Ted Rogers Cardiotoxicity Prevention Program

This program aims to reduce the burden of cardiovascular disease in patients with such diseases as cancer, diabetes, arthritis and inflammatory bowel disease. A unique and diverse team of specialists are performing state-of-the-art clinical care, impactful research, and unparalleled education of patients, medical professionals and future health care leaders.

See: ‘Protecting the hearts of cancer survivors’

It is the world’s first program that focuses on managing cardiotoxicity from any systemic therapies, uniquely situated to leverage the cardiovascular expertise, databases, imaging and patient groups available at University Health Network.

The issue

Diseases such as cancer, arthritis, inflammatory bowel disease, and diabetes are common causes of morbidity and mortality. While improved treatments mean that patients are living longer, some drugs can cause direct toxicity to the cardiovascular system, either during treatment or years down the road. This can lead to circumstances even more serious than the initial diseases posed.

Cardiotoxicity is an ideal model to study heart disease and cardiomyopathy, as there is usually a clear starting point – the beginning of therapy. It is a huge opportunity to study risk factors, prevention strategies, surveillance methods and consequences of cardiotoxicity – with a range of experts working to achieve prolonged survival of patients with systemic disease by reducing cardiovascular morbidity and mortality.

Clinical care

Ambulatory patients are referred to this program to assess and manage their cardiovascular risk, existing cardiac disease during cancer treatment, and cardiac events that occur in the context of other diseases – as well as treat and manage acute or chronic cardiotoxicity. One key aspect is using advanced echocardiographic imaging, which can detect early signs of heart failure, and which will uncover new biomarkers in patient groups with conditions like diabetes.

The program’s ultimate goal is to integrate clinical care with cardiologists and other specialists in oncology, endocrinology, rheumatology, and gastroenterology. The Ted Rogers Centre care team extends to an advanced care nurse practitioner and an exercise physiologist for additional patient support. In all this, educating patients will be paramount in preventing and managing cardiotoxicity.

Research

Our cardiotoxicity research program is focused on (1) development of a large cardiotoxicity database, (2) performance of prospective and retrospective clinical studies, and (3) collaboration with basic scientists to embark on mechanistic work.

Many important answers require work with large databases, and this program is uniquely positioned to generate them through existing infrastructure at UHN and the University of Toronto’s Cardiovascular Data Management Centre.

The Centre will engage first in retrospective studies using data from our local program, in collaboration with subspecialties like oncology and rheumatology, whose results will be used to plan prospective studies focused on detection, prevention and treatment. Finally, multicenter, randomized controlled studies will be a key to answering important clinical questions about cardiotoxicity. Along the way, biological samples from patients will be used to establish a biobank to inform future studies on novel biomarkers and genetic predisposition.

Education

The field of cardiovascular toxicity is emerging. Significant experience and training is needed to understand where cardiotoxicity is originating and how to manage these patients over the long term. This program will include focused training for the next generation of specialists and physicians.

To that end, the Centre has established a world-class fellowship training program in heart failure with a focus on cardiotoxicity. For cardiology residents, this program provides exposure to focused cardiac issues related to cardiotoxicity of systemic therapy for the first time ever. It will also offer education and training to oncology and other specialty residents, internal medicine residents and cardiologists/internists (through CME).

Educational resources

These web pages are intended to be an educational resource for clinicians, as well as a resource for cancer patients.

Health-care professionals: discover more about echocardiography and new imaging techniques such as strain (learning activity included).

Patients and families: learn more about the role of cardio-oncology during your cancer treatment below

What Cardio-Oncology Means for Patients: Understanding Heart Failure and Cancer Therapy

Our Cardio-Oncology Program is based out of the Toronto General Hospital, an affiliate of University Health Network. It is designed specifically for cancer patients who are at risk of, or are already experiencing, cardiotoxicity from their chemotherapy or other forms of cancer treatment.

