Putting the heart first in breast cancer chemotherapy
September 30, 2015
Heart disease is one of the most common conditions that we as breast cancer specialists must deal with, in addition to the cancer. Before chemotherapy and radiation treatment begin, we examine each patient closely for any pre-existing heart disease. We are particularly careful to minimize the risk of causing any potential heart problems through the cancer treatment.
Let’s talk about riskFirst, I ask the patient a number of questions to develop a picture of her current condition and risk for heart failure. Topics for these questions relate to:
- Aging and obesity
- Smoker or nonsmoker
- Arrhythmia (irregular heart beat)
- Previous personal history of angina, hypertension, or heart attack
- Family or personal history of heart disease or high cholesterol levels
Chemotherapy and the heartNo two patients are exactly alike, so we design individualized treatment plans for each patient based on a comprehensive pathology analysis of the tumor. Every treatment plan includes measures to minimize side effects, promote the patient’s quality of life, and preserve the breast whenever possible.
Some types of breast cancer drugs that give the patient a good chance of survival may depress the muscular function of the heart. Because many women are surviving cancer longer, we’re learning that this heart muscle depression can happen as a late side effect, even years afterward. So, knowing that risk, we now weigh the benefits of short-term survival versus possibly dangerous late-term side effects of the therapy.
Proceed with cautionEach time a patient gets chemotherapy, we monitor blood pressure and heart rhythm to check for irregularities. This gives us a good picture of how the patient is tolerating the treatment. In many cases, we order an echocardiogram to observe heart function in more detail. This test (called an ejection fraction) looks at the ventricular functions of the heart and the percent of blood leaving the ventricle with each contraction. If the patient does not have an ejection fraction of at least 50 percent, she is not a candidate for Doxorubicin, for example. All HER2-blocking drugs (Trastuzumab, Pertuzumab, TDM-1, Lapitinib) can have a depressive effect on the heart and are monitored clinically and by ECHO during the course of treatment.
At set times throughout the treatment, the patient may be re-evaluated through additional cardiac echocardiograms.
If we become concerned, the treatment is stopped for several weeks, and then the ECHO is repeated and a decision is made about restarting the treatment. We also have alternate drug regimens available to get around the issue of cardiac dysfunction. After treatment, the patient’s doctor will continue to monitor the heart.
Seventy-nine percent of breast cancer cases occur in women over age 50. While patients may initially have concerns that chemotherapy puts their heart at risk, we always collaborate with their cardiologist and monitor our patients closely. We want them to finish their cancer treatment as healthy as possible – and that includes taking care of their heart.