Cardiotoxicity Remains a Concern as Breast Cancer Survival Rates Improve: Eric H. Yang, MD

A multitude of breast cancer treatments pose cardiovascular risks, and because patients are living longer, their lifetime risk may surpass that of the general population, highlighting the need for early, proactive management, Eric H. Yang, MD, of the University of California, Los Angeles, says in an interview with The American Journal of Managed Care^® at the San Antonio Breast Cancer Symposium.

Yang expanded on this topic yesterday in his presentation, "Approaches for Cardioprotection in Cancer Care," delivered during the educational session, "Optimizing Cardiac Outcomes in Breast Cancer—The Next Chapter."

This transcript has been lightly edited for clarity; captions were auto-generated.

Transcript

Which breast cancer therapies pose the greatest risk for cardiotoxicity, and what cardiovascular complications are most common?

A multitude of therapies, which have been obviously game changers for the breast cancer population over the past couple decades, both historical and new, have been associated with both short-term and long-term cardiovascular risks. Long-term effects, we still don't quite know that yet, but we know that definitely classical historical treatments, like anthracyclines or HER2 treatments, especially if combined with anthracyclines, pose a risk of cardiac dysfunction, which can lead to cardiomyopathy and, later down the line, heart failure.

There's a growing use of immune checkpoint inhibitors, which is a class of immunotherapy now, which is rising in the use of triple-negative breast cancer, which has been associated with a rare but potentially very serious complication known as myocarditis. Other drugs that have been used for maintenance or for advanced breast cancer, which are not necessarily first-line, but medications like capecitabine, as well as bevacizumab or Avastin (Genentech), have also been shown to have effects on blood pressure, causing chest pain, and, in some cases, also cardiomyopathy.

There are a variety of medications that we do believe affect both short- and long-term risk, but as these breast cancer patients live longer and longer, the bigger question is, "What's their lifetime risk of heart disease?" We think it may be higher than the normal population, and it's very important at a very early stage in their diagnosis to do our best to manage their cardiovascular risk factors.

How do you identify which patients are most vulnerable before starting therapy?

That's a very good question, and it's also, frankly, a very difficult question. Usually, we assume that patients going into treatment who already have a lot of cardiovascular risk factors, hypertension, coronary artery disease, or who already have abnormal heart function, as well as age, you probably portend, in general, a higher risk of some of the more historical treatments.

As for immunotherapy, this is still a very challenging arena, because we frankly do not know, long-term, who is at risk for this rare complication. That is something that is still being investigated, but overall, it is important to have a cardiovascular specialist, ideally, in these centers where breast cancer is being treated in the event that these cases occur, because in the midst of these issues, immediate, expeditious care and imaging are really paramount to make sure that patients can be optimized and, ideally, be put back on treatment for most situations if there should be a problem.

But as I said before, the long-term issues down the line 20/30 years as they age, because we know the 5- to 10-year survival rates in general are excellent. Who are the people we need to be watching closer about looking at heart failure and coronary artery disease risk? I'm one of the people who believe that cancer and certain medications do pose more downstream risks of atherosclerosis, heart failure, and arrhythmias. A lot of epidemiological studies are also starting to suggest that, too.