Download Cardiovascular Disease Risk in Cancer Survivors

Cardiovascular Disease Risk
in Cancer Survivors
Carolyn Miller Reilly, RN, PhD, CHFN, FAHA
Assistant Professor
Emory University, Nell Hodgson Woodruff School of Nursing
Speaker Disclosers
Principal Investigator receiving funding for CVD disease research
in Cancer Survivors
• Internal funding Kennedy Survivorship Pilot Grant Award, Emory
University: Novel Testing for Subclinical Cardiovascular Disease in
Lymphoma Survivors
• Funding from Radiation Therapy Oncology Group sponsored by National
Cancer Institute: The Relationship between Radiation Dose Volume and
Adverse Cardiovascular Disease Outcomes in Cancer Survivors who Received
Therapeutic Thoracic Radiation
Objectives
• Discuss the growing population of cancer survivors
• Present an epidemiological model explaining the
elevated CVD risk in cancer survivors.
• Differentiate which cancer survivors are at risk for CVD.
• Identify screening recommendations.
• Discuss effective prevention strategies.
Facts and Figures
Morbidity and Mortality Weekly Report (MMWR)QuickStats: Age-Adjusted Death Rates for Heart Disease and Cancer --- United States,
1999—2009* Weekly June 3, 2011 / 60(21);713
All-site Cancer Survival Today
Percent Surviving
5 years
65.8%
Howlader N, Noone AM, Krapcho M, Garshell J, Neyman N, Altekruse SF, Kosary CL, Yu M, Ruhl J, Tatalovich Z, Cho H, Mariotto A, Lewis DR,
Chen HS, Feuer EJ, Cronin KA (eds). SEER Cancer Statistics Review, 1975-2010, National Cancer Institute. Bethesda, MD,
http://seer.cancer.gov/csr/1975_2010/, based on November 2012 SEER data submission, posted to the SEER web site, April 2013.
What does this mean for
Preventive Cardiology Nurses?
ARS Question # 1
A 65 year old woman presents for her annual
Survivorship Visit following treatment 5 years ago for
Stage IIB breast cancer (T2, N1, M0). At that time,
she received bilateral mastectomies with axilla
lymph node removal and radiation to the left axilla.
What will most likely be the cause of her mortality?
0%
0%
0%
0%
1.
2.
3.
4.
Breast cancer recurrence
Cancer metastasis to brain or bone
Cardiovascular disease
Cancer metastasis to lung
10
Countdown
How the numbers stack up
• Risk of CVD death in cancer survivors is higher than the
actual risk of tumor recurrence
• 7-fold higher mortality than general population
• 15-fold increased risk of developing heart failure
• 10-fold increased risk ischemia
• Higher incidence of hypertension, dyslipidemia, acute
coronary syndromes, CVA.
Epidemiology of CVD in Cancer Survivors
Native Risk Factors
Treatment Risk Factors
• Genetics
• Environmental
•
•
•
Chemotherapy
Radiotherapy
Surgery
Cardiovascular
Disease
Health Behaviors
Tobacco, obesity, sedentary
lifestyle, metabolic syndrome,
insulin resistance
Pathophysiology
• Cardiomyopathy
• Fibrosis
Epidemiology of CVD in Cancer Survivors
Native Risk Factors
Treatment Risk Factors
• Genetics
• Environmental
•
•
•
Chemotherapy
Radiotherapy
Surgery
Cardiovascular
Disease
Health Behaviors
Tobacco, obesity, sedentary
lifestyle, metabolic syndrome,
insulin resistance
Pathophysiology
• Cardiomyopathy
• Fibrosis
Epidemiology of CVD in Cancer Survivors
Native Risk Factors
Treatment Risk Factors
• Genetics
• Environmental
•
•
•
Chemotherapy
Radiotherapy
Surgery
Cardiovascular
Disease
Health Behaviors
Tobacco, obesity, sedentary
lifestyle, metabolic syndrome,
insulin resistance
Pathophysiology
• Cardiomyopathy
• Fibrosis
Epidemiology of CVD in Breast Cancer Survivors
Native Risk Factors
Treatment Risk Factors
• Genetics
• Environmental
•
•
•
Chemotherapy
Radiotherapy
Surgery
Cardiovascular
Disease
Health Behaviors
Tobacco, obesity, sedentary
lifestyle, metabolic syndrome,
insulin resistance
Pathophysiology
• Cardiomyopathy
• Fibrosis
Epidemiology of CVD in Breast Cancer Survivors
Native Risk Factors
• Boerman (2014)
Long-term follow-up for
CVD after chemotherapy
and/or radiation for
breast cancer in an
unselected population.
