Cardio-Oncology
Cardio-oncology is a term that describes the efforts to prevent or treat patients with cancer who face heart problems caused by cancer treatments. Although many cancer patients also have health conditions related to lung disease, infections or kidney disease, the rise of cardiac diseases in these patients has led to the growth of this new field.
Cardio-oncology involves cancer doctors (oncologists), cardiologists and researchers. Thanks to advances in treatment, the number of cancer survivors has never been greater and is expected to reach more than 20 million in the U.S. by 2026. New therapies are helping patients live longer, but that means they also need ongoing cancer treatments that may damage their hearts.
Many of these survivors are at risk for heart disease and now will live long enough after their cancer treatments to develop heart disease. In addition, some cancer medications may damage the heart. New approaches to prevent or manage these side effects are needed, such as: Team-based care from cardiologists and oncologists. Improved methods developed by radiation oncologists to reduce the cardiac side effects of radiation therapy.
Drugs to treat cancer are being developed and released at faster rates. Some may damage the heart in new or unexpected ways. Whether due to research limitations or a process to fast-track drugs for life-threatening conditions, it is hard to detect all possible cardiac side effects before the drugs are released.
Oncologists and cardiologists familiar with these real-world issues are the ones best suited to find these problems and protect patients. Cardiologists and other specialists in imaging of the heart and blood vessels are developing techniques to catch damage to the heart from cancer treatments earlier.
For now, there is no certification of health professionals who have special skill in managing these cardio-oncology problems, but efforts are underway to create a certified training program for the field.
Questions to Ask Your Doctor
If you've been diagnosed with cancer, there are several key questions about cancer treatment and your heart that you should ask your health care professional during your next visit. These questions will ensure that you and your doctor have talked about major risk factors so that you can stay as healthy as possible.
- Am I receiving any cancer treatment that could affect my heart either now or in the future?
- What are my risk factors for developing cardiac side effects from treatment?
- Is it safe for me to exercise during cancer treatment?
- How can I quit smoking?
- How much alcohol is safe for me to drink during or after cancer treatment?
- Do I need to see a cardiologist or cardio-oncologist during or after cancer treatment?
- Do you know of any cardio-oncologists in the area?
- If my cancer treatment could damage my heart, how will my heart be monitored during cancer treatment?
- I already have heart problems. Do I take all of my heart medication during cancer treatment?
- What symptoms should I be aware of that could be related to my heart?
What You Should Know
With nearly 17 million cancer survivors in the United States thanks, in large part, to advances in cancer therapies, there are many reasons to be hopeful.
Cancer treatments save lives. But sometimes these same lifesaving treatments can damage your heart and might increase the risk of heart disease—or worsen any heart issues you might have already.
Certain cancer treatments can weaken the heart, disrupt the normal heart rhythm, or injure blood vessels or heart valves. They also may make risk factors for heart disease, such as high blood pressure or high cholesterol, more likely.
For some people, these heart issues may develop soon after starting cancer treatment. In other cases, they can go undetected for years—perhaps even decades—after being cancer-free. Many cancer survivors are living long enough to experience the effects on their heart health. That’s why it’s so important to think about your heart health before, during and after undergoing cancer therapy.
And while there is much excitement about newer cancer therapies, we don’t fully know how they might affect the heart or other organs.
The good news?
There is more awareness of the heart harms that may be triggered by many cancer therapies than ever before.
- Research is underway to find ways to lessen or prevent this heart damage
- Many heart doctors (called cardiologists) are now working alongside cancer doctors (called oncologists) to help keep patients’ hearts healthy during and after cancer treatments
- Many hospitals and cancer centers have opened cardio-oncology clinics that focus on integrating cardiovascular health as a part of cancer care
Ask your oncologist or primary care doctor whether you should see a cardiologist.
Your Heart Matters Too
If you or a loved one has faced cancer, you know it can be very overwhelming. Frequent cancer treatments can be grueling, and cancer can take a serious emotional and financial toll. There’s a lot to consider, and managing your heart health during and after cancer treatment is very important, too.
Keep in mind that not all cancer treatments cause heart problems, and not everyone who receives cancer therapies will end up having heart troubles. Still, you should:
- Discuss your heart health with your care team
- Ask whether the cancer treatments you’ve had—or expect to receive—can affect your heart and in what ways
- Keep a record of what cancer treatments you have received and when
- Live a heart-healthy lifestyle by keeping an eye on your diet, physical activity and blood pressure and cholesterol levels
- Ask if you need regular heart checkups after treatment, and how often
It's important to learn more about how cancer treatments can affect the heart and strategies to stay on top of your heart health before, during and after undergoing cancer therapy.
