Guarding The Heart : Vital Oncology Insights

By Specialty Rehabilitation Inc. | March 28, 2024

During the month of February, we often think of our loved ones and find information on heart-healthy tips. Heart disease is still the number one killer in the United States, and reminders of prevention and self-care are always a good idea for us and our patients. SRI wants to expand heart health knowledge in cancer rehabilitation. In this month’s blog, we will highlight Oncology-Related Cardiotoxicity: causes, signs, symptoms, and interventions for rehabilitation practitioners. 

Advancements in tailored cancer therapies, including immuno and targeted therapy, are extending lifespans for many patients, even those with advanced stage 4 cancers considered “treatable but not curable.” As a result, cancer is now viewed as a chronic disease. However, with treatments potentially losing efficacy over time, patients often transition to alternative systemic therapies. Rehabilitation practitioners need to be aware of treatment side effects, particularly cardiac risks, and play a vital role in screening and intervention to mitigate these issues. Despite improvements in early detection and medical treatments, the global burden of cancer is increasing rapidly, with projections indicating a nearly 47% surge in cancer cases from 2020 to 2040. (13). One such side effect, cardiotoxicity, is frequently overlooked in discussions about cancer survivorship. Cardiotoxicity – treatment-induced cardiac dysfunction is the 2nd most common cause of morbidity in survivors and can manifest years after treatment. You might be the initial healthcare provider to detect its signs and symptoms. Here is what you need to know. 

Common causes of cardiotoxicity in the cancer population include:

  • Cardiotoxic systemic treatments: chemotherapy, immune and targeted therapies, and endocrine therapy
  • Radiation therapy 
  • Advanced cancer: cachexia from disease progression

The examples and lists provided do not encompass all cardiotoxic therapies. They are merely offered as an illustration of the most common treatments currently available. 

Common cardiotoxic chemotherapies 

  • Doxorubicin and Adriamycin – commonly used with breast, sarcomas, gynecological cancers, and lymphomas
  • Cyclophosphamide – commonly used with ovarian, breast, blood, lymphomas, and nerve cancers
  • Cisplatin – commonly used with testicular, ovarian, cervical, bladder, breast, head and neck, lung, and gastric cancers 
  • Paclitaxel and Docetaxel – lung, breast, and prostate cancers 

Targeted therapies (uses drugs or other substances to target specific molecules that attack cancer/tumors.) Some of these drugs can cause ventricular dysfunction, heart failure, hypertension, and thromboembolic events.

  • Trastuzumab and Herceptin– monoclonal antibody used to treat HER 2+ breast cancer and certain gastric cancers. 
  • Gefitinib, Erlotinib, Sorafenib, and Dasatinib – Non-small cell lung cancer, advanced pancreatic, kidney, and liver cancers 

Immunotherapies are new in advancing cancer treatments by causing your body’s immune cells to kill tumors/cancer cells. 

  • Ipilimumab and Nivolumab are used to treat gastric, advanced melanoma, and non-small cell lung cancers. 

Endocrine/hormonal therapy: used for cancers that feed off hormones in both the breast and prostate. 

  • Flutamide, Bicalutamide, and Casodex – Androgen deprivation therapy (male prostate cancer) – increases the risk of heart disease with hypertension and possible myocardial infarction and stroke 
  • Anastrozole, Letrozole, and Exemestane – Aromatase inhibitors (breast cancer) have been associated with cardiovascular disease 
  • Tamoxifen – (Selective estrogen receptor modulator) is used to treat hormone-positive breast cancers, and is associated with an increased risk of DVTs 

Radiation-induced heart disease – occurs from radiation to the chest area (especially left-sided) most common in treatment for breast, esophageal, Hodgkin’s, and lung cancer. 

  • Immediate side effects may include inflammation, pericarditis, and pericardial effusion (commonly observed in lymphoma treatment), typically emerging weeks to months following radiation therapy. Symptoms may manifest as chest pain alleviated by sitting up and leaning forward, exacerbated by deep breaths, and accompanied by shortness of breath that subsides with bending over. 
  • Long-term effects, which may manifest years after treatment, stem from radiation-induced fibrosis. In certain instances, these effects can even arise up to two decades later. Such long-term repercussions might include congestive heart failure (CHF), coronary artery disease, cardiomyopathy, arrhythmias, valvular heart disease, and pericardial thickening. 

Cancer-induced cardiac cachexia, observed in approximately 80% of patients with advanced cancer, involves severe muscle wasting due to significant weight loss.

  • Specifically affecting the heart muscle, this condition leads to heart failure and is commonly associated with advanced cancers such as pancreatic, gastric, lung, colorectal, and head and neck cancers. 

Hypertension resulting from cancer treatments: the most frequent comorbid condition of cancer patients.

  • Common systemic therapies that increase blood pressure: Bevacizumab, Avastin, Sorafenib, Nexavar, Sunitinib, and Sutent

Regular monitoring of vital signs is essential for all patients undergoing active treatment, as well as those with a cancer history. 

