Dr. Patricia Yarberry Allen is a collaborative physician. This week, she consults cardiologist Timothy C. Dutta on how to counsel a survivor of Hodgkin’s disease who worries about the consequences of the radiation therapy that saved her life 16 years ago.

Dear Dr. Pat: . I am a 52-year-old woman who is a survivor of Stage 4 Hodgkin’s disease. At 36 I was diagnosed and treated with chemotherapy and radiation therapy to the chest. I had a premature menopause at the time of chemotherapy. . Recently I have been reading about the risk of prior radiation therapy to the heart. I am about 30 pounds overweight; I smoked cigarettes from age 18 to 36 (two packs a day); have hypothyroidism, presumably from the radiation therapy; and have elevated cholesterol at 230 total, and 150 LDL. My blood pressure is normal and I exercise aerobically daily. I never have any shortness of breath, chest pain, heart palpitations, or irregular heartbeat. There is no early heart disease or stroke in my family. . I asked my GP if I should have a cardiac evaluation because of the radiation therapy history and my many years of smoking. She told me that I just needed to lose weight and take Lipitor. She said that I should not have any imaging tests of my heart because I had the Hodgkin’s radiation therapy too long ago for it to cause any problem now and that it was not cost-effective for me to undergo any other cardiac evaluation, because it wouldn’t change anything. . What is the general evaluation recommended for women like me who had radiation therapy of the chest or for breast cancer, for that matter? I don’t quite understand how the radiation therapy affects the heart anyway.  . Priscilla


Dr. Pat Responds:

Dear Priscilla: . This is a subject of intense interest and investigation. Radiation therapy to the chest that involves the heart, its blood supply, and its valves may affect all of these structures. Older radiation therapy (RT) techniques that were used to treat patients with malignancies involving the chest clearly caused an increase in cardiovascular morbidity and mortality. Such treatment involved exposure of large volumes of the heart to high doses of radiation. . Your past history of smoking and premature menopause do increase your lifelong risk of coronary artery disease—as does the increase in weight and high cholesterol. You can’t control the past, Priscilla, but you can change some current risk factors for heart disease. Lose those 30 pounds; adopt a heart-healthy diet; begin one of the cholesterol-lowering drugs, unless the weight loss and change in diet decrease the cholesterol to normal levels. . I have asked Dr. Timothy Dutta, a cardiologist in private practice in New York City and a member of the Women’s Voices for Change Medical Advisory Board, to discuss this important issue and to give the general recommendations for cardiac evaluation for patients with your history. You have been so lucky, Priscilla, to have survived a once-lethal cancer. Now take the next steps to do all that you can to have a healthy second half of life. . Dr. Pat Left coronary artery: At left, normal artery. (Photo source: Cardiovascular Ultrasound 2008)  At right, artery showing radiation-induced coronary disease. Arrow points to narrowing. Click image to enlarge. (Photo source: Luke Kim, M.D., Weill Cornell Medical College.)


Dr. Dutta Responds: . Dear Priscilla: . Thank you so much for your question. Surviving cancer is a remarkable feat, and I am sure that being proactive about preventive health is especially significant for you. . Treatment of Hodgkin’s disease using a combination of chemotherapy and radiation has achieved great success in curing Hodgkin’s lymphoma. There are now more than 30,000 survivors of this illness in the United States. Now that patients are surviving and living longer, we are seeing the long-term consequences to the heart of the high-dose radiation and chemotherapy. Fortunately, many patients do not develop any heart trouble at all, but there are important considerations.  Both the radiation that you received and the chemotherapy are important. . Radiation therapy can cause scarring of various structures of the heart, including the pericardium (the membrane or sac that surrounds the heart); the heart muscle itself; the heart valves; and, most important, the coronary arteries. Some of these complications occur soon after treatment, but some of them occur late. The coronary arteries can have premature and accelerated atherosclerosis, creating a risk for heart attack that may not become apparent until decades after treatment.  .


Right coronary artery: At left, normal artery (Photo source: Cardiovascular Ultrasound 2008) At right, artery showing radiation-induced coronary disease. Arrow points to narrowing. Click image to enlarge.  (Photo source: Luke Kim, M.D., Weill Cornell Medical Center.) . The radiation used for diagnostic tests (plain X rays, mammograms, and CT scans) is not enough to damage the heart. The risk from radiation therapy varies with the intensity and location of exposure. For example, a recent paper reported a slight increase of heart attack from radiotherapy for breast cancer. Furthermore, the risk is actually greater for left-sided breast cancer because the heart is behind the left breast and closer to the radiation field. While the risk of heart disease is only slightly increased from breast radiation therapy, Hodgkin’s patients receive much more radiation much closer to the heart and are among the highest risk for heart disease due to radiation.  . The risk of heart attack is increased 3 to 5 times by the radiation used for Hodgkin’s. Most cases of Hodgkin’s involve radiation to the lymph nodes next to the heart, and so higher exposure to radiation is unavoidable. . The fact that you have gone 16 years since treatment without any heart problem is encouraging, but even now you still have a major risk factor for coronary disease. Many people do not develop any trouble at all, but your management should involve screening and risk-factor reduction. . For patients greater than 10 years post-treatment, cardiac screening tests should be considered even in the absence of symptoms. The most appropriate testing has not been agreed upon, but my opinion is that echocardiographic stress testing makes the most sense, because it uses ultrasound instead of radiation. This type of test checks the coronary artery function and also checks all of the other heart structures that can be involved. Managing traditional risk factors is especially important, since these will compound the risk from the prior radiation. Treating high blood pressure, high cholesterol, diabetes, quitting smoking, diet, and exercise will lower your risk. Treating your cholesterol to achieve lower goals, as well as being extra vigilant for any symptoms, is appropriate. . In addition to radiation, the chemotherapy you received is also a late risk. Your regimen likely included Adriamycin. This drug is part of a family of drugs called anthracyclines that also includes daunorubicin. They are commonly used for many cancers, including lymphoma and breast cancer. Its toxicity to the heart muscle when given in high doses is well known. Heart function is checked carefully before, during, and immediately after treatment. Doses are carefully monitored to avoid toxicity.  Because of these precautions, heart toxicity is now uncommon, but it is not unheard of. Late occurrence of weakening of the heart muscle (cardiomyopathy) can occur, but it can easily be screened for using the same echocardiogram test mentioned above.  This test should be repeated every two to five years.  . Your treatment was truly lifesaving, and I don’t know any survivor who regrets having received it. These treatments can have unique consequences that can occur years after therapy.  Large cancer centers have survivorship programs with expertise on what to watch for. I suggest that you learn more about the specifics of your treatment and ask to see a cardiologist with experience managing cancer survivors. . Dr. Dutta


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