Cardio-Oncology is a relatively new sub-specialty of cardiology that focuses on detecting, monitoring, and treating cardiovascular disease which can sometimes arise as a side effect of certain cancer treatments. Dana Shannon is a board-certified Adult Nurse Practitioner in the Rochester community who specializes in Cardio-Oncology. She monitors and treats cancer survivors to prevent and mitigate the after-effects of treatment on the heart, and kindly agreed to answer some questions on this topic for our community.

Question: What led you to pursue the field of Cardio-Oncology?

DS: Prior to working in Cardio-Oncology, I worked with the Advanced Heart Failure team as a Nurse Practitioner in the LVAD (left ventricular assist device) program. During that time, I had a patient that had developed chemotherapy-induced cardiomyopathy. I was interested in how and why this happens and what could have been done to protect her from this occurring.

Question: What medications to treat breast and/or gynecologic cancer are most likely to affect cardiac function?

DS: The anthracyclines such as Doxorubicin (Adriamycin), Daunorubicin, Idarubicin, and Epirubicin. With anthracycline chemotherapy, the risk of cardio-toxicity increases with higher cumulative doses.

HER2 (human epidermal growth factor 2) targeted agents such as Trastuzumab (Herceptin), Kadcyla and Enhertu. Trastuzumab related cardiotoxicity does not appear to be related to cumulative dose. It is often reversible with treatment discontinuation and medical therapy.

Left breast radiation therapy (RT) increases the risk for development of coronary artery disease and heart valve dysfunction. The risk factors for the development of RT-induced cardiac toxicity have been identified, including the total radiation dose, the dose per fraction, the volume of heart irradiated, and the concomitant administration of cardiotoxic systemic agents (for example, anthracyclines and/or trastuzumab). Patient-related factors that may increase the risk of radiation-induced cardiotoxicity include younger age at the time of treatment and the presence of other risk factors for coronary heart disease such as hypertension or smoking.

Question: How commonly do cardiovascular effects occur in people undergoing these treatments?

DS: This is dependent on cardiac risk factors, cumulative dose of an anthracycline chemotherapy, and if patients have received both an anthracycline and a HER2 targeted treatment.

Question: Should people preparing to undergo therapies associated with increased cardiovascular risk be prescreened before beginning their treatment?

DS: Yes, they should. Ideally, they would undergo a baseline echocardiogram for left ventricular function assessment and evaluation for cardiac risk factors.

Cardiac risk factors include age (with those over 65 at greatest risk), obesity, diabetes, hypertension, elevated cholesterol, past or present smoking, and pre-existing cardiac dysfunction.

Question: What sort of surveillance is optimal for those undergoing treatments associated with increased cardiovascular risk?

DS: For those undergoing HER2 targeted treatments, we recommend a baseline echocardiogram prior to starting treatment and then every three months while receiving treatment. We then like to check them with an echocardiogram six to nine months after completion of treatment.

With anthracyclines, echocardiogram monitoring will depend on risk factors and if there is pre-existing cardiac disease. Patients should have a baseline echo prior to starting treatment and if they develop any signs of changes in heart function.

Question: Are there signs that might alert care providers to the presence of cardiotoxicity?

DS: There may not be any signs, particularly in patients who have cardiotoxicity from HER2 targeted treatment. This is why the echocardiogram every three months is important so that any changes in heart function can be caught early.

Signs of cardiac dysfunction include increased fatigue, shortness of breath, exercise intolerance, palpitations and chest pain. Some of these symptoms may be related to other factors, but it is important to make your provider aware of any symptoms so that cardiac reasons can be ruled out.

Question: What pre-existing conditions might predispose some people to cardiovascular complications?

DS: Coronary artery disease, cardiomyopathy, and hypertension.

Question: Do lifestyle interventions such as diet and/or exercise make a difference in preventing or minimizing the cardiovascular effects of treatment?

DS: Studies have demonstrated that interventions targeting weight, diet, and physical activity can improve quality of life, and may minimize disease and treatment-related side effects for cancer survivors.

Exercise is associated with improved survival and patient reported outcomes in most cancer survivors, and it is safe to perform in both the adjuvant* and post-treatment settings.

Question: What is your approach with those whose treatment has impacted their cardiac health? How likely are their symptoms to resolve?

DS: I think that it is important to educate patients about their cardiac health while they are undergoing treatment and following treatment as well. There are risk factors that can be reduced to decrease the risk of developing cardiac disease. I believe it is important for patients receiving potentially cardio-toxic treatments to be monitored routinely. You have fought to beat cancer, you don’t want your heart to be another diagnosis that you have to deal with, especially when there are things that we can do to mitigate that risk.

Thank you, Dana Shannon, for the vital and kind-hearted work you do to care for cancer survivors.

* Additional cancer treatment given after the primary treatment (e.g., surgery) to lower the risk that the cancer will come back