Heart Problems After Chemotherapy or Radiation

Some cancer treatments damage the heart. The damage can start during treatment. It can also start months or years after the last dose. The National Cancer Institute says that certain cancer drugs and radiation to the chest may cause heart problems that do not show up until years after treatment.

So three facts matter. Which drugs did you get? What total dose? Where was the radiation aimed? Those facts guide the rest of your care.

Call your cancer team right away if you have:

• Shortness of breath or trouble breathing, including when lying down.
• New swelling of the hands, feet, ankles, or lower legs.
• Weight gain of more than 5 pounds (about 2.3 kilograms) in 24 hours.
• A heartbeat that is fast, irregular, or pounding.
• Dizziness, or a blackout.

Call 911 or go to the nearest emergency department for chest pain, fainting, or severe breathlessness. Do the same for sudden numbness or weakness on one side of the body, which can be a sign of stroke. Do not wait for a clinic call-back and do not drive yourself.

This list comes from the MedlinePlus drug pages for doxorubicin and trastuzumab. They say to call your doctor immediately if you notice these symptoms. MedlinePlus says heart failure causes fluid to build up in the body.

The National Cancer Institute says chemotherapy with anthracyclines raises the risk of heart and blood vessel problems. It names doxorubicin, daunorubicin, idarubicin, and epirubicin. It says the anthraquinone mitoxantrone does too. The risk depends on the total dose and the type of drug.

MedlinePlus warns that doxorubicin may cause serious or life-threatening heart problems. This can happen at any time during treatment. It can also happen months to years after treatment ends. That is why survivors need long-term heart checks.

NCI lists weakened heart muscle and congestive heart failure among the late effects. Doctors call a weakened heart muscle cardiomyopathy. If it cannot pump enough blood, that is heart failure. NCI lists trouble breathing and swelling of the feet, ankles, or legs as possible symptoms.

Tests are done before doxorubicin starts. They show whether your heart can safely take the drug. MedlinePlus names two. One is an electrocardiogram (ECG), which records the electrical activity of the heart. The other is an echocardiogram, an ultrasound that measures how well the heart pumps blood. Both are repeated during treatment.

Tell the team before the first dose if you have ever had heart disease, a heart attack, or radiation to the chest.

MedlinePlus says trastuzumab may cause serious or life-threatening heart problems. Heart tests are done before and during treatment.

The American Cancer Society says heart damage from these drugs is usually temporary and improves once the drug is stopped. But it can lead to congestive heart failure in some people.

Heart function is checked with an echocardiogram (ECHO) or a MUGA scan. Both are done before treatment and repeated regularly during it.

The risk is higher when these drugs are combined with chemo that also affects the heart, such as doxorubicin (Adriamycin) and epirubicin (Ellence). If your plan has both, ask how the monitoring accounts for that.

The National Cancer Institute says radiation to the chest, spine, brain, neck, or kidneys raises the risk of heart and blood vessel problems. So does total-body irradiation as part of a stem cell transplant. The risk depends on the area, the amount of radiation, and the dose schedule.

Radiation can inflame the sac around the heart. That is called pericarditis. NCI says it is usually linked to radiation doses above 30 Gy (gray, the unit used to measure radiation dose) to the area around the heart. It happens most often after radiation to the middle of the chest for Hodgkin lymphoma or breast cancer. Doxorubicin and cyclophosphamide have also been linked to acute pericarditis with fluid around the heart.

NCI also lists damage to the heart valves, hardening of the heart arteries, and abnormal heartbeat among the heart late effects that radiation and some chemotherapy can cause.

NCI says ifosfamide, cyclophosphamide, methotrexate, asparaginase, and platinum drugs such as carboplatin and cisplatin may also cause heart and blood vessel late effects. The American Cancer Society says cancer treatment can cause high blood pressure and high lipids, which can raise the risk of heart attack.

Here is the National Cancer Institute's list for childhood cancer survivors:

• Abnormal heartbeat.
• Weakened heart muscle.
• Inflamed heart, or inflamed sac around the heart.
• Damage to the heart valves.
• Hardening of the heart arteries (coronary artery disease).
• Congestive heart failure.
• High blood pressure.
• Chest pain or heart attack.
• Blood clots or stroke.

MedlinePlus says there is no cure for heart failure. But treatment can help people live longer with fewer symptoms. Most plans include medicine, less sodium and liquid, and other changes.

Ejection fraction (EF). This is the share of blood the heart pushes out with each beat. Ask for your number each time. Do not settle for "it was normal."

Echocardiogram. MedlinePlus describes it as a test that uses sound waves to measure your heart's ability to pump blood.

MUGA scan. The American Cancer Society says an echocardiogram or a MUGA scan is used before treatment and repeated regularly during it.

Electrocardiogram (ECG or EKG). MedlinePlus describes it as a test that records the electrical activity of the heart.

A baseline test before treatment gives your team something to compare with later. Ask for yours.

• Ask for a written treatment summary. It should list every anthracycline, the total dose, and the radiation fields and doses.
• Ask what your baseline ejection fraction was. Then ask what it is now.
• Ask how long heart monitoring should continue after treatment. Ask who orders it.
• Ask whether you should see a cardio-oncologist. That is a heart doctor who focuses on people with cancer.
• Give the treatment summary to every new doctor. Include your primary care clinician. Late effects usually turn up outside the cancer center.

NCI says risk factors such as high blood pressure, excess body weight, smoking, high cholesterol, and diabetes can raise the risk of late effects. When they are combined, the risk is even higher. Ask the team what exercise is safe for you. Ask for help to quit if you smoke.

• Late Effects of Cancer Treatment — National Cancer Institute
• Late Effects of Treatment for Childhood Cancer (PDQ) Patient Version — National Cancer Institute
• Cardiopulmonary Syndromes (PDQ) Health Professional Version — National Cancer Institute
• Doxorubicin Injection — MedlinePlus, National Library of Medicine
• Trastuzumab Injection — MedlinePlus, National Library of Medicine
• Heart Failure — MedlinePlus, National Library of Medicine
• Targeted Drug Therapy for Breast Cancer — American Cancer Society
• Can Chemo and Other Cancer Treatments Cause Heart Problems? — American Cancer Society
• Long-term and Late Effects of Cancer — American Cancer Society