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Healthy living after treatment of childhood, adolescent, and young adult cancer

Keeping Your Heart Healthy
Most childhood cancer survivors do not develop heart problems; however, certain types of cancer treatment given
during childhood can result in damage to the heart. Because heart problems may occur many years after cancer
treatment, it is important for childhood cancer survivors to be aware of any treatments they may have received that canaffect the heart. With this knowledge, steps can be taken to keep their heart healthy, including regular medical checkups and tests to monitor heart function. And if a problem develops, it can be detected and treated early.
How does the heart work?
The heart is a muscular organ that is at the center of the body’s
circulatory system. The heart is responsible for pumping blood withoxygen and nutrients to body tissues. There are four chambers (twoatria and two ventricles) within the heart that work together to pumpblood. Valves direct the flow of blood through the heart chambers andinto the blood vessels. The rhythm of heart contraction and rate of theheartbeat are coordinated by nerves that send electrical impulses todifferent parts of the heart. A thin membrane (pericardium) surrounds
and protects the heart and anchors it within the chest.
What types of cancer treatments can cause heart
problems?
Some types of chemotherapy and radiation involving the heart can cause problems.
Anthracycline chemotherapy
The anthracyclines are a type of chemotherapy used to treat many childhood cancers. This type of chemotherapy cansometimes affect the heart. Commonly used anthracyclines include:• Doxorubicin (Adriamycin®)• Daunorubicin/Daunomycin (Cerubidine®)• Idarubicin (Idamycin®)• Mitoxantrone (Novantrone®)• Epirubicin
Radiation therapy
Heart problems may also result from radiation therapy to the heart or surrounding tissues. This includes radiation to thefollowing areas:• Chest• Spine (chest or “thoracic” portion)• Abdomen• Total body irradiation (TBI)

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What heart problems can occur after treatment for childhood cancer?
There are several types of heart problems that may result from cancer treatments:• The muscle cells of the heart may be damaged so that the heart doesn’t contract and relax normally (leftventricular dysfunction, cardiomyopathy).
• The electrical pathways that conduct impulses to control heart rhythm may be scarred or damaged, resulting inabnormally fast, slow, or irregular heartbeats (arrhythmias).
• The valves and blood vessels of the heart may be damaged, resulting in stiff or leaky valves (valvular stenosis
or insufficiency).
• The protective covering of the heart may become inflamed (pericarditis) or scarred (pericardial fibrosis).
• The blood vessels of the heart may become scarred or blocked (coronary artery disease), preventing deliveryof oxygen and nutrients to the heart and other tissues.
In severe cases, these problems may result in the death of heart tissue (heart attack or myocardial infarction), a
dangerous heart rhythm (arrhythmia), or an inability of the heart to pump blood properly (congestive heart failure).
Which types of cancer treatment are associated with which heart problems?
• Anthracyclines: can cause problems with heart muscle function (left ventricular dysfunction, cardiomyopathy)
and abnormal heart rhythms (arrhythmias).
• Radiation therapy: can cause scarring and stiffening of heart tissues which can result in an abnormal heart
rhythm (arrhythmia) and/or problems with the heart muscle (cardiomyopathy), heart valves (valvular stenosis
or insufficiency), blood vessels (coronary artery disease), or membrane surrounding the heart (pericarditis or
pericardial fibrosis).
Are there other risk factors for heart problems?
Some other medical conditions may also increase the risk of heart problems from chemotherapy or radiation therapy.
These include obesity, high blood pressure, high cholesterol or triglyceride levels in the blood, and diabetes. You may
have a higher risk of having heart problems if these conditions run in your family. Heart disease is also more common
in people who have gone through menopause, so survivors who go through an early menopause may be at higher risk.
Many health behaviors can add to the risk of heart disease including smoking, having an inactive (sedentary) lifestyle,and eating a diet high in fat.
Who is at risk for developing heart problems?
The risk of developing a heart problem after childhood cancer treatment is related to several factors:• The total dose of anthracycline chemotherapy• The total dose of chest radiation• The amount of the heart tissue included in the radiation treatment field• Treatment with other medications that affect heart function• The presence of other conditions that affect heart function
Most childhood cancer survivors who were treated with anthracyclines or chest radiation have no heart damage atall. Some survivors have very mild changes in heart size or function that have not gotten worse over time. Only asmall number of survivors have developed severe heart problems leading to heart failure or dangerous heart rhythms.
Overall, the risk of developing heart problems after childhood cancer therapy is highest in survivors treated with higher
doses of anthracyclines or chest radiation, especially those who received both treatments at a young age.
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Because we do not understand why some survivors develop heart problems after treatment for childhood cancer andothers do not (even when they have gotten the same treatment), it is important for each childhood cancer survivor
treated with anthracyclines or chest radiation to continue to have regular medical check-ups so that if a problem withthe heart develops, it can be detected and treated early.
What are the symptoms of heart problems?
• No symptoms may be noted with mild to moderate heart problems. Identification of problems may only bedetected by cardiac tests such as ECHO, EKG, or MUGA.
• Shortness of breath• Dizziness• Lightheadedness, fainting or near-fainting• Severe fatigue preventing exercise or normal play
• Chest pain that feels like a heavy pressure or fullness and travels to the arm, chin, or face
• Sweating, nausea, or shortness of breath with chest pain
• Sharp piercing pain in the center or the left side of the chest (often worsens with taking a deep breath)• Very swollen feet or ankles (so swollen that if a finger is pressed firmly on the area for a few seconds it leaves
an indentation)• Cough and wheezing that doesn’t go away
• Periods of feeling your heart racing while at rest or skipping beats• Abdominal symptoms (nausea or emesis)
How does exercise affect the heart?
Aerobic exercise (brisk walking, running) is generally safe and healthy for the heart. However, some types of intensive
exercise are particularly stressful to the heart.
Survivors treated with high doses of anthracyclines (250 mg/m2 or higher), or chest radiation therapy (30 Gy or 3000
cGy/rads or higher), or with a combination of anthracyclines (any dose) and chest radiation (≥15 Gy) should check with
their healthcare provider before beginning any intensive exercise program. Those who plan to engage in strenuous orvarsity team sports may benefit from evaluation by a heart specialist (cardiologist).
What other conditions or activities can make heart problems worsen?
A heart exposed to anthracyclines and/or chest radiation may not adapt well to situations that increase the workload of
the heart. This includes:• Pregnancy• Use of stimulant medications or drugs (amphetamines, cocaine, diet pills, ephedra, mahuang, or performanceenhancing drugs)
Illicit drugs should always be avoided. If you are at risk of heart problems from childhood cancer therapy and planning
to use stimulant medications or become pregnant, it is important to discuss this with your healthcare provider. It may
be recommended that you undergo heart testing such as an echocardiogram before becoming pregnant or taking
certain types of medications that may cause excess stress to the heart.