Cancer and Heart Health
Not everyone who undergoes cancer treatment will develop a heart problem. Still, if you or a loved one has cancer or a history or cancer, it’s important to be aware of the connection and to ask questions about your heart health, too. Here’s why.
People with cancer need lifesaving cancer treatments, some of which can damage the heart and blood vessels. It’s important to remember that these heart diseases can be managed with the help of the right health care team. Be sure to discuss specific cancer therapies or combinations of therapies with your care team so that you understand the potential side effects and work with your doctor to make informed decisions.
Many people already have risk factors for heart or blood vessel disease when they find out they have cancer. These can make treatment-related heart problems even more likely. Risk factors are conditions or behaviors that increase your chance of heart problems. For example, type 2 diabetes, high cholesterol, high blood pressure, smoking, or being overweight are considered risk factors for heart disease.
Heart issues may appear years—even decades—after cancer treatment ends. Some cancer therapies set the stage for heart disease to develop later in life. This is potentially because of earlier injury or scarring to the heart muscle, lining of the blood vessels or valves.
When undergoing cancer treatment, physical and emotional health can decline too. Coping with cancer can be overwhelming. Treatments, including surgery and cancer-fighting medicines, coupled with prolonged recovery times can mean lost muscle mass and decreased fitness. These effects can tax your body and heart. Ask what you can do to get back to some level of activity when you are ready. It may also help brighten your spirits.
Cancer itself can also make certain heart problems more likely. There is overlap between the risk factors for cancer and the risk factors for heart disease. For example, smoking is a risk factor for both diseases. Moreover, cancer can increase one’s risk of blood clots, which can lead to stroke and other complications
Researchers are also discovering many cancers and heart problems may be more connected than previously thought.
Cancer Treatments Linked to Heart Problems
Only certain cancer therapies are linked to heart troubles. These may include:
- Radiation therapy, especially when given to the chest because it’s so close to the heart
- Certain chemotherapy medicines, particularly anthracycline-based chemotherapy, though the amount used today is less than that used in previous decades
- Certain targeted therapies or newer immunotherapy drugs
Other factors can play a role in how likely someone is to develop heart troubles as a side effect of their cancer treatments. For example, if you:
- Already have heart disease—that is, before finding out you have cancer
- Have risk factors for heart disease—such as high cholesterol, high blood pressure, diabetes, being overweight or smoking
- Older age
- Receive higher doses of chemotherapy or radiation therapy
- Are on more than one treatment known to have damaging effects on the heart (for example, chest radiation therapy in addition to an anthracycline-based chemotherapy and trastuzumab).
What You Can Do
Taking charge of your heart health during and after cancer treatment is an important part of your cancer survivorship journey.
- Know and write down any cancer treatments you receive. Record the name of the therapy, amount (dose) and how long the treatment lasted. Ask which, if any, have been linked to heart issues. Keep a health binder or folder so you won’t forget. Your personal history of cancer should be part of any discussions you have with your care team about your cardiovascular health. That means sharing which cancer treatments you’ve had and listing these along with things like high blood pressure, cholesterol, diabetes, smoking and family history.
- Ask about heart checks and go to follow-up visits. For some people, routine monitoring with bloodwork, echocardiograms or other tests may be needed to help pick up on changes in heart function or early signs of damage. Noticing these changes, if any, will help signal whether you need to act.
- Know what signs to watch for to catch any heart problems early on. Trust your gut. You know your body best, so if you feel something just isn't right—if you have trouble breathing or feel unusually tired or sluggish—tell your doctor and remind your care team about your cancer history, too. Some people don’t develop heart problems for many years after finishing cancer treatment.
- Manage other conditions known to lead to heart disease. For example, high cholesterol, high blood pressure, diabetes, and tobacco use.
- Make lifestyle changes that support your heart health. Find ways to:
- Your needs and concerns may change over time. Talk about your concerns and feelings related to surviving cancer and also making sure your heart stays as healthy as possible, too.
Questions to Ask
It is important to talk with your health care team about how you are feeling and share concerns along the way.
Questions to ask:
- Will any cancer treatments I receive harm my heart?
- What types of heart problems should we be watching for during or after cancer treatment? Are there certain signs and symptoms I need to report?
- What steps can be taken to lower the chance that these treatments will do lasting damage to my heart?
- Should I be seeing a cardiologist or cardio-oncologist?
- Do we need to be more aggressive in trying to control other risk factors I have for heart disease? Are there heart medications I should be taking?
