Risk for Cardiac (Heart) Problems Related to Anthracycline Chemotherapy for Childhood Cancer

What is the risk?

A group of chemotherapy medications called anthracyclines can cause heart (cardiac) problems (also called cardiac toxicities). Anthracycline chemotherapies are doxorubicin, daunorubicin, epirubicin, idarubicin, and mitoxantrone. Heart problems linked to these medications are:

• Cardiomyopathy or left ventricular dysfunction (the heart muscle becomes weak).
• Arrhythmias (your heart beats too fast, too slow, or irregularly).

Am I at risk?

Heart problems can start shortly after you are done treatment, or even up to years later, so heart health is important for cancer survivors. Your risk of having heart problems is linked to the total dose of the anthracycline chemotherapy you had (over the whole course of your life) and the age you were when you had the medication. Often, higher doses mean a higher risk of having a heart problem. Survivors who were younger when they had treatment are at a slightly higher risk.

The risk is higher if you also had radiation therapy to your chest. Radiation, even without chemotherapy, can cause early disease in the arteries in your heart. This can raise the risk of heart attack and other heart problems.

What else can raise my risk of heart problems?

Some things, like anesthesia and pregnancy, can cause extra stress on the heart and raise your risk of a heart problem. For this reason, you should see a cardiologist before any planned surgery or if you are pregnant or trying to get pregnant.

Other health problems that can raise your risk are:

• Heart disease (coronary artery disease).
• High blood pressure (hypertension).
• High cholesterol.
• Diabetes.
• Obesity.

If you have heart valve problems, you may need antibiotics before having some medical procedures or work done on your teeth to prevent infection. Talk with your care team to see if you need this.

Some medications can put added stress on the heart and raise your risk of heart problems. These include diet pills, ephedra, cocaine, and performance-enhancing drugs.

What are the symptoms of heart problems?

Cardiac (heart) toxicities can cause symptoms like:

• Shortness of breath (at rest or while moving).
• Having a hard time breathing when lying down (orthopnea).
• Chest pain.
• Feeling like your heart is racing, throbbing, or beating irregularly.
• Being unable to exercise due to fatigue.
• Dizziness/lightheadedness.
• Swelling of your arms or legs (edema).
• Cough or wheezing that won't go away.

Tell your healthcare provider right away if you have any of these symptoms. A yearly history and physical by a healthcare provider should include a cardiac exam and a review of possible symptoms. If you are having chest pain or a hard time breathing, call 911 or go to your nearest emergency room right away.

Prevention

There are ways you can help keep your heart healthy, like keeping a healthy lifestyle. This includes:

• Not smoking or using drugs.
• Keeping a healthy weight.
• Getting regular exercise. Talk to your healthcare provider if you want to start an exercise plan or play sports.
• Eating a diet high in fruits and vegetables.
• Having your weight, blood pressure, and cholesterol checked as needed by your medical team.

What tests do I need to check my heart health?

There are some tests that the Children’s Oncology Group (COG) recommends once you enter “long-term follow-up” from cancer treatment. This is often 2 years after finishing treatment.

• You should have an electrocardiogram (EKG) and an echocardiogram at this time as a baseline measurement.
• An echocardiogram may be done every 2-5 years, depending on the dose of anthracycline medicine or radiation you received.
• If you had a higher dose of radiation or a combination of radiation to the heart and anthracycline chemotherapy, you may be referred to a cardiologist for stress testing 5-10 years after treatment.
• All survivors should have a physical exam by a healthcare provider at least once a year. Your provider should check your heart health, blood pressure, and risk for other health concerns like high cholesterol and diabetes.

How can I learn more about my risk?

• Going to a cancer survivorship clinic can be helpful to learn about your own risk and ways to lower your risk. Find a clinic on our list or call local cancer centers to see if they have a clinic for childhood cancer survivors.
• Make a survivorship care plan with Smart ALACC (Smart Adult Living After Childhood Cancer).
• Visit the Children’s Oncology Group website to learn more about risks and recommendations.
• Talk with your care team about your plan for follow-up care.