MD Anderson Cancer Center
Lisa Garvin: Welcome to Cancer Newsline, a podcast series from the University of Texas MD Anderson Cancer Center. Cancer Newsline helps you stay current with the news on cancer research, diagnosis, treatment, and prevention, providing the latest information on reducing your family's cancer risks. I'm your host, Lisa Garvin, and today our guest is Dr. Jean Bernard Durant, who is the director of the MD Anderson Heart Failure service here at the Cancer Center, and our subject today is basically the heart. I mean, here at MD Anderson, we see people with pre-existing conditions. We have people who are affected by their cancer treatment, but also we are treating non-cancer patients with heart problems. Welcome, Dr. Durant -
Dr. Jean Bernard Durant: Thank you for having me this morning. I'm delighted to be here.
Lisa Garvin: So let's talk about, I'm assuming the primary mission at least of your group would be to a., treat pre-existing conditions, correct. Let's talk about that first -
Dr. Jean Bernard Durant: Yes. Yes. So individuals who have pre-existing heart condition are much more susceptible to injury from chemotherapy, from radiation, from a number of different therapies that we use to treat their cancer. And what our goals and our responsibilities are to assure that patients safely can receive those therapies to go on to have a cure from their cancer.
Lisa Garvin: Now, how do you deal, and I would assume given the demographics of a lot of cancer patients, it's not unusual to see heart disease in a cancer patient.
Dr. Jean Bernard Durant: It is extraordinarily common to see that. One of the things we've learned over the last decade was that, is that the very same risk factors that one has for cancer are the very same risk factors that one also has for heart disease. So, unfortunately, what we see are individuals who two separate conditions exist within them, and that's, thus, where the challenge becomes in our management.
Lisa Garvin: Now, how do you manage a heart problem? I mean, I would assume in some cases you would have to get the heart to be strong enough for treatment or, how exactly do you handle heart issues along with cancer treatment?
Dr. Jean Bernard Durant: So that's a very good question. So number one are those individuals who have a pre-existing condition, and what our responsibilities are is to assure that they are in the correct medicines, that their heart is functioning well, that they are free of symptoms. Patient number two are, is the patient who is doing well, but, unfortunately, develops a toxicity, some sort of injury to the heart during the chemotherapy, and a greater growing part of our population are individuals who have successfully completed their treatment. They are free of their cancer, and now they're at risk of developing heart disease from their previous cancer treatment. So three separate groups that we see.
Lisa Garvin: Now, I, how do you handle, like, say if somebody comes in, and they've got severe blockage in, like, say, three out of their four arteries. I mean, in some cases, do you have to address the heart issue first before their cancer treatment, or how does that go?
Dr. Jean Bernard Durant: So that's a very good question. What we have learned is absolutely, as best as we can, we try to tackle those heart issues first, and one of the lessons we've learned here at MD Anderson because we see such a high number of patients with this is we learn that we would rather tackle and prevent things from happening than to have to face, for the patient to face that problem right in the middle of chemotherapy when they feel the worst. They have no energy. They're fatigued, and, unfortunately, that's when they are dealing with toxicity of the chemotherapy. Their blood counts may be low, and as a result, it is not a strategic time to attempt any kind of fixing of the arteries at that particular time.
Lisa Garvin: So do you do that beforehand?
Dr. Jean Bernard Durant: We do that beforehand. We assess them. We do, as most individuals do, or most practices, we do a complete and thorough history and physical. We pay a lot of attention to prior risk factors. Is there a family history of heart disease? Do they have high cholesterol? Do they have diabetes? Do they have uncontrol high blood pressure? All those things are taken into consideration prior to starting the therapy and a way to risk stratify, and know who are at high risk and who are the lower risk patients.
Lisa Garvin: Does this delay actual cancer treatment, and if it does, by how much?
