A patient with metastatic cancer writes what it has been like to face the dilemma of receiving an effective cancer therapy that may put her heart at risk.
I’m not going to do the math, but I’ve been receiving treatment for metastatic breast cancer since January 2015, which includes an echocardiogram every three months. My cancer center and oncologist are so careful about those every-three-month echocardiograms that my treatment would be postponed if I were to miss one.
There’s a reason that echoes are a requirement for my ongoing treatment: Herceptin (trastuzumab) has been shown to cause damage that affects the ability of the heart to pump effectively. Heart damage is a known potential side effect of newer treatments, like Herceptin, and older, more traditional chemotherapies.
About two years ago, I joined a study at my cancer center looking at the usefulness of heart medications for people receiving Herceptin. I was assigned to the non-intervention group, which means I was in the study, but I was not going to receive any additional medications. At the time, with five years of Herceptin under my belt, I felt confident that my heart was handling my every-three-week IV infusions relatively well. There were the fluctuations that always seem to come with medical tests, whether due to me, the drug, the technician, or the tool, but I had never had treatment delayed because what was being measured (left ventricular ejection fraction) always remained above the pre-determined level.
Then came last month. My cancer scans showed I was still having a great response to Herceptin and Perjeta (pertuzumab) but the echo had my oncologist concerned. The questions asked during my appointment reinforced that concern — did I ever feel faint, did my heart feel like it was beating irregularly — but I hadn’t noticed anything different. Still, I was quickly referred to a cardiologist within the same hospital.
I’ll cut to the chase here and tell you that a subsequent test showed that my left ventricular ejection fraction remained adequate for continued treatment and that the global longitudinal strain had recovered and also indicated I could continue treatment with no changes.
I felt and feel reassured, but I have an extra appointment with my oncologist and another one scheduled with the cardiologist. I can’t guess what they will say, but I know what I want to discuss:
This relatively new field within cardiology is described by Mayo Clinic as, “Doctors trained in heart disease evaluate and treat people who have heart disease or who are at risk of heart disease before, during and after treatment for cancer.” As it turns out, according to the American Heart Association, older women (I’m not there yet but am gratefully heading in that direction) who’ve had breast cancer treatment appear to be at risk for long-term heart complications. Of course, this risk depends on the treatment received, overall health and more. My cancer center, though part of a university system with active research, doesn’t have a cardio-oncology specialty or department. To see a specialist, I’d most likely go to one of two NCI-designated cancer centers in my area; I’d have to pay out-of-pocket for this consultation because of my insurance.
Preventive use of heart medications is part of what the study I’m in is looking at. The cardiologist explained that I have other health considerations that mean I might not be the best person for such heart medications but that, if necessary, we could try them.
I know people who get Herceptin at intervals longer than every three weeks. Is this something that could help my heart and is it an acceptable treatment adjustment? The other drug I’m on for cancer also shows potential heart complications — is there anything we can do to alleviate that risk?
Practically speaking, getting regular treatment with cardiotoxic cancer drugs means that heart damage is a risk regardless of what I do. Still, I’d like to know what the oncologist and the cardiologist have to say. If the standard advice of eating well, exercising, and maintaining a healthy weight is all that can be suggested then I know I’m already doing what I can.
I am grateful that my oncologist is proactive and watchful. Living with ongoing cancer treatments is a minefield of potential dangers. I’ve known since that initial echo in 2015 that my heart was one of those spots where stepping carefully was an absolute must. If you’ve been tempted to ignore or downplay warning signs, consider talking to your doctors instead.
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