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Cardiology Patient Page
Breast Cancer Chemotherapy and Your Heart
Christine Unitt, BS; Kamaneh Montazeri, MD; Sara Tolaney, MD; Javid Moslehi, MD
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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
e680
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?
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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
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/ by guest on June 15, 2017
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
Downloaded from http://circ.ahajournals.org/ by guest on June 15, 2017
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Copyright © 2014 American Heart Association, Inc. All rights reserved.
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