Cancer treatment and cardiac complications
Unlike other diseases , people afflicted with malignant diseases are kept aside from the purview of doctors dealing with other specialities. Whatever they suffer from is taken as part of the cancer disease itself. Even if they are referred back to the general doctors, they are attended to the symptomatic treatment only waiting for the end of the chapter.
Recently one patient who was on treatment for prostatic cancer for about two years developed severe cardiac failure with left ventricular ejection fraction around 30 percent with global hypokinesia of left ventricle. Though he underwent angioplasty and other medical treatment he did not show much improvement. His family members in the meanwhile took him to a nearby cancer centre for the follow of up cancer therapy for prostate. This time a new oncologist reviewed him and found that his PSA score has gone more 200 units despite the treatment. He had told the relatives that the cancer medicine is not effective at all and that the cancer drug itself may be the reason for his recent cardiovascular events. In his opinion instead of going for higher level of treatment which apart from being prohibitively costly, would be very deleterious to his general condition. More than increasing the cardiac complications, its propensity to precipitate seizure and renal damage also should be taken into account. The family members agreed to stop all cancer drugs for the time being and to their relief they started noticing improvement in his general condition.
This incident really made me ponder over the conditions of many cancer patients whom I have come into contact during my career. Most of them after completing their cancer treatment or during the course of the treatment seek medical care for cardiovascular complications with or without respiratory distress. Some may be in the advanced stage of renal failure. One point to be taken note is that most of them are of fairly young age group, say before their sixties. Recently I had two ladies one in her late forties and the other is around 55 years of age. Both were treated for carcinoma of breast and underwent surgical, chemotherapy and radiation treatment. Both suffer from coronary artery disease and in severe heart failure. In carcinoma breast treatment apart from chemotherapy, they get radiation also which by itself can damage coronary arteries and myocardium.

I give below a few important points which I gathered from a few articles:
https://www.sciencedirect.com/science/a … 6616302809
https://www.cancer.gov/news-events/canc … de-effects
. A number of targeted therapies against cancer have been observed to cause cardiac dysfunction. In some instances, a patient may outlive his or her cancer but die due to heart failure.
Cardiotoxicity is a frequent consequence of cancer chemotherapy. The term cardiotoxicity includes direct effects on the myocardium, myocardial ischemia, arrhythmias, thromboembolisms, inflammation of the myocardium (myocarditis), and pericardium (pericarditis) as well as alterations in hemodynamic parameters such as hypertension, acute coronary syndrome, and coronary vasospasms. These effects can manifest acutely during treatment or occur many years after treatment as a result of undiagnosed or subclinical cardiovascular dysfunction.
Outside of major cancer treatment centers, the underlying cardiac dysfunction is not often recognized until much later, owing to the fact that common signs of heart failure, including fatigue, dyspnea and even cachexia, are commonly present in the cancer patient. New drugs may also not carry adequate warnings that would aid the oncologist in recognizing symptoms.
Cardiotoxicity is often not wholly predicted by preclinical and clinical trials. This is primarily because patients with existing cardiovascular disease, or those with risk factors such as hypertension or coronary artery disease, are often excluded from early trials. Additionally, routine cardiac monitoring and identification of cardiovascular endpoints are rarely part of the trial protocol.
A recent study showed that a small percentage of patients who receive immunotherapy drugs called immune checkpoint inhibitor develop inflammation of the heart muscle known as myocarditis. In this study, about half of the patients who developed severe myocarditis died of it.
Another example is a woman who developed heart disease related to treatments for multiple cancers that led to emergency triple-bypass surgery. She died at age 47.
“We cannot cure patients of one cancer, only to have them develop a second cancer and treatment-related cardiac problems that result in a triple bypass” before age 50, Dr. Dent commented.

Over the past decade, breast cancer has been a focus of research on cardiac side effects, in part because certain treatments for the disease are known to cause these side effects.
Based on this evidence, the American Heart Association recently issued a rare scientific statement on cardiovascular disease and breast cancer. For some breast cancer survivors—older individuals in particular—the risk of dying from cardiovascular disease may exceed the risk of dying from cancer, the authors of the statement noted
“The reality is we’ve made a huge amount of progress in treating breast cancer, and today women diagnosed with early-stage breast cancer are more likely to die of cardiac disease than of cancer,”
Although some breast cancer treatments, such as HER2-targeted therapies, doxorubicin, and radiation therapy, are known to cause cardiac side effects, other factors can affect a patient’s cardiovascular health as well, Dr. Hershman pointed out.
“A big part of the problem is that cardiac and vascular risk factors are not always well managed in patients with cancer,” she explained. “When a woman is diagnosed with breast cancer, her adherence to treatments for other health conditions often goes down, such as the management of cholesterol or keeping diabetes under control.”

https://ascopubs.org/doi/10.1200/JCO.2016.71.4204
Prostate cancer (PCa) is the second most commonly diagnosed malignancy in men and affects more than 1.1 million people worldwide.1 Androgen-deprivation therapy (ADT) by medical castration (ie, gonadotropin-releasing hormone agonist [GnRHa]) therapy or surgical castration (ie, bilateral orchiectomy) is the mainstay of treatment for locally advanced or metastatic PCa.2 Both strategies induce hypogonadism to achieve castration levels of testosterone.
Emerging evidence suggests that ADT for PCa is linked to important adverse effects, including the cardiovascular (CV) ischemic events of acute myocardial infarction (MI) and ischemic stroke (IS), as well as diabetes.4-6 Existing evidence is insufficient to determine which type of ADT (bilateral orchiectomy or GnRHa) is associated with higher incidence of long-term adverse events. Analysis of data from the SEER database of cancer registries suggests that the risk of cardiac-related complications is greater for GnRHa than for orchiectomy in patients with metastatic PCa.7 Conversely, another study found that the risk of CV thrombotic events was greater for surgical castration than for GnRHa in Chinese patients with PCa
By bringing forward the other side view of cancer therapy my only aim is to request to bear in the mind that treatment of one condition need not drive the patient to a worse state. All cancers don’t behave alike in individuals. In some they are very aggressive and end may come within a few days’ time and in some other they lie dormant for a long time. We should think twice before we embark on interfering with the natural course of cancer biology.

UA Mohammed