Health Links Rev.12 - Children's Oncology Group

[Pages:9]Health Link

Healthy living after treatment for childhood cancer

Heart Health Version 3.0 - 10/08

K e e p ing Yo ur H e a rt H e a lthy a fte r Tre a tm e nt fo r C hild ho o d C a nc e r

M o s t c h ild h o o d c a n c e r s u r v iv o r s d o n o t d e v e lo p h e a r t p ro b le m s ; h o w e v e r, c e r t a in typ es o f c an c er treatm en t g iven d u rin g c h ild h o o d c an so m etim es resu lt in p ro b lem s w ith th e h eart. S in c e h eart p ro b lem s m ay o c c u r m an y years after c an c er treatm en t, it is im p o rtan t fo r c h ild h o o d c an c er su rvivo rs to b e aw are o f an y treatm en ts th ey m ay h ave rec eived th at c an affec t th e h eart. Th at w ay, th ey c an tak e step s to k eep th eir h eart h ealth y, in c lu d in g reg u lar m ed ic al c h ec k - u p s an d tests to m o n ito r h eart fu n c tio n . A n d if a p ro b lem d evelo p s, it c an b e d etec ted an d treated early.

H ow does the heart w ork?

Th e h eart is a m u sc u lar o rg an th at is at th e c en ter o f th e b o d y 's c irc u lato ry s y s tem . Th e h eart is resp o n sib le fo r p u m p in g b lo o d w ith o x yg en an d n u trien ts to b o d y tissu es. T h e re a re f o u r c h a m b e rs (t w o a t ria a n d t w o ven tric les) w ith in th e h eart th at w o rk to g eth er to p u m p b lo o d . Valves d irec t th e flo w o f b lo o d th ro u g h th e h eart c h am b ers an d in to th e b lo o d vessels. Th e rh yth m o f h eart c o n trac tio n an d rate o f th e h eartb eat are c o o rd in ated b y n erves th at sen d elec tric al im p u lses to d ifferen t p arts o f th e h eart. A th in m em b ran e (p e ric a rd iu m ) s u rro u n d s a n d p ro t e c t s t h e h eart an d an c h o rs it w ith in th e c h est.

W ha t typ e s o f c a nc e r tre a tm e nts c a n c a use he a rt p ro b le m s?

Th e h eart c an b e affec ted b y c ertain typ es o f c h em o th erap y an d b y rad iatio n th erap y.

Anthra c yc line c he m o the ra p y

Th e an th rac yc lin es are a typ e o f c h em o th erap y u sed to treat m an y c h ild h o o d c an c ers. Th is typ e o f c h em o th erap y c an so m etim es affec t th e h eart. C o m m o n ly u sed anth rac yc lin es in c lu d e:

D o x o ru b ic in (A d ria m y c in ? ) D a u n o ru b ic in (d a u n o m y c in , C e ru b id in e ? )

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Health Link

Healthy living after treatment for childhood cancer

Heart Health Version 3.0 - 10/08

Id a r u b ic in (Id a m y c in ? ) M it o x a n t ro n e (N o v a n t ro n e ? ) Ep iru b ic in

R a d ia tio n the ra p y

H eart p ro b lem s m ay also resu lt fro m rad iatio n th erap y to th e h eart o r su rro u n d in g tissu es. Th is in c lu d es rad iatio n to th e fo llo w in g areas:

C h e s t o r t h o ra x (in c lu d in g m a n t le , m e d ia s t in a l, a n d a x illa ry t re a t m e n t f ie ld s ) S p in e (c h e s t o r " t h o ra c ic " p o rt io n ) Abdom en To t a l b o d y ir ra d ia t io n (T B I)

W ha t he a rt p ro b le m s c a n o c c ur a fte r tre a tm e nt fo r c hild ho o d c a nc e r?

Th ere are several typ es o f h eart p ro b lem s th at m ay resu lt fro m c an c er treatm en ts:

Th e m u sc le c ells o f th e h eart m ay b e d am ag ed so th at th e h eart d o esn 't c o n trac t a n d re la x n o rm a lly (le ft v e n t r ic u la r d y s fu n c t io n , c a rd io m y o p a t h y ).

Th e elec tric al p ath w ays th at c o n d u c t im p u lses to c o n tro l h eart rh yth m m ay b e sc arred o r d am ag ed , resu ltin g in ab n o rm ally fast, slo w , o r irreg u lar h eart b eats (a r r h y t h m ia s ).

