Welcome back to an introduction to breast cancer.

I'm Dr. Denise Jagpar.

So first of all, I want to tell you how completely thrilled I am that so

many of you are enjoying our course.

I love getting your emails and your tweets and

your texts about what you are learning during the course.

You have been so active in our discussion boards as well.

And I want to send a huge shout out to our TAs who monitor our discussion boards.

And we're also paying attention to all of the question that you're asking.

Now, many of you have started asking questions about cardio oncology

that is to say, how does your heart interfere with breast cancer treatment?

And how does breast cancer treatment affect your heart?

And so because you've been so interested in that topic,

we've decided to make some bonus material just for you.

And so my special guest today is Lauren Baldassarre.

She is the head of Cardio-Oncology here at Yale.

Thank you so much for joining me.

>> Thanks so much for having me.

It's good to be here.

>> So Lauren, I hope you can start by telling us a little bit about what do

people do when they've got heart issues?

Heart disease is so common these days.

They've got heart issues and then they get diagnosed with breast cancer.

How does their heart issues affect their breast cancer treatment?

>> Sure, I would say one of the most important things, actually for

all the patient not just patient that already have heart disease but

all patient who are under going therapy that could potentially have

cardiac side effects is to know their cardiac service factors first of all.

Things hypertension, diabetes, family history of heart disease,

prior smoking obesity.

Things that to know for their position to be able to help them figure

out what is their their risk going in.

And certainly patients who have already a preexisting cardiac condition should

absolutely make sure that that is fully assessed, ideally by a cardiologist.

But by their oncologist as well and that discussion about the risk and

benefits of treatment should be had between the patient and the physician.

>> So what are the things that you can do as a cardiologist, for

example when patients are undergoing breast cancer surgery.

And we talked a lot in the course about various kinds of surgical options,

things that are very minimal, just a partial mastectomy or

a lumpectomy, to things that are very big, bilateral mastectomies and

free flap reconstructions.

Are there things that people can do in advancive surgery to

optimize their cardiac strength for that kind of a surgery?

>> Sure, absolutely.

So again, all patients should have their risk assessed first.

And based on their cardiovascular risk factors, based on their

baseline cardiac imaging, which usually would include at least an echocardiogram.

Then we can tailor any sort of medical therapy that might be appropriate with

things beta blockers and ace inhibitors to control their blood pressure,

their heart rate, get that in optimal range before they go in to surgery.

And then, of course, patients that already have cardiac preexisting conditions,

similar, make sure we know their blood pressure,

their heart rate, have had recent baseline imaging studies.

If indicated, potentially a stress test or some other assessment of their corner

arteries, if that's appropriate and to be able to help optimize them before surgery.

>> Great, and so for the most part surgery is relatively well tolerated

even if you have a cardiac condition.

But where a lot of times I think patients and oncologist get a little bit

concerned is when they're starting to approach chemotherapy.

Because, as we talked about in the course,

many of the drugs that are used in breast cancer, the anthracyclines, for

example, some of the HER2-directed therapies trastuzumab.

They effect your heart too and so it's kind of a double whammy.

So what do you do for those patients?

>> Sure, so for these patients who are going to be

undergoing potentially cardiotoxic chemotherapy,

again we want to make sure we understand what is their risk kind of going in.

So we recommend a full cardiovascular risk assessment, checking their lipids,

blood pressure, knowing their history, reviewing their medications, and

getting baseline imaging, which is usually primarily with an echocardiogram.

Sometimes we will acquire some further advanced imaging with cardiac MR,I or

nuclear studies, or sometimes cardiac CTs.

And using all that information, we can first off assess, help assess the patients

risk of being able to tolerate the therapy from a cardiovascular risk standpoint.

And then have a real informed discussion with the patient and ourselves,

the cardiologists and the oncologists, and sort of weigh the risks and

benefits of the cancer therapy with their cardiac risk.

In general though, really our goal here is more

of a preventative type of approach, I would say.

It's incredibly rare actually, that we would recommend that somebody not

undergo the therapy that is recommended to be the best therapy for their cancer.

What our job is, is to help assess that risk inform the patient.

And then do everything that we can to get the medications on board, and all of those

things that we talked about, proper monitoring, to really decrease that risk.

Because, overall, as you mentioned,

it's really, this patient has cancer that needs to be treated.

And they may have some preexisting condition or some cardiovascular risk.

But we're really focused on giving them the optimal medical treatment, and

surgical, or radiation if needed.

Treatment for

their breast cancer, to give them the best outcome from that standpoint.

And really we try to just help with that and

very, very rare do we say that the patient cannot have that.

>> And so, when we talk about chemotherapy and the cardiac toxicity of some

of these drugs, some patient have noted that their rejection fraction.

How much blood that their heart can pump

actually reduces with some of those cardio toxic regimens?

Does that ever come back?

Is there a way to kind of make your heart get back to where it was or

are these kinds of changes that people have

with some of the cardiac toxic regimens irreversible?

>> So we see some cases that are reversible.

Absolutely, for sure.

Patients will start often at a normal ejection fraction on their

echocardiogram have treatment at some point we're checking some serial imaging.

And we do see sometimes decreases in the injection fraction,

this is a minority of patients for sure and then depending upon

how low it has gone if it's something mild usually we just monitor more closely

get medications on board and carry the patient through the treatment.

