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Practicing where cancer and heart disease converge.

Cardiovascular disease and cancer are by far the two most common diseases in the developed world, so the extent to which they interrelate should come as no surprise.

There is a remarkable overlap between cancer and cardiovascular disease (CVD). CVD can preexist in a patient who develops cancer, it can become clinically evident over time in cancer survivors, or the adverse effects of various anticancer therapies can trigger or worsen cardiovascular disease. At Memorial Sloan-Kettering Cancer Center in New York, roughly 40% of patients undergoing treatment for cancer have coexisting CVD. The bottom line is that patient care works best when cardiologists and oncologists work in concert and recognize the substantial impact that each of these diseases can have on their patients.

When patients have both disorders simultaneously, it can also mean that their treatments will work at cross purposes. For example, cardiologists generally try to maximize blood flow within the heart and to other organs. But one of the most successful recent approaches to cancer therapy has been limiting vascularization and blood flow within and around tumors so that the cancer starves. Striking a balance between these therapeutic goals is an example of how management of cancer and CVD must take both conditions into account.

Patients cannot be treated as though they were reductionist models who have only one medical problem. One of the unintended consequences of successful contemporary cancer treatment is that patients live longer and thus are more likely to develop CVD, just like most aging persons in Western countries who do not have cancer. And as cancer survivors age, they develop other comorbidities that complicate CVD, including diabetes, chronic obstructive pulmonary disease, and renal dysfunction.

The high prevalence of CVD in Western society, especially as people age, has a direct impact on cancer therapy. Results from a 2001 study found that among breast cancer patients aged 75-84 years, 21% died from heart disease; among those 85 years or older, 33% died from heart disease. A study published last year reported that among patients with early-stage breast cancer older than 50 years, the risk of dying from CVD was about fourfold higher than the risk of death from breast cancer.

Many cancer survivors face an additional, substantial CVD risk because of their anticancer treatment. Major risks of cardiovascular health are posed by radiation treatment, especially for breast cancer and lymphoma, and by treatment with several types of anticancer drugs, including anthracyclines, such as doxorubicin, and the new agents that work by inhibiting the vascular endothelial growth factor signaling pathway, such as bevacizumab, sunitinib, and sorafenib. Radiation and anthracyclines are directly cardiotoxic, while the VEGF inhibitors appear to frequently cause hypertension. Current cardiovascular management of cancer patients focuses on protecting patients from toxicities caused by their anticancer therapy.

Although it is important for physicians to be aware of the cardiovascular dangers posed by these treatments, they should not err on the side of caution and undertreat cancer patients out of concern about CVD. Physicians need to be appropriately cautious, but they must also continue to treat cancer aggressively. We currently have inadequate information on what level of treatment strikes the best balance between efficacy and avoidance of dangerous cardiovascular consequences. More data to guide these decisions are desperately needed.

DR. LENIHAN'S is director of clinical research in the department of cardiology at the University of Texas M.D. Anderson Cancer Center in Houston. DR. STEINGART is chief of the cardiology service at Memorial Sloan-Kettering Cancer Center in New York.
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Title Annotation:GUEST EDITORIAL
Publication:Internal Medicine News
Article Type:Disease/Disorder overview
Date:Jul 1, 2008
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