Interview/ Dr Satish C. Govind, chief of non-invasive cardiology, Narayana Institute of Cardiac Sciences, Bengaluru
Q. What happens when you tell the patient, "You have won your battle against cancer, now let us talk about preventing heart disease"?
A. There is usually a sense of relief that the big C has been tamed or can be tamed. When it comes to heart disease and cancer, patients react in different ways. Some are dejected that they may have another battle on their hands, some are not bothered since they think heart disease is a smaller problem to face than cancer, while some get depressed about it as they feel it is another obstacle for which they don’t have the energy and spirit. Additionally, the cost factor also comes into play as some cardiac investigations can increase their financial burden, so affordability also leaves an imprint on their fragile psyche and their battle to survive. But the interesting part is irrespective of their disease or financial background, their individual personality and mental toughness play a crucial role in fighting additional setbacks. Cancer plays havoc on their mental status and a likelihood of heart disease makes matters worse.
Q. What are some of the cancer drugs or treatments that can lead to cardiovascular disease?
A. There are many anti-cancer drugs that are commonly known as chemotherapeutic agents used for different types of cancers. Cisplatin, cyclophosphamide, doxorubicin, epirubicin, capecitabine, 5-fluorouracil, trastuzumab, vincristine, paclitaxel are some of the more prominent drugs. They are grouped according to their mechanism of action, like anthracyclines, HER2 inhibitors and VEGF inhibitors. Most of them have some effect on the cardiovascular system in one way or the other. These effects are seen either due to a specific drug or a cumulative dose or when multiple agents are combined or in those with pre-existing heart ailments.
Q. As more and more immunotherapies are being used for cancer treatment, what are some of the specific cardiac side-effects that can occur during treatment with some of these agents?
A. The side-effects may be overt where they may manifest as breathlessness, chest pain, fatigue, palpitations and swelling of legs. Some drugs cause injury to the cardiac muscle while some cause blood pressure fluctuations. Injury to the walls of the arteries and predisposition to clot formation is also seen, which may lead to heart attack or clots in the veins. Heart failure or myocardial dysfunction is a frequently seen complication which can be of prolonged duration in some patients. Fluid collection around the heart known as pericardial effusion, pulmonary hypertension and arrhythmias are also known to happen. The effects can also occur at a cellular level where overt features mentioned above are absent and these abnormalities are detected only by certain specialised tests.
Q. Does accepting the risks of treatment that might lead to cardiovascular disease mean that cancer patients will have limited ability for things like exercise?
A. Limitation of activity comes into picture only when cardio-toxic effects manifest. ECG and echocardiography are quite reliable in uncovering abnormalities of the heart. Normal activity and even increased physical activity should not be discouraged. Constant monitoring of symptoms and specific tests should be done and any detection of abnormal findings or onset of cardiac symptoms should be a red flag to limit activity, especially exercise. Early detection using newer and more sophisticated testing may reduce risk of progression of cardio-toxicity.
Q. What are the warning signs that cancer patients should watch out for and report during and even after treatment?
A. Sudden onset of chest pain, increasing fatigue, a new feeling of shortness of breath, unusual palpitations especially a feeling of irregular heartbeat and swelling of legs or dizziness should be immediately brought to the attention of the doctor.
Q. How aware are people in India about cardio-oncology?
A. There is limited awareness about cardio-oncology. This is not just among the general population, but also among the medical fraternity. Dedicated cancer hospitals are more likely to have such focused approaches, but unlikely to be seen in other hospitals. It is still a nascent field and yet to gain visibility and the importance it deserves. It is only in the past few years that we are seeing a few scientific sessions dedicated to cardio-oncology at medical conferences. But it is still far and few. In Europe and the US, there are dedicated societies which are gaining prominence, but India is yet to reach that level. The professional skills of specialists in managing these niche patients are of very high standards, but a dedicated focus can definitely take patient management to the next level. Decreasing cardiac morbidity, mortality and improving quality of life is the aim of this focused approach. Prevent, detect and treat are the key objectives. With more and more cancer hospitals being opened hopefully this gap will be addressed and in the next decade we probably shall reach a level where such goals will be achieved.
―Priya Menon is host and producer of CureTalks, an international online talk show discussing medical breakthroughs, research and treatments.