Rehabilitation Clinical Considerations For High-Risk Patients 

  • Monitor for signs and symptoms of cardiac heart failure (CHF) 
  • Inability to lie flat 
  • Shortness of breath- that is out of proportion to the activity, may progress to SOB with walking then at rest.
  • Tachycardia 
  • Chest pain 
  • Swelling in feet, ankles, and legs 
  • Coughing/wheezing 
  • New onset of significant fatigue, out of proportion for activity level 

Exercise and cardiotoxicity: When working with patients exhibiting left ventricular alterations and reduced ejection fraction due to cancer-induced cardiotoxicity, approach their exercise regimen as if managing heart failure. Continuously monitor for any indications or symptoms suggestive of heart failure. 


Interventions

  • Education on cancer/cardiotoxicity 
  • Exercise: newer studies are showing that exercise may prevent or improve cardiotoxicity
  • Monitor for any signs of heart failure 
  • Monitor vital signs – track heart rate before and after activity 
  • Use the Borg Scale – Keep in a lower range starting in 9 to 11 very light range. 
  • Do not skip the warm-up or cool-down. 
  • Avoid holding breath 
  • Lifestyle modification education 
  • 4 P’s for energy conservation (Problem-solving, Planning, Prioritizing, and Pacing) 

Final Tips 

  • Cardiotoxicity represents just one among a variety of potential side effects stemming from cancer and its treatments. It is crucial to screen and assess all side effects associated with cancer, including distress, cancer related fatigue, chemotherapy-induced peripheral neuropathy, cancer-related cognitive impairment, steroid induced myopathy, and sleep dysfunction. Subsequently, tailor treatment strategies to each patient’s specific needs within an individualized care plan. 
  • Cancer and its treatments can lead to both acute and chronic cardiotoxic side effects. Healthcare practitioners must remain vigilant regarding the signs and symptoms associated with these complications. 
  • If there is a noticeable change in cardiac status, contact the physician promptly, or dial 911 in case of an emergency. 
  • Recent studies suggest that once diagnosed and receiving medical care, patients experience positive outcomes from rehabilitation. Certain side effects may necessitate close monitoring and personalized treatment plans. Begin with conservative approaches and gradually advance based on individual tolerance levels.
  • Adults who survived childhood cancers and underwent cardiotoxic treatments are susceptible to chronic cardiac conditions. Be mindful when an adult patient has a previous medical history of childhood cancer, especially if they received one or more cardiotoxic treatments.

Absolute Contraindications To Treatment: (14, 15)

  • Severe angina
  • Dizziness or pre-syncope
  • Cyanosis
  • O2 saturation at rest < 88%
  • Systolic BP >200mmHg and diastolic >110 mmHg
  • Basal HR above 120bpm after 2 measurements 5 minutes apart

For further details regarding exercise in oncology – encompassing precautions and guidelines for CRF, CIPN, lymphedema, and chemotherapy-induced cytopenias visit our website: specialtyrehab.thinkific.com/collections 