If it's a more significant drop in the ejection fraction and or if it's

accompanied by symptoms of heart failure then we might need to pause for a minute.

Kind of reassess the situation, hold off, get some medications on board.

Usually reimage, and often times we can still resume the treatment.

It just sort of depends on the patient and the situation at the time.

There are some cases where, and again, they're quite minimal but

where patients do have a drop in the eject faction and it does not recover.

But we have many patients where they have a drop during treatment and

then it recovers to normal later on.

>> Great, the other modality of therapy which can potentially affect the heart

is radiation therapy so a lot of patients who, especially if they have left sided

breast cancer, they worry about the effect of radiation on their heart.

Now we know that in radiation there be we talked during the course about

how the treatment is really planned and

how the radiation oncologist use shielding and so on.

How much of an issue is radiation therapy in terms of cardiotoxicity?

>> Well, it can be an issue it's hard to put a number on it as it for

many of these side effects.

Usually when they think about the side effects from radiation, well,

first of all when you combined radiation with chemotherapy than the potential for

the cardio side effect will go up if you have you too risk factors together.

And we think more of about waste that it could cause to fibrocyst, or scarring, or

inflammation, sometimes that can cause an inflammation of the lining of the heart,

they compared pericarditis.

Other times, it could affect the valves, where they could end up becoming a little

bit thickened or stiff, and over time, that could lead to some valvular disease.

>> But you would still recommend that patients,

if they're having breast cancer surgery that would mandate radiation

therapy to lower their risk of recurrence have that even if they had chemotherapy?

>> Yes, many patients get combination therapy, as you know.

And the vast majority do well, and really there's very few circumstances

where we ever recommend that somebody don't continue with the therapy.

That's reserved for times when a patient's very sick from a cardiac standpoint,

having severe side effects, and that's actually is pretty rare.

But there is a real risk of cardiac side effects.

And even if it's mild at the time, what we're starting to see in some of the data

coming out is that that can lead to increased these cardiovascular risk and

events over time for those patients.

So even though they may have just a mild decrease in their ejection fraction and

may not even be symptomatic we are very aggressive about treating

that as tolerated to try to prevent them from having increased cardiovascular

events further on.

In life, so it's very important, and I said, we kind of

think of it as more of a preventative type of approach in those patients.

>> Right, and that's a very nice segue into the next

series of questions that I have, which is really in regards to survivorship.

So during the course one of the things that I think we've tried to really

highlight and I think it so heartening is that, so many people do so

well after breast cancer treatment, right?

We have great screening, we're able to do minimal surgery, we've got

wonderful targeted therapies, we have radiation that can prevent recurrences.

And lots, and lots, and lots of patients survive many,

many years with their disease as breast cancer survivors.

But in that survivorship period, as you pointed out,

they still are at risk of the ramifications of that treatment long-term.

So what can patients and

their physicians do to protect their heart from future events?

>> So the best thing that they can do is continue to be evaluated and monitored,

we don't know exactly how long out we can see as cardiac side effects but

more data we just discussed it's coming out that.

That risk may continue on for many years.

And the best thing that the patient can do is have

continued evaluation either through oncologist or

potentially through a cardiologist where they have serial imaging of their heart.

We know for sure there's guidelines that give us pretty good recommendations

about how often to image during therapy, how often image right after therapy.

And then there's less clear guidelines about how long to keep imaging like that

with our patients here after their a couple years clear of their treatment,

assuming they were no cardiac side effects and

nothing that needs to be looked at regularly.

We ask them to all come back yearly to be seen by us just to,

again take a look at everything.

Are you up to date on your lipids?

How's your blood pressure?

What else is new that is going on with you?

And have you had any repeat imaging?

And if not then we'll get that for them.

>> Excellent, so my last question has to do with diet and exercise.

Because as we talked in the course about survivorship and

we met with Dr. Samft who's the director of the survivorship program here.

One of her messages was really that diet and exercise is really important

both in terms of prevention of breast cancer, but also long-term survivorship.

Patients who have undergone breast cancer treatment, and who may or

may not have cardiac issues, is there anything that they need to

be concerned about in terms of their diet and exercise long-term?

>> Sure, well, similar to most patients absolutely if a cardiac diet and

some aerobic exercise will absolutely help their

cardiac vascular health so we always counsel on that.

We actually counsel on that not just after for survival.

We actually counsel on that during their therapy which can be difficult for

sure when patients understandably are not feeling well, undergoing chemotherapy,

but we try to encourage some element of physical activity.

The best thing being just walking, if you can get outside and do a little bit of

fast pace walking everyday 20 to 30 minutes really can help patients

because as there is a fair amount of deconditioning that can happen after this.

And so we try to encourage as much as we can, some element

doesn't have to be running or anything to crazy, why you're not feeling well.

But just getting out there and

walking kind of keeping yourself as cardio vascular physically fit as you can.

It really be helpful in the long-term will help you be bounced back afterwards.

>> Great, well, thank you so much for being my guest here.

>> Thank you.

>> Until next time, this is Dr. Denise Jagpar.

Interview with Lauren Baldassarre, Director of Cardio-Oncology at Yale

Introduction to Breast Cancer

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