A NEW SPECIALTY WITHIN CARDIOLOGY

Cardio-oncologists are cardiologists who assess cancer patients prior to starting their treatment, monitor patients’ symptoms and heart function during their cancer therapy, and provide long-term follow-up after cancer treatment is completed. Patients who are referred to a cardio-oncologist will be those whose cancer treatment has the risk to harm the heart.

As cancer therapies become more successful, more patients are surviving and living longer. This improvement in survival is sometimes compromised by the occurrence of cardiac complications during and after cancer treatment. This effect is called cardiotoxicity.

HOW TO GET INVOLVED

People are generally referred to this program by their oncologist or hematologist. An initial consult is planned as soon as possible with cardiologist who specializes in cardio-oncology. Echocardiograms (heart ultrasounds) are also scheduled – before, during, and at the end of cancer treatment.

BREAST CANCER: AN EXAMPLE

Cancer treatment depends on the type and stage of the specific cancer that is diagnosed.

For breast cancer, for example, interventions typically include surgery, chemotherapy, radiation and hormonal therapy. About one in five people will have a specific type of tumor called HER2-positive breast cancer, which carry high levels of a protein called human epidermal growth factor 2 (HER2). Medications are then used to target HER2, most commonly Herceptin (trastuzumab).

As a standard of care, women with HER2-positive breast cancer have their heart function assessed every three months during treatment with HER2 targeted therapy. This is due to its cardiotoxic nature.

Chemotherapy and Heart Failure

Heart failure is a disease marked by a heart that is failing to function correctly. A damaged heart is unable to deliver blood to all the tissues and organs in the body. It can also cause blood to back up in the blood vessels and eventually leak into the lungs, legs, and abdomen.

Prominent symptoms of heart failure include shortness of breath, fatigue with normal physical activity, and swelling in your legs. Such symptoms can have other causes, however, including cancer and side effects from its treatment – which is why it’s important to keep monitoring your heart throughout your cancer treatment, to see if symptoms are growing worse. Echocardiograms enable physicians to measure the “ejection fraction” to determine how your heart is functioning.

Heart failure is a serious disease that can be irreversible if undetected or untreated – and can complicate your cancer treatment. Yet, many therapies are effective in improving heart failure and its symptoms – so long as it is identified early, before symptoms get worse. Many people recover their normal heart function by listening to their healthcare provider’s recommendations and taking their daily medications.

SYMPTOMS OF HEART FAILURE INCLUDE:

  • Shortness of breath
  • Fatigue and weakness after regular physical activity
  • Difficulty breathing while lying flat
  • Waking up at night due to difficulty breathing
  • Swelling in feet, ankles and legs
  • Chest pain or discomfort
  • Palpitations (racing, pounding irregular heartbeat that is uncomfortable)

RISK FACTORS FOR HEART FAILURE INCLUDE:

  • Smoking
  • Lack of regular exercise
  • High cholesterol
  • High blood pressure
  • Stress
  • Diabetes
  • Regular use of alcohol or drugs
  • Obesity
  • Underlying heart disease

… and undergoing certain cancer treatments. Chemotherapy is very effective at destroying cancer cells. This also means it can damage healthy cells, including those in the heart. We know that certain cancer treatments can be toxic to the heart and cause heart failure:

Anthracyclines

  • Daunorubicin
  • Doxorubicin
  • Epirubicin
  • Idarubicin
  • Mitoxantrone

Biological agents (HER2-targeted therapies)

  • Trastuzumab (Herceptin)
  • PertuzumabT-DM1
  • Lapatinib

Antimicrotubule agents

  • Paclitaxel (Taxol)
  • Docetaxel

TESTS TO MEASURE HEART FUNCTION

Echocardiogram: Using sound waves to assess the condition and function of the heart chambers and heart valves. Left ventricular ejection fraction (LVEF) is a numerical measurement that tells us how well your heart is pumping. Global longitudinal strain (GLS) can detect early signs of cardiotoxicity.

Electrocardiogram (ECG/EKG): Measuring the heart’s electrical activity to see how it is functioning. It records the heart rate and rhythm and can detect damage to the heart.

