Dr Sinead Clarke and Dr Nicola Harker provide top tips on mitigating the impact of cancer treatment on cardiovascular health

Dr Sinead Clarke

Dr Sinead Clarke

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Read this article to learn more about:

  • best practice on limiting the effects of cancer treatments on cardiovascular health
  • using Read Codes to document a patient’s cancer treatments and cardiac risks
  • monitoring, lifestyle advice, and when to review.

In the UK, it is estimated that 2.5 million people have been diagnosed with cancer and this number is projected to grow to over 4 million by 2030.1 Improvements in cancer treatment and earlier diagnosis have contributed to increased survival. Unfortunately, many cancer treatments carry an increased risk of cardiovascular disease (CVD). The risk of developing CVD is of particular importance in an ageing population of cancer survivors who may have co-morbidities that exacerbate this risk, and in adult survivors of childhood cancer treatment who may present with CVD symptoms at a relatively young age.2 This article draws on some resources developed by Macmillan3,4 and focuses on the role of primary care clinicians in recognising and managing a patient’s CVD risk before, during, and after treatment for cancer.

1. Know the role of primary care

Heart disease following cancer treatment may be the result of direct cardiovascular (CV) damage caused by the treatment or it may be due to the development of cancer treatment-related CV risk factors.

General practitioners and other healthcare professionals working in the community are in a good position to provide follow-up care for people affected by cancer. Practitioners can ensure CV risks are monitored (and preventative action is taken where appropriate) and that any CVD is diagnosed early so appropriate treatments can be initiated. It is worth remembering that many of the risk factors for developing cancer are the same as those for CVD.

Before cancer treatment

2. Provide advice on optimising heart health

Primary care teams, and their colleagues in secondary care, are well placed to offer advice to patients on how to optimise their heart health before, during, and after cancer treatment. Macmillan has produced a booklet, Heart health and cancer treatment, which patients and healthcare professionals can download or order for free.5 Macmillan has also published a booklet in partnership with other heart and oncology organisations, Managing heart health during and after cancer treatment—a quick guide for primary care health professionals,3 as well as a one-page sheet that provides top tips for primary care professionals on heart health in cancer.4

3. Treat CVD risk factors where possible

General practitioners should flag any CVD risk factors to the oncology team at the point of referral or as early as possible after diagnosis (see Box 1). This information will help the oncologists to decide whether specialist cardiology input is required. In some cases particular agents (such as angiotensin-converting enzyme [ACE] inhibitors) can play a role in reducing the risk of cardiac side-effects. In addition, GPs and practice nurses have an important role in optimising blood pressure, blood sugar management in people with diabetes (or dietary advice in people with prediabetes), and appropriate management of dyslipidaemia.

Box 1: Cardiovascular disease risk factors to highlight to secondary care at point of referral3

Demographic and lifestyle: age, family history of premature CVD, ethnicity, stress, social deprivation, smoking, inactivity, obesity, diet, alcohol

Co-morbidities: previous CVD, heart failure, previous MI, stable angina, significant valvular heart disease, left ventricular hypertrophy, peripheral vascular disease, chronic kidney disease, hypertension, diabetes, dyslipidaemia.

CVD=cardiovascular disease; MI=myocardial infarction 

During hospital-based or hormonal treatment

4. Investigate any CV symptoms

Practitioners must be alert to possible CV symptoms in all patients treated for cancer and particularly in those treated with cardiotoxic therapies. High-risk patients are vulnerable to other long-term vascular disease, heart failure, and arrhythmias as well as ischaemic heart disease. It is very important to assess and further investigate any cardiac symptoms that occur during chemotherapy, however mild they are and irrespective of previous cardiac history.3 Practitioners working in hospitals can help by clearly stating the cardiotoxic risks of treatment in the discharge letter/treatment summary. See Box 2 for a list of cardiotoxic cancer treatments.

Box 2: Cardiotoxic cancer treatments3

Anthracyclines

  • Doxorubicin (used to treat a wide range of cancers)
  • Epirubicin (commonly used to treat breast cancer, oesophageal cancer, lymphoma) 

Targeted cancer therapies

  • Trastuzumab (commonly used for breast and stomach cancer)
  • Bevacizumab (used now mainly for cervical and ovarian cancer, used in the past for colorectal, breast, and some other cancers)
  • Imatinib (used mainly for CML and GIST)

Hormonal therapies

  • Anti-oestrogens (e.g. tamoxifen for breast and endometrial cancer)
  • Anti-androgens (e.g. goserelin for prostate and breast cancer)
  • Surgical orchidectomy (for prostate cancer)

Radiotherapy involving the heart

  • Left breast or mediastinal. Note some modern radiotherapy uses a ‘heart-sparing’ technique which is less cardiotoxic than older methods.

CML=chronic myelogenous leukaemia; GIST=gastrointestinal stromal tumours

5. Record Read Codes

It is important that GPs clearly record the relevant Read Codes (see Table 1) for cancer treatments and cardiac risks in their notes so that other clinicians have a full clinical picture during treatment and post treatment.