Th e valves an d b lo o d vessels o f th e h eart m ay b e d am ag ed , resu ltin g in stiff o r le a k y v a lv e s (v a lv u la r s t e n o s is o r in s u ffic ie n c y ).

T h e p ro t e c t iv e c o v e rin g o f t h e h e a rt m a y b e c o m e in f la m e d (p e ric a rd it is ) o r s c a rre d (p e r ic a rd ia l fib ro s is ).

T h e b lo o d v e s s e ls o f t h e h e a rt m a y b e c o m e s c a rre d o r b lo c k e d (c o ro n a r y a r t e r y d is e a s e ), p re v e n t in g d e liv e ry o f o x y g e n a n d n u t rie n t s t o t h e h e a rt a n d o t h e r tissu es.

In s e v e re c a s e s , t h e s e p ro b le m s m a y re s u lt in t h e d e a t h o f h e a rt t is s u e (h e a rt a t t a c k o r m y o c a rd ia l in f a rc t io n ), a d a n g e ro u s h e a r t r h y t h m (a r r h y t h m ia ), o r a n in a b ilit y o f t h e h e a r t t o p u m p b lo o d p ro p e rly (c o n g e s t iv e h e a rt f a ilu re ).

W hic h typ e s o f c a nc e r tre a tm e nt a re a sso c ia te d w ith w hic h he a rt p ro b le m s?

A n t h r a c y c lin e s m a y c a u s e p ro b le m s w it h h e a rt m u s c le f u n c t io n (le f t v e n t ric u la r d y s f u n c t io n , c a rd io m y o p a t h y ) a n d a b n o rm a l h e a rt rh y t h m s (a rrh y t h m ia s ).

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Health Link

Healthy living after treatment for childhood cancer

Heart Health Version 3.0 - 10/08

R ad iatio n th erap y m ay resu lt in sc arrin g an d stiffen in g o f h eart tissu es, c au sin g a b n o rm a l h e a rt rh y t h m (a rrh y t h m ia s ) a n d p ro b le m s w it h t h e h e a rt m u s c le (c a rd io m y o p a t h y ), h e a rt v a lv e s (v a lv u la r s t e n o s is o r in s u ff ic ie n c y ), b lo o d v e s s e ls (c o ro n a ry a rt e ry d is e a s e ), a n d m e m b ra n e s u rro u n d in g t h e h e a rt (p e ric a rd it is o r p e ric a rd ia l f ib ro s is ).

Are the re o the r risk fa c to rs fo r he a rt p ro b le m s?

S o m e o th er m ed ic al c o n d itio n s m ay also in c rease th e risk o f h eart p ro b lem s fro m c h em o th erap y o r rad iatio n th erap y. Th ese in c lu d e o b esity, h ig h b lo o d p ressu re, h ig h c h o le s t e ro l o r t rig ly c e rid e le v e ls in t h e b lo o d , a n d d ia b e t e s . Yo u m a y h a v e a h ig h e r ris k o f h avin g h eart p ro b lem s if th ese c o n d itio n s ru n in yo u r fam ily. H eart d isease is also m o re c o m m o n in w o m en w h o h ave g o n e th ro u g h m en o p au se, so fem ale su rvivo rs w h o g o th ro u g h an early m en o p au se m ay b e at h ig h er risk . M an y h ealth b eh avio rs c an ad d t o t h e ris k o f h e a rt d is e a s e in c lu d in g s m o k in g , h a v in g a n in a c t iv e (s e d e n t a ry ) lif e s t y le , an d eatin g a d iet h ig h in fat.

W ho is a t risk fo r d e ve lo p ing he a rt p ro b le m s?

