Medical advances have led to increased cancer survival and larger numbers of people living cancer-free for many years after treatment. These life-saving treatments, while important for treating cancer, can sometimes cause problems in the heart and vascular (circulation) system - called cardiotoxicity.
The emergence of cardiovascular diseases in people affected by cancer has led to the development of a new field of modern medicine known as cardio-oncology.
In 2011, London’s Royal Brompton Hospital set up the UK’s first dedicated specialist cardio-oncology service. The mission of the service is to improve the cardiovascular health of people before, during and after cancer treatment. This reduces the risk of cancer patients developing heart problems after treatment.
The burden of cancer
Our consultant cardiologist, Dr Alexander Lyon, explains: “In simple terms, we’re trying to prevent the cancer patient of today becoming the cardiac patient of tomorrow. In the UK and internationally, we’ve seen a significant increase in the number of cancer patients with cardiovascular problems, particularly related to pre-existing heart problems becoming destabilised by their cancer treatment.”
In 2018, it was estimated there were 18 million cancer cases around the world, and of these, 9.5 million cases were in men and 8.5 million in women. In the UK, there were approximately 1,000 new cancer cases every day between 2015-2017 – higher than 90% of the rest of the world, with over half of cases being due to breast, bowel, lung or prostate cancer.
However, the success of modern cancer treatments means that more people now survive free of cancer, or with stable, non-progressive disease. Everyday lifestyle choices such as eating a healthy diet, being more active, not smoking and maintaining a healthy weight are important ways to help reduce cancer risk.
Who’s at risk of heart problems?
It is not known when an individual may have a heart attack due to blockage of a coronary artery (the blood vessels supplying oxygen to the heart). But it is known exactly when they will receive chemotherapy or radiotherapy that can put their heart at risk. This gives the doctor an opportunity to develop a strategy before a patient starts cancer treatment, to keep their heart safe.
Cancer treatment can cause the heart to pump less efficiently, cause changes in blood flow and/or increase the risk of blood clots that can cause a heart attack. The goal is not to block cancer treatment but to support it, by closely monitoring the heart to pick up the earliest changes.
“At Royal Brompton Hospital, we can provide a personalised plan to initiate heart protection medicine in people at highest risk before they start their cancer treatment. Alternatively, we can closely monitor their heart health and provide treatment when early signs of heart strain are detected and before they develop more serious heart problems”, explains Dr Lyon.
Breast cancer patients
The Royal Brompton cardio-oncology service looks after many people with abnormalities of heart function picked up on a standard screening for some common treatments. For example, Herceptin for HER2+ breast cancers, requires three to four monthly ultrasound scans of the heart as standard.
Through close monitoring, signals of cardiac strain can be picked up earlier – ensuring breast cancer patients can
continue their treatment safely.
Prostate cancer patients
Over the past 20 years, specialised treatment, known as androgen deprivation therapy (ADT), has allowed patients to live for many years with their prostate cancer controlled. However, the main ADT medications – three monthly injections – can accelerate coronary heart disease and other vascular disease by increasing the development of diabetes and raising cholesterol.
Childhood and young adult cancer survivors
At the Royal Brompton Hospital, the cardio-oncology team also provides care to adults who had cancer in earlier life — either as children or young adults in their 20s and 30s.
Many of these individuals required chemotherapy which is toxic to the heart and/or high doses of radiotherapy to their chest, which results in their heart receiving harmful radiation.
Assessing heart risk
Royal Brompton Hospital’s cardio-oncology service allows cancer patients to benefit from modern cancer treatment safely from a heart perspective and, after treatment, reduce the risk of developing future heart problems.
A heart risk assessment in newly diagnosed cancer patients with pre-existing cardiac conditions or concerns can ensure they are as fit as possible for their cancer treatment - whether that be surgery, chemotherapy and/or radiotherapy.
Dr Lyon, has led the development of a new framework for cardiovascular risk assessment in cancer patients and their surveillance during cancer treatment. The assessment of baseline cardiovascular risk is part of a personalised approach to care for cancer patients. The identification of cancer patients who are at an increased risk of cardiovascular complications in a timely manner is important so that appropriate measures can be implemented to eliminate or at least reduce their cardiovascular disease risk and ensure, where possible, that cancer patients receive their treatment safely.
The future of cardio-oncology
Since starting the service, our team continue to strive to maintain these very high standards and improve each patient’s experience further.
“Royal Brompton hospital has been collecting feedback from patients at the end of their initial visit and 99% of patients would recommend our cardio-oncology service to friends and family”, comments Dr Lyon.
Kreena Dhiman, a cardio-oncology patient, said: “I suffered acute heart failure in 2016, two years after completing treatment for breast cancer. I was incredibly unwell with an ejection fraction (the percentage of blood leaving the heart with each contraction) of 10 percent. My heart had enlarged and the left ventricle was failing to pump blood around my body. Dr Lyon treated my condition with medication to support my heart and bring the ejection fraction into normal range, which should be 55% or higher.”
Our cardio-oncology clinic cares for people who are either living with or have survived cancer, and have heart problems which may be related to their cancer treatment.
Supporting cancer treatment with expert cardiac function monitoring allows our expert team to pick up the earliest of changes. Generating a personalised assessment, and treatment plan can allow patients to benefit from a healthy heart after surviving their cancer. It can prevent a patient from developing more serious heart problems, particularly if they are at highest risk before commencing their cancer treatment.
To find out more about Royal Brompton Hospital’s cardio-oncology service, please contact us on +44 (0)20 3131 0535 or email firstname.lastname@example.org.
Dr Alexander Lyon is a consultant cardiologist at Royal Brompton Hospital in London. He is also president of the British Cardio-oncology Society, chair of the cardio-oncology study group of the Heart Failure Association of the European Society of Cardiology, and is the cardiology adviser to the charity, Macmillan Cancer Support.