Support Care Cancer
•Haque (2014).
Comorbidities and
cardiovascular disease
risk in older breast cancer
survivors. AJMC.
Health Behaviors
Treatment Risk Factors
Cardiovascular
Disease
Pathophysiology
Epidemiology of CVD in Breast Cancer Survivors
Native Risk Factors
•Boerman (2014)
•Haque (2014)
•Obi (2014).
Determinant of newly
diagnosed comorbidities
among breast cancer
survivors. Journal of
Cancer Survivorship.
Health Behaviors
Treatment Risk Factors
Cardiovascular
Disease
•Obi (2014).
Determinant of newly
diagnosed comorbidities
among breast cancer
survivors. Journal of
Cancer Survivorship.
Pathophysiology
ARS Question # 2
A 65 year old woman presents for her annual Survivorship Visit
following treatment 5 years ago for Stage IIB breast cancer (T2,
N1, M0). At that time, she received bilateral mastectomies with
axilla lymph node removal and radiation to the left axilla.
True or False: She is at increased risk for CVD because she
has been treated for breast cancer?
0%
0%
1. True
2. False
10
Countdown
ARS Question # 3
A 65 year old woman presents for her annual Survivorship Visit
following treatment 5 years ago for Stage IIB breast cancer (T2,
N1, M0). At that time, she received bilateral mastectomies with
axilla lymph node removal and radiation to the left axilla.
Her increased risk for developing CVD is most influenced by:
0%
0%
0%
1. History of 30 pack year smoker, HTN,
hypercholesterolemia, BMI 35,
2. Receipt of left axilla radiation
3. Failure to receive Tamoxifen during her cancer treatment
10
Countdown
Audience Query 4:
A 45 year old woman presents for her annual Survivorship Visit following
treatment 5 years ago for Stage IIB breast cancer (T2, N1, M0). At that time,
she received bilateral mastectomies with axilla lymph node removal,
chemotherapy with CAF (cyclophosphamide, doxorubicin (Adriamycin),
and 5-FU), and radiation to the left axilla.
True or False: She is at increased risk for CVD because she has been
treated for breast cancer?
A. True
B. False
ARS Question # 4
A 45 year old woman presents for her annual Survivorship Visit
following treatment 5 years ago for Stage IIB breast cancer (T2,
N1, M0). At that time, she received bilateral mastectomies with
axilla lymph node removal, chemotherapy with CAF
(cyclophosphamide, doxorubicin (Adriamycin), and 5-FU), and
radiation to the left axilla.
True or False: She is at increased risk for CVD because she
has been treated for breast cancer?
25%
75%
1. True
2. False
Known Cardiotoxic Chemotherapies
Coronary Ischemia:
LV dysfunction:
• Fluorouracil (5-FU)
• Anthracyclines
• Interleukin-2
• Tratuzumab
• Sorafenib
• Sunitinib
Arrhythmias:
• Thalidomide
• Vandetanib
CVD Risk from Radiation
• Routine mapping often prevents radiation induced disease now.