Th e risk o f d evelo p in g a h eart p ro b lem after c h ild h o o d c an c er treatm en t is related to several factors:

Th e ag e o f th e p atien t at th e tim e o f c an c er th erap y Th e to tal d o se o f an th rac yc lin e c h em o th erap y Th e to tal d o se o f c h est rad iatio n Th e am o u n t o f th e h eart tissu e in c lu d ed in th e rad iatio n treatm en t field Tre a t m e n t w it h o t h e r m e d ic a t io n s t h a t a ffe c t h e a rt fu n c t io n Th e p resen c e o f o th er c o n d itio n s th at affec t h eart fu n c tio n

M o st c hild ho o d c anc er survivo rs w ho w ere treated w ith anthrac yc lines o r c hest rad iatio n have no heart d am ag e at all. S o m e su rvivo rs h ave very m ild c h an g es in h eart size o r fu n c tio n th at h ave n o t g o tten w o rse o ver tim e. O n ly a sm all n u m b er o f su rvivo rs h ave d evelo p ed severe h eart p ro b lem s lead in g to h eart failu re o r d an g ero u s h eart rh yth m s. O verall, th e risk o f d evelo p in g h eart p ro b lem s after c h ild h o o d c an c er th erap y is h ig h est in su rvivo rs treated w ith h ig h er d o ses o f an th rac yc lin es o r c h est rad iatio n , esp ec ially th o se w h o rec eived b o th treatm en ts at a yo u n g ag e.

S in c e w e d o n o t u n d erstan d w h y so m e su rvivo rs d evelo p h eart p ro b lem s after t re a t m e n t f o r c h ild h o o d c a n c e r a n d o t h e rs d o n o t (e v e n w h e n t h e y h a v e g o t t e n t h e s a m e t re a t m e n t ), it is im p o rt a n t f o r e a c h c h ild h o o d c a n c e r s u rv iv o r t re a t e d w it h a n t h ra c y c lin e s o r c h est rad iatio n to c o n tin u e to h ave reg u lar m ed ic al c h ec k - u p s so th at if a p ro b lem w ith th e h eart d evelo p s, it c an b e d etec ted an d treated early.

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Healthy living after treatment for childhood cancer

Heart Health Version 3.0 - 10/08

W ha t a re the sym p to m s o f he a rt p ro b le m s?

N o sym p to m s m ay b e n o ted w ith m ild to m o d erate h eart p ro b lem s. Id en tific atio n o f p ro b lem m ay o n ly b e n o ted b y c ard iac stu d ies su c h as EC H O , EK G , o r M U G A .

Sho rtness o f b reath D izzin ess L ig h t h e a d e d n e s s , fa in t in g o r n e a r- fa in t in g S evere fatig u e p reven tin g ex erc ise o r n o rm al p lay C h est p ain th at feels lik e a h eavy p ressu re o r fu lln ess an d travels to th e arm , c h in

or face S w eatin g , n au sea, o r sh o rtn ess o f b reath w ith c h est p ain S h a rp p ie rc in g p a in in t h e c e n t e r o r t h e le f t s id e o f t h e c h e s t (o f t e n w o rs e n s w it h

tak in g a d eep b reath ) Ve ry s w o lle n f e e t o r a n k le s (s o s w o lle n t h a t if a f in g e r is p re s s e d f irm ly o n t h e a re a

fo r a few sec o n d s it leaves an in d en tatio n ) C o u g h an d w h eezin g th at d o esn 't g o aw ay P erio d s o f h eart rac in g o r th ro b b in g P e rio d s o f irre g u la r h e a rt b e a t (f e e lin g o f t h e h e a rt s k ip p in g b e a t s )

H o w d o e s e xe rc ise a ffe c t the he a rt?

A e ro b ic e x e rc is e (b ris k w a lk in g , ru n n in g ) is g e n e ra lly s a f e a n d a c t u a lly h e a lt h y f o r t h e h e a r t . H o w e v e r, s o m e t y p e s o f e x e rc is e a re p a r t ic u la r ly s t re s s f u l t o t h e h e a r t . T h e s e in c lu d e in ten sive iso m etric ac tivities, su c h as he a vy w e ig ht lifting a nd w re stling . W h en a p erso n is sq u attin g to lift a very h eavy w eig h t, th e h eart m u st w o rk h ard er b ec au se b lo o d p ressu re in c reases as a p erso n strain s. U sin g lo w er am o u n ts o f w eig h ts to p e rf o rm lim it e d h ig h re p e t it io n w e ig h t lif t in g (lif t in g a lig h t e r w e ig h t re p e a t e d ly ) is le s s stressfu l to th e h eart an d is m o re lik ely to b e safe. Th e n u m b er o f rep etitio n s sh o uld b e lim ited to th at w h ic h c an b e d o n e w ith ease.