References 
1.Adhikari A, Asdaq SMB, Al Hawaj MA, Chakraborty M, Thapa G, Bhuyan NR, Imran M, Alshammari MK, Alshehri MM, Harshan AA, Alanazi A, Alhazmi BD, Sreeharsha N. Anticancer Drug-Induced Cardiotoxicity: Insights and Pharmacogenetics. Pharmaceuticals (Basel). 2021 Sep 25;14(10):970. doi: 10.3390/ph14100970. PMID: 34681194; PMCID: PMC8539940 
2.As nani A. Cardiotoxicity of Immunotherapy: Incidence, Diagnosis, and Management. Curr Oncol Rep. 2018 Apr 11;20(6):44. doi: 10.1007/s11912-018-0690-1. PMID: 29644505. 3Chen ZI, Ai DI. Cardiotoxicity associated with targeted cancer therapies. Mol Clin Oncol. 2016 May;4(5):675-681. doi: 10.3892/mco.2016.800. Epub 2016 Mar 
3. PMID: 27123262; PMCID: PMC4840776. 
4.Florescu DR, Nistor DE. Therapy-induced cardiotoxicity in breast cancer patients: a well-known yet unresolved problem. Discoveries (Craiova). 2019 Mar 31;7(1):e89. doi: 10.15190/d.2019.2. PMID: 32309607; PMCID: PMC7093073. 
5.Gilchrist SC, Barac A, Ades PA, Alfano CM, Franklin BA, Jones LW, La Gerche A, Ligibel JA, Lopez G, Madan K, Oeffinger KC, Salamone J, Scott JM, Squires RW, Thomas RJ, Treat-Jacobson DJ, Wright JS; American Heart Association Exercise, Cardiac Rehabilitation, and Secondary Prevention Committee of the Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; and Council on Peripheral Vascular Disease. Cardio-Oncology Rehabilitation to Manage Cardiovascular Outcomes in Cancer Patients and Survivors: A Scientific Statement From the American Heart Association. Circulation. 2019 May 21;139(21):e997-e1012. doi: 10.1161/CIR.0000000000000679. PMID: 30955352; PMCID: PMC7603804. 
6.Mauro AG, Hunter K, Salloum FN. Cardiac complications of cancer therapies. Adv Cancer Res. 2022;155:167-214. doi: 10.1016/bs.acr.2022.03.006. Epub 2022 Apr 20. PMID: 35779874; PMCID: PMC9648627. 
7.Mudd TW Jr, Khalid M, Guddati AK. Cardiotoxicity of chemotherapy and targeted agents. Am J Cancer Res. 2021 Apr 15;11(4):1132-1147. PMID: 33948350; PMCID: PMC8085845. 
8.NCI cancer.gov 
9.Saha S, Singh PK, Roy P, Kakar SS. Cardiac Cachexia: Unaddressed Aspect in Cancer Patients. Cells. 2022 Mar 14;11(6):990. doi: 10.3390/cells11060990. PMID: 35326441; PMCID: PMC8947289. 10.Schmitz KH, Stout NL, Maitin-Shepard M, Campbell A, Schwartz AL, Grimmett C, Meyerhardt JA, Sokolof JM. Moving through cancer: Setting the agenda to make exercise standard in oncology practice. Cancer. 2021 Feb 11127(3):476-484. doi: 
10.1002/cncr.33245. Epub 2020 Oct 22. PMID: 33090477; PMCID: PMC7899181. 
11.Schmitz, K.H. (Ed). Exercise Oncology. Springer Nature Switzerland. 2020; Doi/10.1007/978-3-030-42011-6. 
12.Scott J. et al. (2018). Exercise therapy and cardiovascular toxicity in cancer. Circulation;137(11):1176-1191. doi:10.1161/circulationaha.117.024671 
13.Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, Bray F. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021 May;71(3):209-249. doi: 10.3322/caac.21660. Epub 2021 Feb 4. PMID: 33538338. 
14.Stubblefield MD. Cancer Rehabilitation Principles and Practice 2nd ed. Springer Publishing Company; 2019\. 
15.Venturini E, Iannuzzo G, D'Andrea A, Pacileo M, Tarantini L, Canale ML, Gentile M, Vitale G, Sarullo FM, Vastarella R, Di Lorenzo A, Testa C, Parlato A, Vigorito C, Giallauria F. Oncology and Cardiac Rehabilitation: An Underrated Relationship. J Clin Med. 2020 Jun 10;9(6):1810. doi: 10.3390/jcm9061810. PMID: 32532011; PMCID: PMC7356735. 
16.Zamorano, J.L., Lancellotti, P., Rodriguez Muñoz, D., Aboyans, V., Asteggiano, R., Galderisi, M., Habib, G., Lenihan, D.J., Lip, G.Y.H., Lyon, A.R., Lopez Fernandez, T., Mohty, D., Piepoli, M.F., Tamargo, J., Torbicki, A., Suter, T.M., Zamorano, J.L., Aboyans, V., Achenbach, S., Agewall, S., Badimon, L., Barón-Esquivias, G., Baumgartner, H., Bax, J.J., Bueno, H., Carerj, S., Dean, V., Erol, Ç., Fitzsimons, D., Gaemperli, O., Kirchhof, P., Kolh, P., Lancellotti, P., Lip, G.Y.H., Nihoyannopoulos, P., Piepoli, M.F., Ponikowski, P., Roffi, M., Torbicki, A., Vaz Carneiro, A., Windecker, S., , and (2017), 2016 ESC Position Paper on cancer treatments and cardiovascular toxicity developed under the auspices of the ESC Committee for Practice Guidelines. Eur J Heart Fail, 19: 9-42. https://doi.org/10.1002/ejhf.654 
17.CDC.gov.https://www.cdc.gov/physicalactivity/basics/measuring/index.html#:~:text=The%20talk%20test%20is%20a,not%20sing%20during%20the%20activity.&text=In%20general%2C%20if%20you%27re%20doing%20vig orous%2Dintensity%20activity,without%20pausing%20for%20a%20breath. 
18.Okwuosa, T.DO, Morgans, A, Rhee,J., Reding, K. Maliski, S., Plana, J., Volgman, Moseley, K.,MD, Porter, C., Ismail-Khan,R., Impact of Hormonal Therapies for Treatment of Hormone-Dependent Cancers (Breast and Prostate) on the Cardiovascular System: Effects and Modifications: A Scientific Statement From the American Heart Association Circulation: Genomic and Precision Medicine, Vol14, Issue 3, June 2021 
19..Zhu, X., Wu, S. Risks and management of hypertension in cancer patients undergoing targeted therapy: a review. Clin Hypertens 28, 14 (2022). https://doi.org/10.1186/s40885-022-00197-3.
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