most commonly diagnosed cancer in women. One in 8 women is diagnosed with breast cancer. Over the past 2 decades, death from breast cancer has decreased. As a result, today there are ≈3 000 000 breast cancer survivors in the United States, a number that will increase in the coming years. Increased breast cancer survivorship has occurred in part as a result of improved breast cancer treatments. Breast cancer treatments include the following: 1. Chemotherapy involves drugs that are intended to kill the cancer cells or stop them from dividing. In many cases, chemotherapy includes a class of chemotherapies called anthracyclines. 2. Surgery involves removal of the breast tumor. How much of the breast is removed depends on the size of the tumor and location of tumor and other factors. 3. Radiation uses high-energy radioactive beams and often accompanies surgery to lower the chance cancer will recur in the breast or nearby lymph nodes. 4. Targeted therapies target specific receptors that are highly expressed on cancer cells. For
instance, some breast cancer types have a receptor called HER2. As a result, novel therapies have been developed that target HER2. One such example is trastuzumab (Herceptin). 5. Breast cancer treatments are often used in combination to provide the highest chance for a cure. Although these therapies have increased the survival of cancer patients, some may cause cardiotoxicity or damage to the heart. Cardiotoxicity can occur in various forms and can include damage to the heart muscle itself, the heart arteries, or the heart valves. If the heart muscle is damaged, the heart will pump less efficiently—a disease called cardiomyopathy, or heart failure. This Cardiology Patient Page will discuss heart failure that can arise from breast cancer therapy, especially from anthracyclines or trastuzumab. Anthracyclines are strong chemotherapy drugs that disrupt tumor growth. An example is doxorubicin (also known as Adriamycin). HER2 targeted therapies, for example trastuzumab (also called Herceptin), are often given in combination with other chemotherapies and
decrease the risk of cancer recurrence in a subset of patients. Both doxorubicin and trastuzumab can lead to heart failure—either during the duration of therapy or several years after the cancer has been in remission.
What Is Heart Failure? Heart failure or cardiomyopathy occurs when the heart is unable to pump as efficiently as it should. There are 2 types of heart failure—systolic and diastolic. Systolic heart failure occurs when the heart muscle becomes weak, and cannot push enough blood through circulation. In diastolic heart failure, the heart muscle stiffens and cannot relax to fill completely. In either case, the heart pump efficiency diminishes, and the heart fails to deliver adequate oxygenated blood to the rest of the body, especially during activity when the body demands more oxygen and nutrients. Heart failure can occur with or without symptoms (Table 1). The most common symptom associated with heart failure is shortness of breath. Shortness of breath can occur during exertion, when lying flat in bed, or at night when the patient tries to sleep.
The information contained in this Circulation Cardiology Patient Page is not a substitute for medical advice, and the American Heart Association recommends consultation with your doctor or healthcare professional. From the Cardio-Oncology Program (C.U., K.M., J.M.) and Medical Oncology (S.T., J.M.), Dana-Farber Cancer Institute, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (J.M.); and Cardio-Oncology Program, Vanderbilt School of Medicine, Nashville, TN (J.M.). Correspondence to Javid Moslehi, MD, Cardio-Oncology Program, Vanderbilt University Medical Center, 2220 Pierce Avenue, Nashville, TN 37232. E-mail [email protected] (Circulation. 2014;129:e680-e682.) © 2014 American Heart Association, Inc. Circulation is available at http://circ.ahajournals.org
DOI: 10.1161/CIRCULATIONAHA.113.007181
Downloaded from http://circ.ahajournals.org/ e680 at UNIV OF NORTH DAKOTA on May 31, 2015
Unitt et al Breast Cancer Chemotherapy and Your Heart e681
Because the heart pump is less efficient during heart failure, it can also lead to build-up of fluids behind the heart, causing edema or fluid build-up in the legs and the lungs, which can cause further shortness of breath.
What Tests Should the Doctor Order to Determine Heart Function? 1. Electrocardiogram, commonly referred to as an EKG or ECG, records the electric activity of the heart. It may show irregularity in the beats or damaged parts of the heart. 2. Echocardiogram or Echo, is an ultrasound of the heart. It is a painless procedure whereby a technician moves a device across your chest. Echocardiogram uses sound waves bouncing off your heart to create images of the heart that allow your doctor to see the Table 1. What Are the Symptoms of Heart Failure? 1. Are normal activities, such as getting dressed, difficult to complete? 2. Are you getting out of breath performing routine activities? 3. Are you coughing more than usual? 4. Have you experienced unusual tiredness or weakness? Dizziness? 5. Have you felt as if you might pass out? 6. Do you feel full, even before eating a meal, or you don’t want to eat much? Do your clothes around your waist feel tighter? 7. At rest, do you feel your heartbeats are irregular or fast? Can you feel your heart beats thumping? 8. Have your legs or ankles become swollen? Do your socks or shoes feel tighter? 9. Do you experience shortness of breath during exercise? Chest Pain? 10. How far can you walk before needing to rest? 11. Have you gained >2 pounds over 48 h, or 5 pounds over a week’s time when weighed in the morning before breakfast? 12. Do you wake in the middle of sleep, unable to catch your breath? Must you use more pillows to sleep at night? If you’ve answered yes to these questions, you should discuss with your physician, and if appropriate undergo evaluation of your heart.
size and shape of your heart, the heart valves, how well the heart fills with blood, and how well your heart pumps (measured as ejection fraction [EF]). A normal EF is between 55% and 70%; an EF ≤50% is indicative of heart failure. 3. MUGA, also known as RVG, is a procedure used to measure how well your heart squeezes during every beat by measuring the EF. It does use radiation, so in our practice we generally use an echocardiogram to assess heart function. As a general rule, we recommend that all patients being treated with either anthracyclines or Her2 targeted therapies undergo cardiac evaluation either during or after completion of breast cancer treatment. This should include an echocardiogram.
