FRIDAY, April 18, 2013 — It was more than a decade ago that Stephanie Cirilo fought breast cancer — and won. Her treatment began in 2000, which included eight rounds of chemotherapy and 33 rounds of radiation. For Cirilo, now 57, that scary time feels like an eternity ago, just a mere blip in the screen of her life.

Since beating stage 2 breast cancer, Cirilo has been fortunate once again to enjoy feeling well, and she's remained hyper-vigilant about maintaining a healthy lifestyle and following up with her doctors.That is why, in 2009, during a routine visit to her family physician for allergies or a cold, Cirilo was confused when he ordered several tests for her heart. The confusion quickly turned to horror when her doctor informed her she needed emergency heart surgery to clear a severe blockage in her arteries and also have several stents put in to prevent an imminent heart attack. He insisted that Cirilo check into a hospital immediately. But even in the flurry of her anxious doctor's orders, Cirilo said she was skeptical. Her gut told her she was paying a price for the aggressive breast cancer treatments she'd received years ago.

"When I went through the chemo I knew the side effects," she said. "I knew the risks that could be happening way down the road." At the time, those risks were clearly laid out in a six-inch thick pamphlet provided to her by the oncology nurse just before she started the aggressive course of Adriamycin — the drug most commonly used to treat breast cancer. Cirilo said she was made aware that this particular chemotherapy drug could cause cardiotoxicity and mild or severe congestive heart failure. When a patient goes into cardiotoxic shock the damaged heart muscle weakens, which makes it less efficient at pumping blood.

After hearing her primary care doctor's diagnosis, Circilo immediately contacted her oncologist at the Cleveland Clinic Taussig Cancer Institute. He ordered her to come in for additional tests, including a cardiac catheterization, and he arranged for Cirilo to meet with a heart specialist at the hospital's Cardio-Oncology Center, one of 10 centers of its kind in the country that specializes in diagnosing and treating heart problems in cancer patients and survivors.

When Cirilo's tests came back, they revealed what she already knew. "It was not blockage. It was muscle damage directly related to the chemo," she said. "They probably would have put stents in me, and it wouldn't have been the issue, and I wouldn't be alive talking to you today."

Cirilo currently manages her heart disease by seeing the right doctors and using appropriate medications. She takes Carvedilol to prevent heart failure; Enalapril for high blood pressure; and Simvastatin for high cholesterol. "I take them everyday and they keep my little heart healthy," she said.

Preventing Cardiotoxicity

Though it's widely known among oncologists that certain types of chemotherapy, as well as radiation treatments, can vastly impact heart health, this is frequently not understood among cardiologists less familiar with these drugs. Only in the past decade or so have cancer treatment centers sat up, paid attention, and sought to address this problem that has become more prevalent as breast cancer survivorship also increases.

A study published in 2011, in the journal Breast Cancer Research, found that among 63,566 breast cancer patients, cardiovascular disease was the leading cause of death. Clinical research has also found that radiation exposure puts breast cancer patients at risk for developing serious heart problems later in life, most typically cardiac fibrosis, which is an abnormal thickening or scar tissue formation of the heart valves. A study published in the New England Journal of Medicine in March, found that the risk for heart complications increased by 7 percent per interval of radiation level. Additionally, women who received radiation treatment to the left breast — closest to the heart — had a higher risk for heart disease.

Eric Harrison, MD, medical director for cardiac advanced imaging at IASIS Healthcare Inc, a privately-owned company that operates community-focused hospitals in high-growth urban and suburban markets, is at the helm of these efforts. A few years ago, he formed a consortium of health centers throughout the country that is working together to improve cardio-oncology care.

"We’re people committed to trying to recognize early that a patient is having cardiotoxity from chemotherapy before there’s changes in the heart function," said Dr. Harrison, who is a practicing cardiologist in Tampa, Fla. "We don’t want the patient who is getting chemotherapy for her breast cancer to have a cardiotoxic reaction."

Thomas Budd, MD, Cirilo's oncologist at Cleveland Clinic, said that heart monitoring is a routine part of breast cancer treatment and management, and changes can sometimes be difficult to detect if they're not assessed by the right specialist. "It can happen slowly over time, the cardiac function deteriorates," he said. He added that if a breast cancer patient has a history of other heart disease risk factors, such as high blood pressure, they are monitored more closely. "What we're trying to do is to avoid compromising heart function."

Harrison said that if heart changes are detected while a patient is in treatment for breast cancer, there is usually some measure of intervention. Doctors may give their patient a chemotherapy "drug holiday," reduce the dose of chemotherapy, or prescribe medications for congestive heart failure, such as angiotensin-converting-enzymes (ACE inhibitors) or beta-blockers.

"To recognize it early, we have certain things we can do such as imaging and blood tests to test for biomarkers," explained Harrison. The tests include a more advanced echocardiogram, which is a type of sonogram that has become a standard test for diagnosing heart disease. The device uses sound waves to form an image of the heart, and allows doctors to see the beating patterns of the heart and monitor its valve functions. "These tests measure changes in the heart's form as it squeezes, and will tell us if there’s any area that is lagging which would be a subtle change," he said. Valve function damage is measured partially by detecting a slower heart beat, which impacts the ejection fraction, or volume of blood that's pumped out by the heart valves.

"You can't measure a drop in 5 percent with a regular echocardiogram," he said. "And you can't just go into any echocardio lab, you have to go to one that's supervised by a cardio-oncologist that would understand these limits and accuracy that's required for these tests."

But detecting heart damage in a breast cancer patient can be difficult since many of the symptoms of heart damage — shortness of breath on exertion, palpitations, coughing, and fatigue — are experienced by patients as a side effect of chemotherapy, explained Harrison. "It's hard to sort it out if you can't look for those symptoms. Harrison hopes breast cancer drugs in the future will be available that don't put heart health at risk, though he said he isn't aware of any that are in development. But until then doctors must understand these risks and treat even subtle changes.

Treating the Whole Patient — Not Just the Cancer

Nieca Goldberg, MD, clinical associate professor, Department of Medicine, Leon H. Charney Division of Cardiology and director of the Joan H. Tisch Center from Women’s Health at NYU Langone Medical Center, thinks that former breast cancer patients often remain fixated on the illness for years, even after they've been treated and recover. Some women may forget that they're also at risk for heart disease, which is the leading killer among women.

"Because more women survive cancer they also have risk for heart disease the way women who haven’t had breast cancer do," she said. Dr. Goldberg recommends that breast cancer patients and survivors take time to advocate for themselves and ensure that their heart function is properly monitored by a team of appropriate doctors and on a regular basis.

She also believes that while having a specific facility that specializes in cardio-oncology is helpful, ultimately patients simply need better coordination of care among their doctors. "We have to remember that when we take care of woman, whether she has breast cancer or heart disease, that we take care of the whole woman and the treatment in the context of all of her medical issues," she said.