S u rvivo rs treated w ith an th rac yc lin es o r c h est rad iatio n th erap y sh o u ld c h ec k w ith th eir h ealth c are p ro vid er b efo re b eg in n in g an y ex erc ise p ro g ram . In ten sive iso m etric ex erc ises sh o u ld g en erally b e avo id ed . Th o se w h o c h o o se to en g ag e in stren u o us o r varsity team sp o rts sh o u ld d isc u ss ap p ro p riate g u id elin es an d a p lan fo r o n g o in g m o n ito rin g w ith th eir c ard io lo g ist.

W ha t o the r c o nd itio ns o r a c tivitie s c a n m a k e he a rt p ro b le m s w o rse n?

A h eart affec ted b y an th rac yc lin es an d c h est rad iatio n m ay n o t b e ab le to h an d le th e stress o f c ertain c o n d itio n s th at d ram atic ally in c rease th e h eart rate, b lo o d p ressu re, o r

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Healthy living after treatment for childhood cancer

Heart Health Version 3.0 - 10/08

b lo o d vo lu m e in th e c irc u lato ry system . Th ese c h an g es m ay o c c u r d u rin g p re g na nc y o r d u rin g illn esses w ith hig h fe ve rs. If yo u r c an c er treatm en t in c lu d ed m ed ic in es th at c an affec t h eart fu n c tio n , b e su re th at yo u r h ealth c are p ro vid er is aw are, so th at step s c an b e taken to red uc e the stress o n yo ur heart.

S o m e d ru g s c an in c rease stress o n th e h eart, in c lu d in g c o c a ine , d ie t p ills, e p he d ra , m a hua ng , a nd p e rfo rm a nc e e nha nc ing d rug s. Th ese typ es o f d ru g s h ave b een asso c iated w ith w o rsen in g o f h eart fu n c tio n an d even d eath in c h ild h o o d c an c er su rvivo rs w h o rec eived an th rac yc lin e c h em o th erap y.

Are the re a ny o the r sp e c ia l p re c a utio ns?

S u rv iv o rs w it h a b n o rm a lit ie s o f h e a rt v a lv e s (le a k y o r s c a rre d v a lv e s ) o r t h o s e w it h c u rre n t ly a c t iv e c h ro n ic g ra f t - v e rs u s - h o s t d is e a s e (c G V H D ) f o llo w in g h e m o t o p o ie t ic t ra n s p la n t (H C T ) m a y n e e d t o t a k e a n a n t ib io t ic p rio r t o d e n t a l w o rk o r o t h e r in v a s iv e m e d ic a l p ro c e d u re s (s u c h a s t h o s e in v o lv in g t h e re s p ira t o ry, g a s t ro in t e s t in a l, o r u rin a ry t ra c t s ) t o p re v e n t a s e rio u s in f e c t io n o f t h e h e a rt (e n d o c a rd it is ) t h a t c a n re s u lt f ro m b ac teria en terin g th e b lo o d stream d u rin g su c h p ro c ed u res. If yo u h ave b een to ld th at y o u h a v e a n a b n o r m a l h e a r t v a lv e o r if y o u h a v e a c t iv e c G V H D , a s k y o u r d o c t o r, h e a r t sp ec ialist, an d /o r d en tist if yo u sh o u ld tak e an tib io tic s to p reven t en d o c artitis b efo re d en tal o r o th er m ed ic al p ro c ed u res.

W ha t m o nito ring is re q uire d fo r p o te ntia l he a rt p ro b le m s?

A n yo n e treated w ith an th rac yc lin e c h em o th erap y o r c h est rad iatio n fo r c h ild h o o d c an c er sh o u ld h ave a yearly c h ec k - u p w ith sp ec ial atten tio n to an y sym p to m s relatin g t o t h e h e a rt . In a d d it io n , a n e le c t ro c a rd io g ra m (E C G , E K G ) s h o u ld b e d o n e a t t h e t im e t h e s u rv iv o r e n t e rs lo n g - t e rm f o llo w - u p (u s u a lly a b o u t 2 y e a rs f ro m c o m p le t io n o f t h e ra p y ). A n e c h o c a rd io g ra m o r M U G A s c a n is a ls o re c o m m e n d e d a t t h e f irs t lo n g - t e rm f o llo w - u p v is it , t h e n a c c o rd in g t o t h e f o llo w in g s c h e d u le (o r a s re c o m m e n d e d b y y o u r h e a lt h c a re p ro v id e r):

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