Cardio-Oncology: When Cancer Puts You at Risk for Cardiovascular Disease

No cancer patient wants to hear that their disease ― or the treatment that could potentially cure it ― is putting them at risk for a heart attack, heart failure or other cardiovascular problem. But the reality is that some 10 percent of cancer patients die of heart disease, not cancer.

Socrates V. Kakoulides, M.D., a cardiologist with Baptist Health Miami Cardiac & Vascular Institute and medical director of the Institute’s Ambulatory Diagnostic Center.

The good news is that special cardio-oncology programs, like the collaborative effort between Baptist Health Miami Cardiac & Vascular Institute and Miami Cancer Institute, can help those most at risk avoid heart problems altogether or minimize complications. The key is early cardiovascular referral and evaluation, says cardiovascular imaging specialist Socrates Kakoulides, M.D., medical director of the Institute’s Ambulatory Diagnostic Center.

“Cancer is a scary diagnosis. The entire team is focused on treating that cancer and getting rid of it, as they should be,” he says. “At the same time, we now know much more about the toxicity of some of the drugs cancer patients are given and how they affect the heart. Our role is to help them avoid additional problems. This is very treatable.”

Compounding the issue is that earlier cancer detection and better treatments mean that cancer patients are surviving and living longer lives than ever before. Aging, in and of itself, increases the odds of developing cardiovascular disease.

Cardiovascular Risk Screening

Patients typically complete some basic cardiovascular screening questions as they prepare for cancer treatment. When physicians in the cardio-oncology program receive a referral, they go in-depth into a patient’s risk. The evaluation may include:

• A review of family history.
• A determination of a patient’s pre-existing heart disease risk factors, which may cover problems such as smoking, diabetes, obesity, and high blood pressure and cholesterol.
• Treatment plan recommendations, particularly those that involve drugs important to cancer care yet known to be toxic to the heart, as well as a review of any radiation therapy that may be ahead.
• Special tests or imaging to get a more comprehensive picture of the heart.
• A look at issues that may limit the ability to exercise or problems that may lead to muscle wasting and deconditioning, requiring oncology and/or cardiac rehabilitation.

Medications and Radiation Can Carry Risks

Some chemotherapeutic drugs, such as anthracyclines, put patients at risk for heart muscle damage. One of those drugs, doxorubicin, also known as “The Red Devil,” is a very effective IV medication commonly used in limited doses for patients with breast and ovarian cancer, as well as lymphoma. The drug can lead to heart failure, not only while the patient is receiving it but even years after.

Checkpoint inhibitors can cause myocarditis or pericarditis, which can be life-threatening. Herceptin, often prescribed for breast cancer and gastrointestinal cancer patients, can damage heart function.

“Some patients are on these medications for a long time. We will screen them regularly using echocardiography to make sure heart function is maintained. If it is reduced, we may give medications known to improve heart function,” Dr. Kakoulides says.

The physicians also consult with pharmacists to look at any drug interactions that may occur and to recommend replacement medications if necessary. “There are times we pause medications, but what we don’t like to see is a patient declining cancer treatment because they are afraid of a cardiovascular problem,” he says. “We really encourage them to talk to us because we can identify risks early and complications are treatable.”

Because radiation to the chest area can be damaging to the heart, careful consideration is given before determining optimal treatment. “Radiation affects the lining around the heart, the arteries themselves and the valves of the heart. This can lead to heart attack or heart failure. We try to avoid the chest area when possible, but it can be necessary, especially with breast cancer and lymphoma,” Dr. Kakoulides says.

Special Concerns for Children and Younger Adults 

Research has shown that children who survive cancer develop cardiovascular disease at a much higher rate than their peers who never had cancer. Again, toxic treatment and therapies that make it possible to beat cancer can contribute to cardiovascular problems later in life.

“Children with cancer really need to be followed by a cardiologist, and while we stress healthy eating and exercise with all patients, it is very important for children and young adults to maintain a healthy lifestyle. We don’t want them to add to their risks by becoming obese or developing diabetes or high blood pressure. And being in good shape before treatment also helps in the fight against cancer and in recovery,” says Dr. Kakoulides.

Exercise and Conditioning

Dr. Kakoulides has watched two young adult cousins battle breast cancer, undergoing mastectomies and having chemotherapy. One, a Karate champion was particularly concerned about being inactive and also anxious that resuming her training after a bilateral mastectomy too soon might harm her recovery. Fortunately, she was able to return to physical activity quickly, and she blogged about her experience to help others.

The cardio-oncology team also works closely with Miami Cancer Institute’s rehabilitation team. Patient outcomes are better when patients are able to stay strong and take part in physical activity. Exercise also helps diminish side effects of treatment. Depending upon their limitations, a patient may go to cardiac rehab or oncology rehab before, during or after cancer treatment.

“We urge patients to exercise as much as they can, understanding that there are some periods when they must take a break to recover from surgery or when they are just too sick,” Dr. Kakoulides explains. “Not only is it good for their physical health, it is good for mental health as well.” Patients should talk to their surgeons or oncologists about when it is safe to exercise. And for those uncertain about beginning an exercise program or picking up where they’ve left off, they might consider one of several exercise and gym programs offered by Miami Cancer Institute.

Cardio-oncology is a growing specialty. To learn more about the program at Miami Cardiac & Vascular Institute.