Dr. Jean Bernard Durant: So another excellent question. The goal of this is to never delay. We work as a team, and that's probably one of the largest advantages that we have here at MD Anderson is this multi-disciplinary approach. And what that means is that there is constant communication with the patient, the cardiologist, and the oncologist, and the goal is that in working together we minimize toxicity and minimize any kind of injury to the patient's heart while allowing them to successfully complete their therapy. If there is a delay, there usually are minimum. We try to conduct all of our work within several days so that it doesn't interfere. So the goal is not so much that we try to work with them to have minimal interference and to enhance their experience and enhance the success of treatment of their cancer.
Lisa Garvin: But what about a patient who says, doc, I came here for cancer. Why are you treating my heart? I mean, do you get a lot of that?
Dr. Jean Bernard Durant: We do, but we see it less and less. Patients are so well educated now, and they understand the issues. By the time they come to us, they will tell us we know that this drug can make my heart muscle weaker. We know that this drug can make our blood pressure higher. So we see it less and less because they're so well educated.
Lisa Garvin: And are there people who have had previously undiagnosed heart disease who found out when they came to MD Anderson?
Dr. Jean Bernard Durant: There are, and that, I think we would all be surprised. That probably happens one-third of the time. Individuals who have no symptoms. They've never been diagnosed with heart disease, and because they have risk factors, we start to evaluate them, and we find that this problem exists. We identify this problem early. We treat them aggressively. Most of the time, we can do this with just medicines. It's a rarity that we have to actually go and do procedures on them, and the medicines do a wonderful job of being able to get them through their treatment.
Lisa Garvin: Now, say somebody who came in our example had previously undiagnosed heart disease. They have cancer. It would seem like psychologically that would be a double whammy because, you know, people who have had heart attacks are all of a sudden very, think they're very fragile and vulnerable. Same goes for a cancer patient. So how do they, how do patients handle that?
Dr. Jean Bernard Durant: It is very difficult. I can't think of two situations that is more difficult for a patient to be told you have cancer and along the way to be told that you have a heart problem. What we do is a lot of education with the patient and their family members. We forget that in addition to the patient's experience, there's the caregivers and the provider, the spouses and the children. So we educate them about what to expect. The things to look for. Why we start them on certain medicine. And as a lot of other things in life, once the patient is empowered with education, it's a lot easier for them to deal with this issue. So the key is education, education, education and knowledge because knowledge is power. That helps them to get through that. If they do have difficulty, we actually have a support group called Heart to Heart, and this is a support group that's offered through the wellness program and through our department, and spouses and children are involved in this as well, and we go through a very step-by-step process of the simplest types of therapy that requires medicine up to and including having to have, for example, bypass surgery prior to having their treatment. So we're there to support them as best as we can.
Lisa Garvin: And we are seeing a lot more targeted therapies that are honing in on cancer cells and ignoring the healthy cells. What strides have we made with making drugs that are less cardio toxic?
Dr. Jean Bernard Durant: We've made some good strides over the last decade. The strides that have been made has more, has been more in identification. The field in general, these targeted therapies, they're working more and more towards having less toxicity. When these targeted therapies were developed, they were developed with the idea that the example I can give you is a difference between a shotgun and a sniper. Prior to the 21st century, how we were treating cancer was using three, four, five different drugs. That's the level of a commitment it took in terms of drug therapy in order to kill cancer cells. There was a tremendous change in discovery that led to these targeted therapies. So instead of using a shotgun, you would the idea of a principle of a sniper. You would lose one bullet to kill the tumor as opposed to five different bullets. We still had collateral damage, and what we learned from that is many of the different chemicals that are produced for a cancer to grow are also the very same chemicals that are used in order for the heart to stay healthy, and this was purely an accidental discovery. So we have learned to try to get ahead of the curve by using medicines that do not interfere with the heart but still allow the cancer to be treated.
Lisa Garvin: What about other treatments? I don't, surgery probably would not have much of an effect on the heart unless it was thoracic perhaps, but are there side effects from radiation?
