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Heart Matters Post-Cancer

Some cancer treatments pose risks to the heart, forcing many patients into a fearful state of perplexity over what to do in this difficult situation.

“Often, all the information with a new diagnosis of cancer seems overwhelming, but we are here to help and guide you through your journey,” says Dr. Megha Agarwal, a non-invasive cardiologist with UCLA Health in Ventura and Thousand Oaks with a sub-specialty in women’s heart disease and cardio-oncology.

“Even in survivorship where you want to put cancer in your rearview mirror, the road ahead may have steep turns and bumps,” Dr. Agarwal says, “but navigating them not knowing they are there is way worse than being prepared.”

After her internal medicine training at Cedars-Sinai Medical Center, Dr. Agarwal did a year of research on women and heart disease under Dr. Noel Bairey Merz at the Barbra Streisand Women’s Heart Center at Cedars-Sinai Medical Center.

“That was where I started to see gender disparities in cardiology,” remembers Dr. Agarwal, who then began a cardiology fellowship at UC Irvine, where she learned cardiovascular medicine.

“It was there where I identified a particular group of women cardiac patients that sparked my interest—breast cancer survivors,” she recalls. “I was seeing early onset heart disease and consequences from breast cancer therapy. This led me to pursue cardio-oncology electives at the University of Pennsylvania Cardio-Oncology program, under Dr. Joe Carver.”

Oncologists have done such a great job curing cancer that many of their patients endure years or decades as survivors.

“It is during these survivorship years that heart disease from these prior therapies can often develop,” says Dr. Agarwal, adding that usually these therapies are not always alone in triggering heart disease.

“Often during cancer therapy, patients become less active and change their eating styles leading to weight gain and poor diet choices,” she continued. “In fact, it is a misconception that cancer makes you lose weight, and many patients gain weight during the course of therapy. These lifestyle changes lead to the development of high blood pressure, diabetes and high cholesterol that when paired with their prior therapies, can really accelerate the onset of heart disease.”

Some of the most potent, cancer-killing chemotherapies can make the heart muscle weak, causing cardiomyopathy, a disease of the heart muscle that makes it harder for your heart to pump blood to the rest of your body.

“That can sometimes occur during therapy or many years after,” Dr. Agarwal notes.

Newer cancer therapeutic drugs, such as small molecules and antibodies, have changed how oncologists treat cancer, “but can lead to issues such as high blood pressure, blood clots, heart attacks, heart arrhythmias and strokes,” she says. 

Radiation therapy often affects not only the tissue with the cancer but surrounding tissue, so a lung or breast cancer that receives radiation can also deliver radiation to the heart, lungs or intestines.

“Newer protocols minimize this, however, patients who received radiation therapy 20- to 30-plus years ago were treated with wide fields of radiation at higher doses,” Dr. Agarwal explains. “This can accelerate plaque formation in coronary arteries and most commonly seen, valve disorders of the heart.”

While there can be cardiovascular complications from therapy, “this should not be a reason to not undergo the cancer therapy,” emphasizes Dr. Agarwal, noting that as a cardio-oncologist, her job is to work very closely with your oncologist to carry you through your cancer treatment, even when there is a complication. “Our goal is to never stop your therapies, but merely to find a way to manage heart consequences so that you can continue to fight your cancer.” 

How can a person pursue heart fitness after undergoing chemo and radiation? Tests for cholesterol, diabetes, blood pressure and ECGs should be done at least once a year, she advises.

“Echocardiograms are needed, sometimes at the frequency of every three months during certain cancer therapies,” Dr. Agarwal recommends. “Stress testing should be done 10 years after radiation therapy and other imaging tests are indicated for certain cancers and therapies.”

Additionally, exercise and good nutrition are key aspects to good heart health. More specifically, 150 minutes per week of moderate exercise, or 75 minutes of vigorous exercise, are recommended by the American Heart Association. A heart healthy diet, which resembles a Mediterranean diet, is also recommended.

“Sometimes, it’s a good idea to pursue heart fitness even before you start cancer therapies,” Dr. Agarwal affirms.

Similar to patients seeing their physician prior to surgery to get cleared, “oncologists I work closely with will send higher risk patients—above age 60 to 65, diabetes, high blood pressure, high cholesterol, heart arrhythmias, heart valve conditions, other pre-existing cardiac disease: stents/open heart surgery/pacemakers—to me prior to starting cancer therapy so that I can discuss with them signs and symptoms to monitor for, get baseline assessments of their heart, and start them on preventative medicines so that heart issues are less likely to arise.”

When it comes to heart fitness after people undergo chemo or radiation, it’s also important to avoid leaving their risk factors untreated. For instance, blood pressure should be adequately controlled with medications—the same for cholesterol and diabetes.

“Additionally, they should avoid long gaps in their care and always be in touch with a physician at least once a year,” Dr. Agarwal suggests. “It’s hard sometimes in our busy lives to take time out for ourselves and our health, but oftentimes we see patients present with years of uncontrolled risk factors with heart disease that could have been prevented.”

As far as the time it takes to establish heart fitness after undergoing chemo and radiation is concerned, this depends on the therapy, “but some cancer drugs can cause issues during the course of therapy while others may cause issues five, 10 or even 30 years later,” she says.

One of the reasons Dr. Agarwal went into cardiology is because as a cardiologist, “you have so many tools in your tool belt,” she adds.

“From prevention, medications, to stents and non-surgical valves, pacemakers, surgery, stem cells, and even heart transplant; there are many ways to treat heart disease,” Dr. Agarwal says. “Even if there is a complication with the heart with your cancer therapy we have so many strategies to fix it. It’s only hopeless if you don’t ask and know your options.”

For more information or to make an appointment, visit https://www.uclahealth.org/thousand-oaks/ or call 805.418.3500.

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