How to Manage and Treat Heart Failure? Heart failure is a disease that can increase the risk of other diseases or the risk of death if it is not detected early and treated effectively. To keep the same amount of blood flowing as with a healthy heart, the diseased heart compensates by increasing the size of its chambers to hold more blood. Over time, as the heart stretches and enlarges, the walls of the heart thicken, further decreasing the amount of blood being pumped through the body. There are several medications that protect the heart and help alleviate the stress that the heart endures during heart failure. β-Blockers (for example metoprolol [Toprol] or carvedilol [Coreg]) or angiotensin-converting enzyme inhibitors (eg, lisinopril) are 2 classes of medications that help protect the heart. Both classes of medications do this, in part, by decreasing the blood pressure thus decreasing the workload of the heart. If heart failure as a result of breast cancer therapy is suspected, your oncologist should refer you to a cardio-oncologist, or a cardiologist who
specializes in the care of the heart for cancer patients.
What Are My Risks of Developing Heart Failure? The chance of developing heart failure varies depending on the cumulative dose of doxorubicin. The frequency of developing heart failure due to doxorubicin is 1% to 2% at a cumulative dose of 300 mg/m2, in contrast to a 30% rate with a cumulative dose of >500 mg/m2. Risk factors include female sex, young or old age, underlying cardiovascular disease, or concurrent treatment with other chemotherapy or radiation. The incidence of trastuzumabrelated heart failure is 2% to 7% and increases with patients aged ≥50 years, borderline heart function before treatment, and a history of cardiovascular disease (such as hypertension). Heart failure may be “silent” and not present with any symptoms; therefore, have your heart function monitored periodically during and after doxorubicin or trastuzumab therapy. If heart failure symptoms occur, immediately consult your doctor.
What Can You Do (as the Patient) to Monitor Your Progress and Prevent Your Heart From Getting Worse? 1. Record your blood pressure at home. 2. Weigh yourself periodically. 3. Take your medications to manage heart failure symptoms 4. Lifestyle changes: - limit salt/liquids - decrease alcohol - cease smoking - stay active every day - eat a balanced, healthy diet - get adequate sleep/rest As a patient, you play an important role in managing your health in partnership with your doctor, especially after your cancer is in remission (Table 2). By recognizing symptoms of heart failure, ensuring that your hear is monitored if necessary, and maintaining appropriate
Downloaded from http://circ.ahajournals.org/ at UNIV OF NORTH DAKOTA on May 31, 2015
e682 Circulation June 24, 2014
Table 2. How to Monitor Heart Function Before, During, and After Chemotherapy Before • Baseline ECG and Echo to assess heart function
During
After
• Echocardiogram every 3 months for patients receiving trastuzumab • Cardiac evaluation if patient has symptoms of heart failure
• At the end of therapy with chemotherapy especially if this includes anthracycline, patients should have a cardiac evaluation, which may include an echocardiogram
lifestyle changes, breast cancer patients undergoing chemotherapy can feel better and enjoy life more without the risk of heart disease.
Additional Resources Brigham and Women’s Hospital. Understanding and Treating Heart Failure: A Guide for Patients and
Families. Boston: Brigham and Women’s Hospital, n.d. Print. Moslehi, Javid. “The Cardiovascular Perils of Cancer Survivorship.” New England Journal of Medicine. 2013. http://www.cardio-onc.org (This Web site lists some of the specifics of the cardiovascular care of cancer patients and cancer survivors and is both a reference for patients as well as physicians.)
Disclosures None.
Downloaded from http://circ.ahajournals.org/ at UNIV OF NORTH DAKOTA on May 31, 2015
Breast Cancer Chemotherapy and Your Heart Christine Unitt, Kamaneh Montazeri, Sara Tolaney and Javid Moslehi Circulation. 2014;129:e680-e682 doi: 10.1161/CIRCULATIONAHA.113.007181 Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2014 American Heart Association, Inc. All rights reserved. Print ISSN: 0009-7322. Online ISSN: 1524-4539
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://circ.ahajournals.org/content/129/25/e680
Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in Circulation can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Once the online version of the published article for which permission is being requested is located, click Request Permissions in the middle column of the Web page under Services. Further information about this process is available in the Permissions and Rights Question and Answer document. Reprints: Information about reprints can be found online at: http://www.lww.com/reprints Subscriptions: Information about subscribing to Circulation is online at: http://circ.ahajournals.org//subscriptions/
Downloaded from http://circ.ahajournals.org/ at UNIV OF NORTH DAKOTA on May 31, 2015