- How will my heart function be checked over time?
- Does the damage from certain cancer treatments improve over time? How?
- Should I discuss my cancer history when talking about my general heart health with my doctors in the future?
- Can you provide a complete list of treatments I received for my cancer?
Radiation and Heart Disease
Being told you have cancer is a life-changing experience for most patients and leads to many new concerns such as:
- What is my prognosis ?
- What are my treatment options?
- How will my life be different with cancer?
- How am I going to share this news with my loved ones?
Typically, concerns about the potential impact of cancer treatment on the heart are not among the first that come to mind. However, some patients with cancer may receive radiation therapy to the chest area, and these patients should be aware of the side effects that radiation therapy may cause to the heart. These potential adverse effects are known as radiation cardiotoxicity.
Radiation cardiotoxicity may affect the heart in various ways and at any time. Some conditions develop during or soon after treatment. Others become apparent years, or even decades, after treatment. The specific adverse effects depend on which area of the heart is affected, such as injury to the heart muscle, the heart lining, or blood vessels. Examples of the conditions that may develop include cardiomyopathy, coronary artery disease, and heart rhythm problems.
Radiation treatment can be delivered using several methods. The specifics of your treatment will influence your risk of developing radiation cardiotoxicity. In addition, many other factors may increase or decrease your risk, including age, additional cancer treatments, and other heart risk factors. Your oncologist (cancer doctor), radiation oncologist (radiation doctor), or cardiologist (heart doctor) will help you understand your unique risk from radiation.
Use this condition center to learn more about radiation cardiotoxicity, radiation techniques, and tips for healthy living after cancer treatment.
Fluoropyrimidine Chemotherapy
Treatment with 5-fluorouracil (5FU) or capecitabineTreatment using drugs to kill cancer cells is called chemotherapy. More than 100 chemotherapy drugs are used in cancer treatments.
If you have cancer, your treatment will depend on the type of cancer you have and how far it has progressed. While your treatment will target the cancer cells, sometimes it also may cause heart problems. Although these heart side effects are rare, it’s important to understand and be aware of them.
Chemotherapy with fluoropyrimidine, which includes 5-fluorouracil (5FU) and capecitabine, may be used to treat solid tumors such as those involving your stomach and intestine (gastrointestinal), breast, or head and neck.
These medicines belong to a type of chemotherapy called antineoplastic or antimetabolite, which describes how they work on cancer cells. The drugs stop cancer cells from forming DNA—which contains genetic information—and growing.
This chemotherapy is often well tolerated, but you can have side effects depending on other medications you are taking. Your health history including age, risk factors for heart disease, and other chemotherapy treatments can also play a role in whether you develop complications.
The most common side effects with this chemotherapy are fatigue, nausea, diarrhea and lab abnormalities. It also can cause heart side effects including chest pain, spasm of the heart arteries or irregular heart rhythms, which can be felt as palpitations.
Use this condition center to learn more about damage to your heart, also called cardiotoxicity, from chemotherapy using 5-fluorouracil or capecitabine.
Breast Cancer and Your Heart
Finding out that you have breast cancer can be overwhelming. As a person newly diagnosed with the condition, you may have several questions. A common concern relates to cancer treatments and their side effects: How will they impact your life over the following days, months and years?
Breast cancer treatment depends on the type of breast cancer you have as well as the stage, or progression, of the disease. Often, breast cancer treatment will involve a combination of different therapies:
- Surgery
- Radiation therapy
- Chemotherapy
- Hormonal therapy
- Targeted therapies
About 20% of patients diagnosed with breast cancer will have a specific type of tumor called HER2-positive breast cancer (breast tumors with high levels of a protein called human epidermal growth factor 2, or HER2). Treatment of HER2-positive breast cancer involves medications that target HER2, also called HER2-targeted therapies.
Ask your provider about the HER2 status of your tumor and whether HER2-targeted therapy is an option for you. Use this condition center to learn more about targeted therapy for breast cancer and how it can affect your heart.
Prostate Cancer and Your Heart
If you have prostate cancer, hormone therapy may be part of your treatment. Stopping some hormones can prevent the growth of cancer cells. Androgen deprivation therapy (ADT) includes surgery or medicines that aim to block the effects of male hormones such as testosterone—called androgens—that can cause cancer cells to grow and spread.
This therapy can make developing cardiovascular disease (heart and blood vessel problems) more likely. It also can make existing heart disease worse.
Use this resource to learn how hormone therapy can affect your heart, how to prevent heart disease, and questions to ask your doctor.
