2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

Short- and Long-term Cardiovascular
Complications of Cancer Treatment:
Overview for the Practicing Oncologist
By Chetan Shenoy, MBBS, and Gretchen Kimmick, MD, MS
Overview: As new therapies improve survival from cancer,
attention to comorbid illness and complications of therapy—
both short- and long-term—become much more important to
improving not only quality of life but also overall survival.
Recognized for its importance as the leading cause of death in
the United States, heart disease often coexists with cancer,
and cancer treatment may increase risk and/or severity. In
AN ESTIMATED 1.6 million new cases of invasive
cancer are diagnosed in the United States each year. 1
Modern cancer therapies have improved survival, such that
some cancers that were deemed uncontrollable a few years
ago are now considered “chronic diseases” and some are
cured. In other words, there are more people living with and
living after cancer. In these patients, we have recognized the
importance of not only the short-term, but also the long-term
side effects of our therapies. For instance, many cancer
survivors may have a higher risk of cardiovascular disease
than of cancer recurrence; in a study of 63,566 women with
breast cancer age 66 and older from the Surveillance,
Epidemiology and End Results (SEER)-Medicare linked
database with 12 years follow-up, survivors were equally
likely to die as a result of cardiovascular disease as they
were from breast cancer. 2
In oncology, the complex business of preventing cardiovascular
disease, treating predisposing factors for cardiovascular
disease, ongoing management of the disease itself, and
minimizing cardiovascular complications of cancer therapy
needs multidisciplinary attention—and requires us to be
acutely aware of these issues.
Both cardiovascular disease and cancer are more prevalent
with increasing age. An estimated 82.6 million American
adults (more than one in three) have one or more types
of cardiovascular disease—hypertension, coronary artery
disease, heart failure, or cerebrovascular disease. 3 It is,
therefore, not surprising that patients diagnosed with cancer
might also have cardiovascular disease or may be more
vulnerable to cardiovascular complications of therapy. In
one report, 38% of patients with cancer had hypertension. 4
An analysis of the SEER-Medicare database found that
among breast cancer survivors, 1.7% had myocardial infarction,
6.7% had congestive heart failure, 2.6% had peripheral
vascular disease, and 4.3% had cerebrovascular disease at
the time of diagnosis. 5 Furthermore, pre-existing cardiovascular
disease, such as hypertension, coronary artery disease,
or cardiomyopathy, is a well-recognized risk factor for cardiovascular
complications from chemotherapy, such as anthracyclines
6,7 and trastuzumab. 8,9 Some of our newer
cancer therapies also have specific adverse effects on the
cardiovascular system, regardless of age. Cardiotoxicity related
to anticancer treatment, therefore, may have an important
effect on the overall prognosis and survival of
patients with cancer. 10
Recognized cardiovascular complications of cancer treatment
are many. The more commonly recognized include
addition, there are well-recognized cardiovascular toxicities
of cancer treatment, including not only cardiomyopathy, but
also hypertension, hypercholesterolemia, and others. Oncologists
and cardiologists are working closely to learn more
about the complex interaction and to improve management
and outcome for patients.
KEY POINTS
● The high prevalence of cardiovascular diseases and
cancer requires attention to their interactions and
prevention.
● Many cancer survivors have a higher risk of cardiovascular
disease than of cancer recurrence.
● Cardiovascular complications of cancer treatment
have long been recognized and we are now beginning
to understand the mechanisms and design logical
preventive strategies.
● Preexisting cardiovascular diseases, including hypertension,
coronary artery disease, cardiomyopathy,
and others, are well recognized risk factors for cardiovascular
complications of chemotherapy.
heart failure or left ventricular dysfunction, myocardial
ischemia/infarction, hypertension, and thromboembolism.
Less commonly seen are arrhythmias, myocarditis, and
pericarditis. Also important and recently recognized are
changes in cholesterol profiles, which may increase risk of
adverse cardiovascular outcomes. These range in severity
and chronicity according to the patient and the agent (type
of chemotherapy or radiation) and likely require the attention
of our cardiology colleagues.
Management of cardiovascular complications of cancer
treatment is likely to remain a significant challenge for both
cardiologists and oncologists in the future, as a result of the
growing size of the aging population of patients with cancer
and the introduction of new cancer therapies. Identifying
and understanding these effects is therefore crucial to the
successful treatment of patients with cancer. Unfortunately,
strong scientific evidence for the treatment of patients with
cardiovascular complications from cancer treatment is lack-
From the Divisions of Cardiology and Medical Oncology, Duke University Medical
Center, Durham, NC.
Authors’ disclosures of potential conflicts of interest are found at the end of this article.
Address reprint requests to Gretchen G. Kimmick, MD, MS, Division of Medical Oncology,
Duke University Medical Center, Box 3204, Suite 3800 Duke South, Durham, NC 27710;
email: gretchen.kimmick@duke.edu.
© 2012 by American Society of Clinical Oncology.
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