ASCO Clinical Evidence Review on Long-Term Side Effects to the Heart and Lungs in Adult Survivors of Cancer
| More than 10 million cancer survivors are living in the United States, according to the National Cancer Institute (NCI) and Centers for Disease Control and Prevention (CDC), including 300,000 long-term survivors of adolescent and childhood cancers. Because more people are surviving cancer, there are more reports of long-term (late) effects from the cancer treatment, including second cancers, organ damage, and physical disabilities. However, it is not known how many survivors experience late effects and how common they are among survivors of a specific cancer. It is also not known what type of long-term follow-up care is needed for cancer survivors. Because few studies address these issues, there is a lack of evidence-based guidelines that address long-term follow-up care for cancer survivors.
To learn more about this issue, the American Society of Clinical Oncology (ASCO) convened a panel of experts to review the scientific evidence surrounding the incidence of long-term side effects to the heart and lungs from chemotherapy, radiation therapy, and trastuzumab (Herceptin) treatment. Although the panel identified a variety of long-term side effects to the heart and lungs from these treatments, there was not enough evidence to recommend specific screening tests for survivors for these potential complications. This summary, called a clinical evidence review, will be published in the September 1, 2007 issue of the Journal of Clinical Oncology. PLWC discussed ASCO's clinical evidence review with Patricia A. Ganz, MD, Professor, UCLA Schools of Medicine and Public Health, Division of Cancer Prevention and Control Research, Jonsson Comprehensive Cancer Center. Long-term side effects to the heart Chemotherapy, radiation therapy, and trastuzumab treatment may cause long-term side effects to the heart. Specific drugs are associated with this risk (see below), and radiation therapy to the chest and heart area places individuals at risk. Survivors who received both chemotherapy and radiation therapy have a higher risk of heart failure. Because all of these changes happen slowly, a survivor may not experience symptoms for 10 to 20 years after treatment ends. Several drugs, such as doxorubicin (Adriamycin, Rubex), daunorubicin (Daunomycin, Cerubidine), epirubicin (Ellence), and cyclophosphamide (Cytoxan, Neosar), may injure the heart muscle and cause congestive heart failure (when the heart can't pump enough blood to support the body) when given in high doses. Symptoms of heart damage may include:
If these drugs were given to treat cancer during childhood, the effects of treatment may not show up for many years. Radiation therapy to the chest may cause the following heart problems:
The treatments for symptoms of heart failure include medications that decrease the work of the heart by lowering blood pressure and reducing blood volume. Usually, these symptoms can be managed if detected when symptoms first occur, or an abnormality is discovered during a heart scan that examines how well the heart is pumping. Long-term side effects to the lungs Chemotherapy, such as bleomycin (Blenoxane), methotrexate (Rheumatrex, Trexall), and cyclophosphamide, and radiation therapy may scar lung tissue. Both treatments may cause a pneumonia-like situation, resulting in shortness of breath and coughing shortly after treatment. Scarring and/or thickening of the lung tissues may occur many years later, making breathing difficult. Trastuzumab treatment Survivors of breast cancer treated with trastuzumab are at risk for heart failure. Patients taking trastuzumab should be monitored carefully while receiving this drug and it should be stopped if their heart function drops below normal. Usually, heart function returns to normal when the drug is stopped. Because trastuzumab is a relatively recent treatment for breast cancer, the long-term risks are not known. Patients taking or who have taken trastuzumab should talk with their doctor for more information. Adult survivors of childhood cancer Long-term survivors of childhood cancer seem to be at greater risk for heart injury, even though children are given somewhat lower doses of the same chemotherapy that causes problems for adult survivors. This is probably because the chemotherapy is given at a time when the child's body is developing and is more susceptible to the effects of these drugs. The Children's Oncology Group, a cooperative group of doctors who treat children with cancer, has established consensus guidelines for childhood cancer survivors. Talking with your doctor It is important to talk with your doctor about the potential long-term side effects of cancer treatment both before and after treatment. Patients should ask their doctors specifically what drugs and/or radiation therapy they received as part of their cancer treatment and whether there are any potential risks to the heart or lungs. If so, they should discuss whether any special tests or follow-up care is needed. For some survivors, it may be more difficult to identify the specific treatments received, especially if the treatment took place many years ago. Even if you cannot locate your medical records, it is important to tell your current doctor about your cancer treatment history so if symptoms of late effects do appear (such as chest pain), they can be addressed as quickly as possible. More Information PLWC: Institute of Medicine Survivorship Report PLWC: Institute of Medicine Report on Childhood Cancer Survivorship |
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