If you’ve just been diagnosed with cancer or are preparing to start treatment, heart health might be the furthest thing from your mind. But cardio-oncologists (cardiologists who specialize in caring for people who have cancer) often urge careful monitoring of your heart before, during, and after cancer therapy—all times when your heart may be at risk.
Some cancer treatments can injure the heart muscle and blood vessels, increasing the risk of developing heart disease in the days, weeks, months, or years following cancer treatment. That’s because many of the treatments used to fight cancer, including certain chemotherapies, chest radiation, immunotherapy, and targeted therapies, can have toxic effects on the heart. Not only can people develop cancer treatment-related cardiac dysfunction (CTRCD)—the decreased ability of the left ventricle to pump blood effectively, which may lead to heart failure—they can also develop any number of other heart problems including hypertension, arrhythmia, inflammation of the pericardium (the sac-like membrane surrounding the heart), or progressive coronary artery disease.
These cardiac problems don’t happen to everyone undergoing cancer treatment, but they arise often enough that Yale Medicine’s Cardio-Oncology Program at Smilow Cancer Hospital has on-staff specialists focused on their prevention and treatment. This level of expertise is not widely available elsewhere. “We’re here to support and protect hearts while people are getting cancer therapies,” says Yale Medicine cardiologist Lauren Baldassarre, MD, director of the program. “Our goal is to take care of patients so they can get through their cancer treatment without developing new or worsened cardiovascular disease.”
What’s more, there are cardiovascular risks associated with simply having cancer. “Cancer is a pro-inflammatory state,” explains Sarah C. Hull, MD, MBE, a Yale Medicine cardiologist, who is part of the Cardio-Oncology Program at Smilow. And while inflammation can be helpful in the short term to help the body mount a defense against an infection—or cancer—over a long period of time, inflammation can irritate arteries and blood vessels and cause blood clots or plaque buildup—triggers for having a heart attack, she says.
What does a cardio-oncologist do?
For people undergoing cancer treatment, Dr. Baldassarre recommends seeking cardio-oncology care early. She emphasizes the importance of undergoing a cardiovascular risk assessment from a doctor who specializes in providing this level of care. It can determine if further testing, such as cardiac imaging studies or medications, are necessary. “There are some intricacies in taking care of cancer patients that go a little above and beyond a general cardiology approach,” says Dr. Baldassarre, who says patients can be referred by their doctor or seek this care out on their own.
At Yale, the Cardio-Oncology Program offers advanced cardiac imaging studies, like 3D echocardiography with strain imaging, cardiovascular magnetic resonance imaging, and cardiac computed tomography, as well as advanced nuclear imaging such as cardiac positron emission tomography. Because cardio-oncology services are not readily available at many institutions, talk to your oncologist if you are unsure if you should see one, or contact the program directly to make an appointment.
Here’s some heart-healthy information cardio-oncologists want you to know:
It’s important to get high cholesterol and high blood pressure under control before treatment.
It’s not just people with pre-existing heart disease (such as arrhythmia, valve disease, or coronary artery disease) who benefit from seeing a cardio-oncologist, says Dr. Hull. “Even if you just have risk factors like hypertension or high cholesterol, it is time to get it under control.” Poorly controlled high blood pressure is a major risk factor for heart damage from certain forms of chemotherapy, she says.
Cardio-oncologists monitor the heart throughout cancer treatment. They use imaging to pick up on small changes in heart function and address them quickly so cancer treatment doesn’t have to be interrupted. Depending on the type of treatment, they also prescribe medications that can be cardio-protective, such as beta blockers, ACE inhibitors, statins, and dexrazoxane. In addition, they recommend heart-healthy lifestyle improvements—healthy eating habits, daily walks, and quitting smoking, among others.
Survivors of childhood cancer should be monitored in adulthood for heart problems.
Over the past few decades, strides have been made in treating childhood cancers, allowing more children to become long-term survivors. However, the very treatments that have allowed children to survive cancer can have unwanted cardiovascular side effects, which may not show up for 10 years or longer.
“Survivors of childhood cancers already went through so much at such a young age. Now they're often free of their cancer and just want to live a normal life without worrying about health problems,” says Dr. Baldassarre. However, it is important to know that serious heart problems can occur in adulthood if treatments prevented the young heart from developing normally. Cardiac issues such as cardiomyopathy and early coronary artery disease can arise as early as age 40 in survivors of childhood cancer, says Dr. Baldassarre.
Although modern cancer treatments for children, such as chemotherapy and radiotherapy, have improved over time and are now often given in lower but still-effective doses, new and long-term survivors should know about the possibility of what’s called “late effects” of treatment. If you’re involved in a survivorship clinic, cardiac late effects are something doctors will look for and can lead to a cardio-oncologist referral. Or, you can make an appointment directly with a cardio-oncologist to discuss any concerns you may have.
Some hearts are at greater risk than others.
In addition to children, women and all adults ages 60 and over are considered at higher risk for cardiotoxic side effects. The following health concerns are associated with the development or worsening of cardiovascular disease in general and may dramatically increase the risk of cardiac injury from cancer therapy:
- Hypertension (high blood pressure)
- High cholesterol
- Pre-existing heart problems
These cancer therapies are associated with cardiotoxic side effects:
- Anthracyclines (chemotherapy)
- Trastuzumab (breast cancer medication)
- Checkpoint inhibitors (immunotherapy drugs)
- High-dose chest radiation
- Some targeted therapies such as tyrosine kinase inhibitors
Catching cardiac problems that arise early is key. Cardio-oncologists can implement strategies to prevent certain cardiac conditions from becoming worse. In some cases, they can even help heal prior damage.
“At the end of the day,” says Dr. Hull, “we’re helping keep hearts healthy, so you can live a longer and healthier cancer-free life.”