Breast cancer

When breast cancer treatment and cardiovascular risk collide: new AHA advice

A warning that breast cancer survivors, especially those treated with chemotherapy, are at increased risk for heart failure and other cardiovascular diseases has been issued by the American Heart Association.

And while the organisation stresses the statement is not intended to discourage women from having treatment, it asks clinicians to weigh up the benefits of breast cancer treatments against the potential heart risks.

Its first-ever statement on the topic, published in Circulation, notes that cancer treatment can result in a wide range of heart damage, including left ventricular systolic dysfunction; overt heart failure; hypertension; arrhythmias; myocardial ischaemia; valvular disease; thromboembolic disease; pulmonary hypertension; and pericarditis.

The statement notes that breast cancer therapies that raise risk for cardiac dysfunction include:

  • High-dose anthracycline therapy: doxorubicin ≥250 mg/m2 or epirubicin ≥600 mg/m2
  • High-dose radiation therapy when heart is in the field of treatment: radiotherapy ≥30 Gy
  • Sequential treatment: lower-dose anthracycline therapy (doxorubicin <250 mg/m2 or epirubicin <600 mg/m2 ) and then subsequent treatment with trastuzumab
  • Combination therapy: lower-dose anthracycline (doxorubicin <250 mg/m2 or epirubicin <600 mg/m2 ) combined with lower-dose radiation therapy when heart is in the field of treatment (<30 Gy)

And the presence of any of the following risk factors in addition to treatment with lower-dose anthracycline or trastuzumab alone:

  • Older age at time of cancer treatment (≥60 y) ≥2 CVD risk factors during or after cancer treatment: diabetes mellitus, dyslipidemia, hypertension, obesity, smoking;
  • History of myocardial infarction, moderate valvular disease, or low-normal left ventricular function (50%–55%) before or during cancer treatment

Improved risk assessment and development of personalised preventive strategies in cancer survivorship programs are imperative for improved outcomes and reductions in CVD mortality in breast cancer patients, the statement concludes.

It notes that over the past decade, the number of cardio-oncology programs has increased, but many are centered on the treatment of CVD secondary to cancer therapies, and less emphasis has been placed on prevention before development of cardiotoxicity.

“Clearly, there are common risk factors between breast cancer and CVD. The care of these patients extends beyond the silos of cardiology and oncology and should be interdisciplinary, with vigilance with regard to the primary prevention of CVD along with the secondary prevention of CVD,” the statement concludes.

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