Cardiovascular Disease in Cancer Patients
Hearing ‘You have cancer’ brings with it an abundance of emotions. It leads to a series of not-always-clear decision points. The hopes and fears surrounding potential treatments, side effects, morbidity and mortality scenarios, the gauntlet of healthcare providers, along with the insurance and financial stressors can be an incredible burden to a patient and family. But there is one more hurdle to consider: the increased risk of cardiovascular disease (CVD) in cancer patients.
Imagine beating a cancer diagnosis and then doing all it took to be labeled ‘in remission’ or ‘cancer-free.’ Then finding out, months or years later, that your risk of CVD is now much greater than it would have been if you hadn’t had cancer. A new cancer diagnosis may be independently associated with a significantly higher risk for cardiovascular death, stroke, heart failure, and pulmonary embolism—particularly in the first 12 months. This scenario continues to increase, across the country and across the globe, and requires attention from clinicians in cardiology, oncology, and the relatively new sub-specialty of cardio-oncology. Nurses are on the front lines of addressing CVD risk in these patients and are key to ensuring patients
Why is There an Increased Risk of CVD in Cancer Patients?
Extended Lifespan of Cancer Patients
Along with advances in cancer screening, the efficacy of chemotherapy and other cancer treatments has improved dramatically over time. This has led to the expanded life expectancy of cancer patients. At the most basic level, since the risk of cardiovascular disease generally increases with age and with the presence of comorbid risk factors, any patient who lives a long life is already at increased CVD risk.
But for cancer patients, the risk is even greater. Overall, the risk of fatal heart disease in patients with cancer is more than twice the rate of that in the general population.2
Cardiotoxicity of Treatment Regimens
In use for more than 50 years, anthracyclines have been very successful in treating a wide array of cancers.3 They are FDA-approved for specific types of leukemias, bladder cancer, tumors, breast cancers, and many other diseases.4,5,6 Research has indicated, however, that anthracyclines and other cancer treatment-induced cardiotoxicity occurs in up to 25% of cancer patients—depending upon underlying cardiovascular risk factors and the specific chemotherapy utilized7 —and rates may still be underestimated.8 For survivors of childhood cancers, the numbers are even bleaker, with an eightfold risk of cardiac-related mortality.9,10
Reducing CVD Risk in Cancer Patients
What can clinicians and patients do to reduce the risk of CVD? While research continues on point-of-treatment as well as long-term strategies, there are some best practices that can be implemented immediately, if they are not already in place. Nurses are at the forefront of working to enhance patient and family understanding through education and follow-through, improve patient outcomes, and maximize the quality of life for patients.
- Managing comorbidities before, during, and after cancer treatment. Along with managing cancer treatment and side effects, focusing on heart-healthy strategies that include lifestyle, smoking cessation, and addressing hypertension hyperlipidemia, diabetes, and other factors can reduce overall risk.
- Be aware of the cardiotoxicity of treatments. Stay informed about the research on treatment options and their risk—particularly when multiple therapies are used in succession or in tandem. As an example, anthracyclines, particularly when used in conjunction with HER2 therapies Herceptin, and Perjeta®, for example, put patients at a higher risk of cardiac side effects. Another example is radiation that is used to treat cancer or tumors on the left side of the chest or the left lung, which can lead to cardiac-related effects.
- Utilize technologies, diagnostics, and other strategies to help pinpoint issues that might otherwise go undetected. The use of a 3D echocardiogram with GLS strain echo is an example. Not only does it provide a specific number for ejection fraction, rather than a range that would be identified using 2D echocardiography. But it also allows clinicians to identify global longitudinal strain (GLS) values, which is the strain on the myocardium. If GLS values are low, this can be a red flag to help catch long-term symptoms as early as possible and more easily manageable.
- Team-based care taps into everyone’s expertise. Having experts in cardiovascular disease partnering with those who excel at cancer diagnosis and treatment, and working alongside those who are adept at sharing education and engaging with patients and families to effect change, provide not only a support network for a patient but ensures that the latest guideline-based practices can be evaluated and utilized to maximize patient outcomes.
- Contribute to research about CVD in cancer patients. Your healthcare system and/or other organizations may be looking to gather data and information. Encouraging patient participation in clinical trials, and ensuring diverse representation in trials and research, requires the involvement of a variety of clinical practitioners.
- Long-term commitments to patient care can make a big difference. In addition to connecting to other healthcare providers and researchers, enduring connections with patients, where practicable can provide a consistent point of contact. Activities such as continuing to encourage heart-healthy behaviors, suggesting appropriate screenings, etc. can reduce the risk of individuals getting lost in the potential ‘shuffle’ among an array of providers.
- Reach for resources. For both providers and patients, a number of quality resources and organizations are available. See more in the section below.
More Resources on Cardiovascular Disease in Cancer Patients
While not meant to be an exhaustive list, the following resources can benefit you, your colleagues, patients, and families.
- PCNA has three podcast episodes on CVD in cancer patients. Check out the Heart to Heart Nurses podcast on your favorite podcast source.
- The International Cardio-Oncology Society (ICOS) has both patient and professional resources.
- Patients and their support networks can engage with the Cancer Support Community both online and in person.
- Advocacy and education are key activities of the Association for Cancer Community Centers.
- Paterson DI, Wiebe N, Chung W, et al. Incident Cardiovascular Disease Among Adults with Cancer: A Population-Based Cohort Study. J Am Coll Cardiol Cardio Onc. 2022 Mar,4(1)85-89.
- Stoltzfus KC, Zhang Y, Sturgeon K, et al. Fatal heart disease among cancer patients. Nat Commun. 11, 2011 (2020). Doi:10.1038/s41467-020-15639-5.
- Minotti G, Menna P, Salvatorelli E, Cairo G, Gianni L. Anthracyclines: molecular advances and pharmacologic developments in antitumor activity and cardiotoxicity. Phamacol Rev. 2004 Jun;56(2):185-229.
- Megías-Vericat JE, Martínez-Cuadrón D, Sanz MÁ, Poveda JL, Montesinos P. Daunorubicin and cytarabine for certain types of poor-prognosis acute myeloid leukemia: a systematic literature review. Expert Rev Clin Pharmacol. 2019 Mar;12(3):197-218.
- Antolín S, Acea B, Albaina L, Concha Á, Santiago P, et al. Primary systemic therapy in HER2-positive operable breast cancer using trastuzumab and chemotherapy: efficacy data, cardiotoxicity and long-term follow-up in 142 patients diagnosed from 2005 to 2016 at a single institution. Breast Cancer (Dove Med Press). 2019;11:29-42.
- Meyer M, Seetharam M. First-Line Therapy for Metastatic Soft Tissue Sarcoma. Curr Treat Options Oncol. 2019 Jan 24;20(1):6.
- Ades F, Zardavas D, Pinto AC, Criscitiello C, Aftimos P, de Azambuja E. Cardiotoxicity of systemic agents used in breast cancer. Breast. 2014;23(4):317–28.
- Chargari C, Guy JB, Falk AT, Schouver ED, Trone JC, Moncharmont C, et al. Cardiotoxicity research in breast cancer patients: past and future. Am J Cardiol. 2014;113(8):1447–8.
- Chargari C, Kirov KM, Bollet MA, Magne N, Vedrine L, et al. Cardiac toxicity in breast cancer patients: from a fractional point of view to a global assessment. Cancer Treat Rev. 2011;37(4):321–30.
- Senkus E, Jassem J. Cardiovascular effects of systemic cancer treatment. Cancer Treat Rev. 2011;37(4):300–11.