• When occurs, commonly involves pericardium, aortic valve,
vascular diseases, baroreflex failure
• Radiation-induced CVD: oxidative stress, fibrosis, and
inflammation
• Risk factors for radiation- associated CVD: dose > 30-35 GY,
dose per fraction> 2 Gy, large volume of irridated heart,
younger age at exposure, longer time since exposure, use of
cytotoxic chemotherapy, and presence of other CVD risk factors.
Epidemiology of CVD in Cancer Survivors
Native Risk Factors
Treatment Risk Factors
• Genetics
• Environmental
•
•
•
Chemotherapy
Radiotherapy
Surgery
Cardiovascular
Disease
Health Behaviors
Tobacco, obesity, sedentary
lifestyle, metabolic syndrome,
insulin resistance
Pathophysiology
• Cardiomyopathy
• Fibrosis
Epidemiology of CVD in Cancer Survivors
Native Risk Factors
Treatment Risk Factors
• Genetics
• Environmental
•
•
•
Chemotherapy
Radiotherapy
Surgery
Cardiovascular
Disease
Health Behaviors
Tobacco, obesity, sedentary
lifestyle, metabolic syndrome,
insulin resistance
Pathophysiology
• Cardiomyopathy
• Fibrosis
What about other cancers?
Adult and Pediatric Cancers
Screening recommendations
Screening recommendations
• No evidenced-based guidelines for adults!
• There is one consensus based clinical practice guidelines:
Boveli, Plataniotis and Riola (2010). European Society of
Medical Oncology Clinical Practice Guidelines
• IOM 2005 Report “From Cancer Patient to Cancer Survivor:
Lost in Transition”
• Importance of risk-based care with individualized recommendations
• Children’s Oncology Group Guidelines:
www.survivorshipguidelines.org
Screening
(condition)
US Preventive
Services Task
Force
COG
UK Children’s
AAP /AHA
Cancer Study Group
Blood pressure
(hypertension)
Annually for adults
Annually if treatment
risk factors present
Regularly for all
survivors
Measured at
every healthcare
episode if >3yo
Fasting lipids
(dyslipidemia)
Males 20‐34yo /
females 20‐44yo
with CHD risk
2y after completing
therapy and q2y if
risk factors present
Consider if
received chest
radiation or BMT
All cancer
survivors
EKG / ECHO
N/A
(cardiomyopathy)
EKG 2y after
therapy / ECHO q1‐5
yrs depending
exposures
ECHO q3‐5 y depending N/A
on exposures
Fasting glucose
(glucose
intolerance /
diabetes)
q2y in cancer
survivors exposed to
specific treatments
Survivors who
received BMT
Only asymptomatic
adults with blood
Pressures
>135/80mmHg
Baseline for all
cancer survivors
COG, Long Term Follow‐up Guidelines, 2008
Current Clinical Practice of Monitoring
• Echocardiogram for baseline and serial assessment of
LVEF
• BP and weight with survivorship clinic
• May or may not get lipid panel with routine labs
• No consistency of when these should be measured or
how frequent.
Purpose
1) to describe the subclinical
incidence and calculated risk for
the two most prevalent CVDs (HF
and CAD), and
2) to examine perceived risk, knowledge and behaviors
related to cardiovascular health in the lymphoma
cancer survivorship population.
Methods
A cross-sectional, correlation
study, with a purposive sample of
50 asymptomatic patients who
are 2 to 10 years post diagnosis
and treatment for lymphoma
A secondary aim of this study will be to explore patients’
perspectives on the content and delivery approaches of a
patient-specific cardiac risk reduction plan developed from the
clinical findings collected in this research, integrating
survivorship and preventive cardiology services.