Table 1: Read Codes3

 Systm OneAll other systems

Radiotherapy

Xa8S1

7M371

Chemotherapy

X71bL

8BAD

Coronary heart disease risk

XaFxA

388A

At risk of heart disease

XaFs8

1407

High risk of heart disease

14070

14070

6. Monitor and manage CVD risks

Some cancer treatments last for a number of years and it is therefore important to continue to review CVD risk throughout long-term treatment. It is good practice to perform reviews annually while treatment is ongoing. Monitor and manage (as appropriate) the patient’s:3

  • weight
  • blood pressure
  • diabetes status
  • cholesterol profile (if receiving hormonal cancer therapy).

Any risks to future heart health should be fully discussed with the patient, especially in women who are planning a pregnancy.3

After cancer treatment

7. Include a CVD risk assessment in the cancer care review

Performing a comprehensive review at 6 months post-diagnosis gives a good opportunity to ask about treatment-related problems including the physical and psychological effects of treatment, and financial implications. This can be carried out by the GP or practice nurse. It is good practice to continue annual cancer care reviews, as is done for other areas of chronic disease management. The cancer care review appointment can be used to discuss the treatment the patient has had and any long-term CVD risks.

Remember that in older people there is a higher short-term risk of CVD, but in people who receive cardiotoxic anti-cancer treatment in childhood, adolescence, or as young adults, there is a significant lifelong risk of CVD.

8. Highlight the importance of a healthy lifestyle

A healthy lifestyle should be recommended to all patients treated for cancer. In particular, discuss the physical and psychological benefits of exercise and explain that exercise will help reduce the risk of developing CVD and other long-term conditions, and reduce the risk of metastases and recurrence.6,7 Macmillan has produced several resources for patients to support increasing physical activity.8,9

9. Refer patients to cardiology where necessary

Practitioners should closely monitor women during pregnancy and women who are planning to become pregnant. If a woman has had potentially cardiotoxic treatments for cancer she should be referred to a cardiologist for specialist advice. It is also important to consider referral to a cardiologist for anyone wanting to participate in a very high level of exercise, for example, a marathon.3

Box 3: When to refer to cardiology3

Patients who should be referred to cardiology include:

  • those who develop abnormal cardiac function or CV symptoms during or after treatment
  • those with any new cardiac abnormality in symptomatic patients with established CVD
  • women who were treated with cardiotoxic chemotherapy or radiotherapy and are pregnant or planning to become pregnant
  • those who have been treated with cardiotoxic chemotherapy or radiotherapy who wish to compete at a high level of exercise.

10. Consider cardiac surveillance

For some patients, regular cardiac surveillance (e.g. echocardiogram, brain natriuretic peptide) is likely to be beneficial but there is not enough evidence yet to recommend a specific surveillance and monitoring regime. GPs could consider contacting their local cardiologist for further advice.

Conclusion

People are living longer with cancer and while this is something to be celebrated it also means the long-term effects from cancer treatments can be more problematic. Certain cancer treatments are cardiotoxic and require long-term monitoring and advice; most cancer patients are at increased risk of CVD due to shared risk factors and treatments. Primary care is very well placed to empower patients to decrease their CVD risk factors and to monitor and pick up any CVD symptoms early. As with all long-term effects from cancer and its treatment, further education, training, and resources are needed in primary care to increase knowledge and awareness of these important issues.

Dr Sinead Clarke

Macmillan GP Adviser

Dr Nicola Harker

Macmillan GP Adviser

References 

  1. Maddams J, Utley M, Møller H. Projections of cancer prevalence in the UK 2010–2040. Br J Cancer 2012; 107 (7): 1195–1202.
  2. Scottish Intercollegiate Guidelines Network (SIGN). Long term follow up of survivors of childhood cancer. SIGN 132. Edinburgh: SIGN, 2013. Available at: www.sign.ac.uk/assets/sign132.pdf
  3. Levitt G, Lyon A, Burton C et al. Managing heart health during and after cancer treatment—a quick guide for primary care health professionals. Macmillan Cancer Support, 2015. Available at: www.macmillan.org.uk/documents/aboutus/health_professionals/consequencesoftreatment/hearthealthguide.pdf
  4. Macmillan Cancer Support. Tips for managing heart health during and after cancer treatment. Macmillan Cancer Support, 2015. Available at: www.macmillan.org.uk/_images/managing-heart-health-quick-tips-guide_tcm9-297838.pdf
  5. Macmillan Cancer Support. Heart health and cancer treatment. Macmillan Cancer Support, 2015. Available at: be.macmillan.org.uk/be/p-22060-heart-health-and-cancer-treatment.aspx
  6. Stevinson C, Campbell A, Cavill N, Foster J. Physical activity and cancer—a concise evidence review. Macmillan Cancer Support, 2017. Available at: www.macmillan.org.uk/_images/the-importance-physical-activity-for-people-living-with-and-beyond-cancer_tcm9-290123.pdf
  7. National Cancer Institute website. Physical activity and cancer. www.cancer.gov/about-cancer/causes-prevention/risk/obesity/physical-activity-fact-sheet (accessed 11 June 2018).
  8. Macmillan Cancer Support. Maintaining a healthy lifestyle—keeping active. www.macmillan.org.uk/information-and-support/coping/maintaining-a-healthy-lifestyle/keeping-active/index.html (accessed 12 June 2018).
  9. Macmillan Cancer Support. Physical activity.www.macmillan.org.uk/about-us/health-professionals/programmes-and-services/physical-activity.html (accessed 12 June 2018).