Cheryl Martin (Host): Coming up, what you need to know about breast cancer and heart health. Here to tell us about the connection is Dr. Courtney Campbell. She's the Medical Director of the Cardio-Oncology Center on the Dallas campus of Baylor Scott & White Heart and Vascular Hospital. Dr. Campbell is also a cardio-oncologist on the medical staff at Baylor University Medical Center, a part of Baylor Scott & White Health.

This is HeartSpeak, the podcast from Baylor Scott & White Heart Vascular Hospital Dallas and Fort Worth. I'm Cheryl Martin. Dr. Campbell, so glad you're here to discuss breast cancer and heart health.

Courtney Campbell, MD: Thank you, Cheryl. I'm happy to be here.

Host: So, first, briefly explain what a cardio-oncologist does.

Courtney Campbell, MD: So, a cardio-oncologist is a cardiologist, someone who trained in internal medicine and cardiology who did an additional fellowship in cardio-oncology. In my case, I did an additional year of training at Washington University in St. Louis, which is one of the largest cardio-oncology programs in the country. So with cardio-oncology, it is about taking care of patients with cancer, taking care of their hearts before, during, and after cancer treatment. And really, the field evolved from patients with breast cancer. So in the late 1990s, early 2000s, there were big strides made in treating breast cancer and women were surviving and doing really well.

But with this growing group of survivors, we found that people that were otherwise really healthy would show up in our emergency rooms five, ten, 15 years after their treatment with really severe heart disease. Sometimes that could be heart failure where the heart is weak or coronary artery disease where there's blockages in the blood vessels that supply your heart. And with this, they presented so late in their disease course, are options where things like bypass surgery or sometimes even heart transplants. It was recognized that the unique thing they had was their breast cancer treatment. And we found that if we monitor patients. And if we have defined disease early before they develop end-stage heart disease, we can really change their treatment course. There was a publication in 2015 that showed if we put cardioprotective therapy that a lot of women that had some decrease in their heart function had recovery and were able to complete their cancer treatment.

With this knowledge, it's really what spurred the development of cardio-oncology and has expanded far beyond breast cancer survivors. It's been really such a treat to take care of this patient population and make sure that they're living long, happy, healthy lives.

Host: You've touched on this somewhat, but I would love for you to reiterate why is it important for breast cancer patients to consider their heart health.

Courtney Campbell, MD: Well, in the modern era of treatment, a patient with breast cancer's risk of dying of breast cancer is about the same as the risk of dying of heart disease. So, it's really important that while you focus a lot on really intense treatment during your breast cancer initial therapy, that we don't forget about regular cardiovascular risk factors. So, things like cholesterol, making sure that's well controlled, making sure blood pressure is well controlled. The most common side effect we see longterm in breast cancer survivors is higher blood pressure. Making sure nutrition is good, that you're being active. We recommend about three hours a week of a moderate intensity aerobic activity. And what's really important for women too is strength training, some resistance training that gets those muscles sore a couple of times a week. All of this helps protect against heart disease later in life. And we do know breast cancer survivors are at increased risk. And we also know folks don't always want to see doctors after they go through cancer therapy. But it is really important that definitely with your primary care and depending upon some of the treatments you received on the past, you might need a little more monitoring to make sure we catch and treat and give the appropriate preventative care needed to prevent cardiovascular disease.

Host: Now, are there specific treatments that put patients at a higher risk for heart problems?

Courtney Campbell, MD: There are. So, I'd like to talk about four main categories of treatments. The first is anthracyclines. The next is HER2 targeted, then radiation therapy and hormone therapy.

So anthracyclines, this includes a very commonly used medicine, doxorubicin. It's also known as adramycin. A lot of women remember it as the red devil. It's really not a pleasant medicine to receive, an infusion during your treatment. And originally in the '90s, we often gave pretty high doses of it. And we know that the higher doses someone receives of it, the more likely their risk is of developing heart disease. And this particular one is most commonly heart failure where the heart gets weak. So with that, we now limit the total dose someone receives. If they need more of this particular medicine, we have protective treatment, one called dexrazoxane, that can help mitigate the risks and allow us to do higher doses safer.

There's also a recent clinical trial that was just published this year that showed treating patients with a statin. Atorvastatin was used in this study. They were one-third less likely to develop a decrease in their heart function within the first year of treatment. And so with anthracyclines, we recommend making sure your risk factors are well controlled if you're on it, considering if there's any need for protective medications, definitely getting on cholesterol medicine like a statin if you need it because there's protective effects, and then making sure you're being monitored. This can affect the heart within the first year. Everyone's recommended to have a heart function test within one year of treatment. And then depending upon if you have other risk factors anywhere every two to five years, we should do some type of screening, making sure we catch disease when it's in an asymptomatic stage before heart failure presents. And this unfortunately can sometimes present 10 to 15 years later.