Instruments & Measures
Antecedents and
Screening
Concepts
Demographic/ clinical factors
Cognitive Screening
Blessed Orientation-Memory-Concentration
(BOMC)
Previous cardiac events or symptoms Shortened WHO Rose Angina Questionnaire
Routine Noninvasive
Measures
Routine Lab testing: CBC, Chemistry
& Lipid panels
Calculated CVD risk
Novel/ Investigational Biomarkers of inflammation &
Measures
myocardial injury
Atherosclerosis
Patient Reported
Measures
Instruments/ Measures
Demographic/ clinical factors
Routine Lab testing: CBC, Chemistry & Lipid
panels
Framingham Risk Assessment
Biomarkers: HS-CRP, cTnI, BNP
Myocardial Dysfunction
Heart Disease Knowledge
Coronary Artery Calcification Computed
Tomography (CAC-CT)
Echocardiogram
Heart Disease Knowledge Questionnaire
CVD risk-reducing behaviors
Health-Promoting Lifestyle Profile II (HPLPII)
Physical and psychological symptoms Memorial Symptom Assessment Scale- Heart
Failure (MSAS-HF)
HRQL
SF-36 & EQ-5D
Early Evaluation (N=20)
Sociodemographic & Risk Variables
Value
Male Gender
55%
Caucasian
80%
Working Full-time
70%
Low annual income
20%
Average Age
Heart disease in 1 Degree Relative
Smoking
47.5 years
Range
(29-73)
75%
1 current/ 4 former
Exercise minutes per week
91.11 (SD 76)
• 150min/ week or greater
35%
History
• HTN
20%
• Hyperlipidemia
25%
(0-210)
Identification of the Metabolic Syndrome - Any 3 of the
Following:
Risk Factor
Abdominal obesity*
Men
Women
Triglycerides
HDL cholesterol
Men
Women
Blood pressure
Fasting glucose
Defining Level
Waist circumference**
>102 cm (>40 in)
>88 cm (>35 in)
150 mg/dL
<40 mg/dl
< 50 mg/dl
130/85 mmHg
110 mg/dL
Framingham Risk Calculator http://cvdrisk.nhlbi.nih.gov/calculator.asp
Early Evaluation (N=20)
Concerning CV Findings
Waist to hip ratio
Value
• > .85 in women
• >.90 in men
Triglycerides > 150
HDL Cholesterol
• <40 in men
• <50 in women
Blood pressure > 130/85
Fasting Glucose >110 mg/dl
50%
80%
25%
Total patients with metabolic syndrome
40%
33%
1 (5%)
20%
25%
Range
(.75-1)
(.75-1)
Early Evaluation (N=20)
Concerning CV Findings
Positive Cardiac CT
Heart Dysfunction
• Systolic Dysfunction
• Diastolic Dysfunction
Diagnosed with hyperlipidemia
Framingham Risk
• Moderate (11-19% risk of having event in next 10
years)
• High (>30% risk of having even in next 10 years)
Value
1 (5%)
2 (10%)
1 (5%)
7 (35%)
3 (15%)
1 (5%)
Challenges in cardio-oncology care
• Improve the evidence base
• Develop, approve, disseminate, and adhere to
guidelines
• Cost effectiveness?
• Limit additional risk
• Risk Prediction
Prevention Strategies
Prevention strategies
• Incorporate preventive cardiology within Survivorship
Clinics
• Support Survivorship Clinics!
• Routine monitoring of CVD risk factors and patient
centered counseling to address
• Start with AHA’s Simple 7
Education
AHA’s Simple Seven
1.
2.
3.
4.
5.
6.
7.
Get Active
Control Cholesterol
Eat Better
Stop Smoking
Manage Blood Pressure
Lose Weight
Reduce Blood Sugar
Source: American Heart Association
Effects of Physical Activity Guidelines on Cancer and CVD
Mortality: The Cooper Center Longitudinal Study
N=53,000
Hazard Ratio
1
0.8
0.6
Cancer Mortality
CVD Mortality
0.4
0.2
0
Not Meeting
Guidelines
Meeting Guidelines
Exceeding
Guidelines
CE Barlow, WL Haskell, SG Lakoski: Meeting the Physical Activity Guidelines and
Risk of Cardiovascular Disease and Cancer Mortality: Cooper Center Longitudinal
Study. AHA Scientific Sessions (2013), Dallas, TX