Anthracycline Associated With Heart Failure in Patients Treated for Breast Cancer, Lymphoma

In this video, Hector R. Villarraga, MD, discusses the long-term incidence of heart failure in patients with breast cancer or lymphoma treated with anthracycline therapy and the clinical impact of his study's findings.

Additional resource:

• Larsen CM, Garcia Arango M, Dasari H, et al. Association of anthracycline with heart failure in patients treated for breast cancer or lymphoma, 1985-2010. JAMA Netw Open. 2023;6(2):e2254669. doi:10.1001/jamanetworkopen.2022.54669.

For more heart failure content, visit the resource center.

Hector R. Villarraga, MD, is a cardiologist in the Department of Cardiovascular Medicine at the Mayo Clinic (Rochester, Minnesota).

TRANSCRIPTION:

Hector R. Villarraga, MD: Hello everyone. My name is Hector Villarraga. I'm a cardiologist at the Mayo Clinic in Rochester, Minnesota. My interest is, one of my interests is cardio-oncology, looking at earlier detection of cardiac dysfunction and also epidemiology of the different side effects of cancer therapy.

Consultant360: What was the impetus for this study? Why now?

Dr Villarraga: So this study took a whole team to put it together. We started in around 2015 gathering the database using the Rochester Epidemiology project, which is a nice area here in Minnesota that has patients that go to only two medical centers for their care and they stay and live for a long time here. So we could access their medical records back 50 years if we wanted to and see what was happening. So the question was, what is the incidence of heart failure in patients with breast cancer or lymphoma when you compare them to match peers that have same risk factors, same age, same gender, but not cancer. And then we wanted to follow them for around 20 to 30 years to see what happened in this community. So a group of fellows, clinical fellows, research fellows, went through close to 1500 controls charts and around 800 cases and we verified everything that was there to make a solid database and then produce this, which is one of the many articles which are going to come out from this cohort answering the question, what is the incidence of heart failure in a group of patients with cancer that received anthracyclines versus the normal controls?

C360: How does this study fill a current gap in our knowledge?

Dr Villarraga: So it fills a very interesting gap because before this, the majority of the studies were done using the disease codes. So patients that go to an ex hospital system or an HMO with a code already because they had cancer and heart failure were compared, or where described, heart failure was described in this cohort how much it was. This one brings it from the community and say, okay, in your community setting where X and Y live and you had cancer and somebody else did not, how does that affect the possibility of you having heart failure after you had anthracycline therapy?

C360: What are the knowledge gaps that still remain, and what kind of research can fill those knowledge gaps?

Dr Villarraga: So for now we know that the incidence of heart failure in patients that receive anthracyclines is up to 20 years of follow up is double of the normal controls. So it happens and it happens twice as much. Now what we have to do is how can we prevent the development of heart failure in this patients? So first and foremost, you have to go to your cardiologist and your oncologist from day one that you have been diagnosed with cancer and that you're going to receive these chemotherapies and have a strategy which already in guidelines from groups here in the US and in Europe, what to do with a patient. They follow an algorithm how to evaluate and follow the patient during their cancer journey and how to cardio protect the heart if it's needed, if you have certain signs that maybe your heart muscle is not functioning well. So that's the way. Then the other way is if you have hypertension, hyperlipidemia, diabetes, or you smoke, make sure your physician knows because all these risk factors when taken into account and working with lifestyle changes help protect your heart as well because definitely what's happening now with all the new cancer therapies, even though anthracycline is an old therapy, survival is getting longer and longer as each decade progresses from the 1980 to now the even 2030. But now the patients are, they have issues is with their heart and their cancer is no longer there. So that's the important thing.

C360: How should a clinician weigh the results of your study against the benefits of anthracycline therapy for patients with breast cancer, lymphoma, and/or sarcoma? What goes into that decision making process?

Dr Villarraga: So first and foremost you have to be very well engaged with your oncologist because you have to get your treatment. But now you can ask your oncologist that probably you need a cardio oncologist or a general cardiologist to follow you at the same time to see if there can be signs of early cardiac dysfunction. And that's in the guidelines what to do. The easiest method is doing an echocardiogram, which is an ultrasound of your heart looking at function. And there's some other markers within the ultrasound of your heart, which we do a lot of research also in which is called strain. And that looks at the deformation of the muscle and we can look at it and can predict with around 85% accuracy when the dysfunction could happen. So that's when the clinician will start cardioprotective medications or will optimize your diabetic medications, your hypertensive medications, your high cholesterol medications to try to diminish that possibility of harm to the myocardium.

C360: What kind of specialists will be most impacted by the results of this study?

Dr Villarraga: So our study was very dedicated only to oncology patients that had risk factors. And what happens is that patients with cancer has the same risk factors as patients with cardiac disease, but if you optimize lifestyle in the cancer patients, also you decrease the possibility of damaging more than myocardium, the heart muscle. So definitely having a good relationship with your oncologist, the same relationship with your cardiologist or your internist or family care can help you guide and go through the journey of the cancer therapy and optimizing all the other entities or comorbidities that you could have instead of, now that you're in cancer therapy, I'll let my blood pressure into 200s and that's going to be okay. Well maybe you have to take care of it and also try to do some exercise even though we understand it's tough because you're undergoing chemo, radiation and then comes a doctor and says you have to exercise and you'll say he's crazy. It's going to be difficult but take it all into account and when you can, you should try to optimize all this and probably with it you can try to decrease the damage to your heart.

C360: What is the main takeaway from your study?

Dr Villarraga: So the big take home message is be aware that in a percentage of patients that receive cancer therapy with anthracyclines, heart failure can happen. But if you're engaged with your oncologist and your primary care physician or cardiologist, you can decrease the possibility of that harm to your heart muscle. But never stop your medications or your chemotherapy for cancer because that's very important. Survival is now in breast cancer, lymphoma is quite ahead of what was it 40 years ago. So keep it up and work together with a group, with a team.