Anti-Angiogenic Therapies
To survive and grow, cancer tumors depend on blood vessels supplying oxygen and nutrition. The growth of blood vessels, which is called angiogenesis, also helps cancer tumors spread to other areas of the body.
That is why cancer treatment often includes therapies to block the growth of blood vessels. These agents are also known as anti-angiogenic therapies.
Targeted therapies to block growth of new blood vessels include:
- Monoclonal antibodies (mAbs): These drugs attach and block those proteins that help blood vessels grow.
- Tyrosine kinase inhibitors (TKIs): These drugs block the action of enzymes known as tyrosine kinases, which help cells grow, divide, and send and receive signals.
Monoclonal antibodies and certain tyrosine kinase inhibitors that block the growth of blood vessels are called vascular endothelial growth factor inhibitors (VEGF inhibitors).
VEGF inhibitors block the signals causing abnormal growth of blood vessels and to prevent oxygen and nutrients from reaching the cancer cells. At the same time, it is important to know that VEGF inhibitors also can affect healthy cells.
Use this condition center to learn how anti-angiogenic therapies can affect your heart and what you can do to prevent developing heart disease.
Cancer Treatment and Exercise
You may have been given medicine or therapies that target your cancer cells, but did you know that some cancer treatments also can damage your heart and blood vessels? This is called cardiotoxicity. The most common forms of cardiotoxicity include:
- Cardiomyopathy and heart failure (heart muscle is damaged so that it can’t pump or receive blood normally)
- Coronary artery disease (major sources of blood supply to the heart are damaged)
Your risk of cardiotoxicity depends on the treatments you receive (type and dosage). It also depends on certain risk factors — some of which you can’t control, and some you can.
Risk factors that can’t be controlled include your sex, age, and family history. Some examples of controllable risk factors are inactivity, obesity, and smoking. You are more likely to develop cardiotoxicity after a cancer diagnosis if you:
- Are overweight
- Smoke
- Have diabetes, high blood pressure or high cholesterol
- Don’t exercise regularly
- Already have heart disease
The good news is that exercise can help control your risks. Use this condition center to learn about the benefits of exercise for patients with cancer, what questions you should ask your care team, and how to get started.
What is a Cardio-Oncologist?
Cardio-oncology is a new field in cardiology. Cardio-oncologists are typically cardiologists who see cancer survivors or patients getting cancer treatment who develop side effects that affect the heart. Cardio-oncologists have a special interest in and knowledge about cardiac side effects of chemotherapy, targeted therapy and radiation to treat cancer. Since it is a fairly new field in cardiology, many U.S. cities do not yet have cardio-oncologists.
If you are having symptoms that you think could involve your heart, talk to your cancer doctor (oncologist) or primary care doctor. If your doctors are concerned, they can refer you to a cardiologist or a cardio-oncologist. Make sure to learn about what side effects can be caused by your cancer treatment. That way you can help to inform your health care team.
How Do I Find a Cardio-Oncologist?
You may find a cardio-oncologist at many academic medical centers and other centers across the United States. Searching the department of cardiology website of the medical school nearest you can help you find a cardio-oncologist. Also, ask your cancer doctor as he or she may know a cardio-oncologist in the area.
Exams and Tests
What types of heart tests might you receive before beginning your cancer treatment? Tests may include:
Electrocardiogram (ECG)
An electrocardiogram (ECG) is a picture of your heart's electrical activity. Some cancer treatment makes certain measurements on an ECG change so you may have more than one ECG during treatment. An ECG can detect abnormal heart rhythms, called arrhythmias.
Studies to Measure Ejection Fraction
In many ways, your heart is a muscle like those in your arms or legs. The muscle of your heart is in the left ventricle. Every time your heart beats, it is expected that a certain amount of blood is pushed out of your left ventricle to the rest of your body with each heartbeat: This is known as your ejection fraction. In general, an ejection fraction of greater than or equal to about 55% is considered normal.
Some cancer treatments can lower your ejection fraction. If you have had chemotherapy or radiation in the area of the heart, you may receive several echocardiograms during treatment, for years after treatment or both. Studies for ejection fraction:
- Echocardiogram
- Multigated acquisition (MUGA) scan (involves your receiving a radioactive solution given through a vein using an intravenous (IV) line and then having an X-ray taken)
- Cardiac MRI
Cardiac Catheterization
During a cardiac catheterization, a thin tube or catheter is guided into an artery, usually in the wrist or leg, and up to the heart. The test goes into the body to directly evaluate the arteries of the heart
Source: https://www.cardiosmart.org/topics/cancer-treatment-and-your-heart
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