Dr. Jean Bernard Durant: There are, indeed. We have recognized more and more that there are, in fact, side effects from radiation. Radiation affects every structure in the heart. It affects the valves, it affects the blood flow, the coronary bed, it affects the electrical system, it affects the sac around the heart called the pericardium, and it affects the muscle. So all those five different areas of the heart can be affected by radiation. Radiation, what is interesting about it, it's not something you can see. It's a source of energy that it delivered to you. The high-risk patients are patients who've had radiation to their chest or to the head and neck. There is a concept that we call scatter, and when an energy source is applied to the chest, when it strikes bone, it will scatter and affect other different areas. The individuals who are at highest risk gets back to what we were discussing at the very beginning. Those are individuals who've had a previous history of high blood pressure, previous heart attack, high cholesterol, diabetes. Especially a vulnerable group are women who have breast cancer and patients who have lymphoma, specifically if they have breast cancer on the left side of their chest. Radiation that is sent to the left side of the chest, unfortunately, strikes the area where the opening of the blood vessels of the heart are located. So it puts them at much higher risk for developing heart disease, and as a result, having a heart attack.
Lisa Garvin: Now how, is proton therapy or partial breast irradiation, any of these more minimally invasive radiation therapies, are they helping with cardio toxicity?
Dr. Jean Bernard Durant: We're hoping that they will. The proton therapy is a very promising because it's very focused energy to one particular source. It's still a little bit early for us to say that it definitely has found some survival or protective benefits. There is a recent publication from a Dr. Sarah Darby, D-A-R-B-Y, who's in UK, and she looked at breast cancer patients who were exposed to radiation to their chests. What she found was that there was a dose-dependent effect. What that means is that the higher the dose of radiation, the more cycles of radiation, the more likely you develop a complication. What was interesting, though, she went out on a limb and actually said in her manuscript that there is no safe level of radiation. So even low doses can still cause some damage. So we still have work to do, and the promising area is, of course, proton therapy.
Lisa Garvin: And you touched on, you said that we do treat people at MD Anderson who have heart problems but don't have cancer. How would they arrive here for heart treatment?
Dr. Jean Bernard Durant: Our program has become recognized nationally and internationally for the work that we do in managing patients with different type of muscle disorders, and in collaboration with some of our colleagues within the Texas Medical Center. We offer groundbreaking techniques and tools and procedures and medical therapies that we can treat these aggressive types of heart disorders to patients even who don't have cancer, and that allows patients to become candidates for aggressive therapies that they may not find in their community.
Lisa Garvin: So in closing, what would you say to patients who are coming, and they know they have heart disease, and they've got cancer, what sort of advice or encouragement or support could you give them?
Dr. Jean Bernard Durant: The support and encouragement I would give them is, of course, always talk to your oncologist. Let them know your concerns. Let them know your risk factors so that we are available to help you. The second thing that's encouraging is that the oncologists are doing a wonderful job of treating cancer. Such a good job that these patients go on to survive their cancer, and they're cancer free, and then the heart becomes the issue. While in the 21st century, heart disease is a very, very treatable condition. There is so much more we can do that allows you to live a long and healthy life. And we cannot, of course, talk to a cardiologist without the issue of exercise. We know that exercise prolongs your life. It prevents heart attacks. It prevents stroke. There's now work being done here in breast cancer survivors that are showing that individuals who exercise after their treatment, they live longer. They're less likely to develop heart disease. So we still have to watch our diet and exercise, even though we successfully have survived cancer.
Lisa Garvin: Not new advice, but always good advice -
Dr. Jean Bernard Durant: Absolutely.
Lisa Garvin: Thank you, Dr. Durant. If you have questions about anything you've heard today on "Cancer Newsline", contact ask MD Anderson at 1-877-MDA6789 or online at MD Anderson dot org slash ask. Thank you for listening to this episode of Cancer Newsline. Tune in for the next podcast in our series.
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