The next treatment I want to talk about is HER2 therapy. So, a lot of breast cancers are HER2 positive when they can use a targeted therapy against this HER2 type of breast cancer cell. We know that this can affect the heart. And so, people on this treatment are going to get echocardiograms every three months. And I like to also check cardiac biomarkers. These are blood tests to look for signs of stress or strain on the heart. We know that if we see a decrease in the heart function, it's not a reason to stop treatment. Usually, your course is about a year on it. But if we see a decrease, we can put people on protective medicine and help let them continue their treatment uninterrupted and help prevent the heart from getting weak. We do know that if we do nothing, some people do develop heart failure. And when it gets severe, not all of them can recover. But most of the time, they did a study in Canada, 90% of folks were able to complete their treatment if we got them on cardioprotective therapy. With HER2 therapy, there are a lot of new formulations of the medicine that are thought to be less cardiotoxic. We still don't have good studies to tell us how much less. And once you complete the treatment, this isn't one that has long term side effects. So usually, we check an echocardiogram within one year. We don't do any more monitoring.

The next type of treatment I want to talk about is radiation. So, radiation has evolved a lot in the last 20 years. Folks that received radiation maybe 20 years ago, a lot of times the heart got a pretty high dose. They're fairly high risk of having valve disease, so the valves don't open as well, and then coronary artery disease where you get blockages in the blood vessels that supply the heart. The radiation induces a fibrosis calcification process that can narrow the valves and narrow the vessels.

So with patients that received it particularly 20 years ago, we recommend we screen. We screen for blockages. We look at their heart at least every five years. And we take symptoms related to coronary artery disease, and this is shortness of breath when you exert yourself, chest tightness, chest pressure, any symptoms, especially if you're exercising regularly and you suddenly find yourself not able to do as much as you could a few months ago, we take that seriously, even if it is a woman in their 40s who doesn't meet the typical picture of-- We think of 60, 70-year-old men with coronary artery disease, but we need to take that seriously.

But radiation oncology has improved a lot. And in the modern era, those risks have really been mitigated. Anyone that gets radiation therapy now, they'll do a lot of breathing techniques, particularly if it's on the left side of their left breast cancer to get the heart out of the way and out of the line of fire of the radiation. So, we expect to see a lot less of radiation-induced heart disease in the future. And certainly, I've seen some people be really scared about getting radiation treatment because they've read about it in the past. But in the modern era, we really don't anticipate those side effects.

And with radiation, I'll say one study, it's certainly not everyone that has radiation treatment that gets these side effects. So, one study from Canada followed patients that had radiation on their left or right side. And they found about 10 years later the patients with left-sided radiation for breast cancer, and again, this era is around 2005 is when they were treated, 2000, 2005, they were about twice as likely to have coronary artery disease, but that risk and actual numbers is 5% versus 10%. So, 90% of people were okay. So, I really don't want to scare anyone with their prior history, but just take your symptoms seriously.

The very last one I'd like to talk about is hormone therapy. After breast cancer, if you have hormone positive treatment, you're often put for five to ten years on treatments like letrozole, anastrozole or exemestane. These don't have many long-term side effects from the heart standpoint, but they can increase your cholesterol levels. So mostly, I want to reassure women that think they're doing all the right things and get really frustrated with their cholesterol numbers after cancer treatment that are on these medicines that it's really the drug's fault. That doesn't mean we should ignore it, we should treat it. And it's, you know, just the price of decreasing your risk of recurrence. With that, those are the main treatments that we think about with breast cancer from a cardio oncology perspective.

Host: So doctor, what tips do you have then for a patient, the best way to talk with her oncologist about a treatment plan and heart health? What do you recommend?

Courtney Campbell, MD: Absolutely. Talk with your oncologist and see are you on a type of treatment that merits additional monitoring. And is it in the short term or is it in the long term? And if you have symptoms, to be sure to, you know, see a cardio-oncologist, someone that specializes in this treatment. And then for all women, and especially breast cancer survivors, I recommend they stay close in touch with their primary care doctor, and that you're getting your cardiovascular risk factors checked, your blood pressure under control, and you're taking care of the things we know that help keep all of us healthy in the long term.

Host: This has been great, great advice. Dr. Courtney Campbell, thank you so much for sharing your expertise on this vital topic. Extremely helpful.

Courtney Campbell, MD: Thank you so much, Cheryl. Such a pleasure to be here.

Host: To learn more or to refer to the Cardio-Oncology Center at Baylor Scott and White Heart and Vascular Hospital Dallas, you can call 214-820-7162. That's 214-820-7162. Thanks for listening to Heart Speak, a podcast by Baylor Scott and White Heart and Vascular Hospital in Dallas, Fort Worth and Waxahatchee.

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