Cardiac MRI: Taking detailed images of the heart using magnetic waves, a non-invasive and painless procedure that does not include radiation.  

Blood tests: One measures brain natriuretic peptide (BNP), a protein hormone that is produced and released by the heart ventricles when there is too much volume and pressure. It is used as a “biomarker” to reveal how well the heart is pumping. Another measures troponin, proteins that regulate how well the heart contracts. If heart muscle cells are damaged, troponin is released into the bloodstream.

MEDICATIONS FOR HEART FAILURE

Heart medications must be taken daily until otherwise recommended by your physician – even if you begin to feel better. If not, the heart function may decrease and symptoms can get worse. Following a schedule can help ensure you take medications about the same time each day.

It is important to monitor for symptoms of low blood pressure: dizziness, lightheadedness and fatigue. Contact your doctor if any unpleasant side effects are experienced. And monitor blood pressure and heart rate frequently.

Medications include:

ACE inhibitors

  • Prevents body from creating angiotensin II, which causes the blood vessels to narrow
  • Relaxes blood vessels and decreases blood pressure
  • Potential side effects: cough, dizziness, decrease blood pressure, headache

Angiotensin II receptor blockers

  • Similar to above, helps block the action of angiotensin II

Beta-blockers

  • Blocks epinephrine and norepinephrine – hormones that cause the heart to work harder, increase blood pressure and heart rate
  • Helps to lower blood pressure and heart rate, while improving heart function
  • Potential side effects: dizziness, fatigue, headache, slow heart rate, low blood pressure.
  • Can worsen symptoms of chronic obstructive pulmonary disease (COPD) or other lung conditions

Diuretics

  • Works in the kidneys to increase your body’s rate of eliminating fluid and salt
  • Reduces amount of fluid in your blood
  • Decreases blood pressure
  • Potential side effects: low blood pressure, increased urination, increased blood sugar, leg cramping

TIPS TO PROTECT HEART AFTER CANCER THERAPY

There are many steps you can take to stay healthy and decrease the risk of heart damage after cancer therapies.

  • Follow up with your doctor: It’s critical to get routine, scheduled checkups on an ongoing basis, to ensure the cancer has not returned and your heart is functioning well.
  • Stay physically active: Exercise reduces the risk of heart disease – find physical activity that is enjoyable to you. Getting at least 30 minutes of exercise most days a week can help you achieve the target of 150 minutes per week of moderately intense exercise.
  • Eat well: Nutritious food lowers the risk of cancer, heart disease, and a host of other health problems. Up your intake of vegetables and fruits, reduce foods high in salt and saturated fat, and see if you can follow diets close to the Mediterranean and DASH approaches.
  • Smoking cessation: Quitting smoking is very important to achieving quality outcomes.
  • Manage stress: A cancer diagnosis and treatment is extremely stressful, not to mention other stressors in life. Do your best to manage stress via support groups, talking with family, friends and your doctor, and finding activities that you know reduce your own stress levels.
  • Sleep well: Not necessarily in our full control, but healthy sleeping habits are important for your heart health and overall well-being. Search for ways to improve your sleep if it is a problem.
  • Listen to your body: If you are worried about any symptoms, do not hesitate to call your doctor.

BE AN ACTIVE MEMBER OF YOUR OWN CARE TEAM

  • Learn about your condition: Ask questions if anything to do with your condition or treatment is unclear. The more you know, the better you can manage it.
  • Work with your healthcare team: Engaging in your care can help you feel more in control, and working with them helps them devise a treatment plan best suited for you.
  • Keep track of all your appointments: You will have regular appointments to monitor your health. These are usually time sensitive and are booked to monitor for side effects from your cancer treatment.
  • Follow your treatment plan: This will help your team determine if the treatment is working or if it needs to be adjusted.
  • Take medications as directed: Get to know why you are taking each pill, and don’t skip, stop or alter doses. Keep a list of all medications (including over-the-counter) you are taking.