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Are there any other special precautions?
Survivors with prosthetic heart valves and those with currently active chronic graft-versus-host disease (cGVHD)
following hematopoietic cell transplant (HCT) may need to take an antibiotic prior to dental work or other invasive
medical procedures (such as those involving the respiratory, gastrointestinal, or urinary tracts) to prevent an infection
called endocarditis. If you have a prosthetic heart valve or if you have active cGVHD, ask your doctor, heart specialist,
and/or dentist if you should take antibiotics to prevent endocarditis before dental or other medical procedures.
What monitoring is required for potential heart problems?
Anyone treated with anthracycline chemotherapy or chest radiation for childhood cancer should have a yearly checkup with special attention to any symptoms relating to the heart. In addition, an electrocardiogram (ECG, EKG) should
be done at the time the survivor enters long-term follow-up (usually about 2 years from completion of therapy). An
echocardiogram or comparable imaging is also recommended at the first long-term follow-up visit, then according to
the following schedule (or as recommended by your healthcare provider):Cardiac Imaging Schedule Recommendations
Anthracycline Dose*
None to <100 mg/m2
None to <100 mg/m2≥ 100 to < 250 mg/m
≥ 100 to < 250 mg/m2
2

Radiation Dose**
None to < 15 Gy
15 to < 30 Gy
None to < 15 Gy≥15 Gy≥30 GyNone to Any

Recommended Frequency of ECHONo screening
Every 5 years

Every 2 years
None to Any≥ 250 mg/m2*Based on doxorubicin isotoxic equivalent dose**Based on radiation dose with potential impact to heart (radiation to chest, abdomen, spine [thoracic, whole], total
body [TBI])
Survivors who received radiation at a dose of 30 Gy (3000 cGy) or higher to the heart or surrounding tissues orradiation at a dose of 15 Gy (1500 cGy) or higher plus anthracycline chemotherapy may be advised to undergo
evaluation by a cardiologist for stress testing 5 to 10 years following radiation, with repeat testing as recommended by
the cardiologist.
Survivors who received radiation to the heart or surrounding tissues should also have periodic blood tests to check forother cardiac risk factors (lipid profile and fasting glucose or hemoglobin A1C).
Additional evaluation by a cardiologist is recommended for survivors who are pregnant or planning pregnancy andreceived any of the following therapy:•

Anthracycline chemotherapy at a dose of 250 mg/m2 or more•

Radiation at a dose of 30 Gy (3000 cGy) or higher to the heart or surrounding tissues•

Radiation to the heart (15 Gy) or higher in combination with anthracycline chemotherapy (at any dose)Heart monitoring may be necessary due to the extra strain on the heart during the later stages of pregnancy andduring labor and delivery. Suggested monitoring includes an echocardiogram before and periodically during pregnancy,
especially during the third trimester, and cardiac monitoring during labor and delivery.

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How are the heart tests done?
An electrocardiogram (ECG, EKG) is a test used to evaluate heart rate and rhythm. Electrodes (small sticky patches)are placed on the chest, arms, and legs. Wires are attached to the electrodes and the electrical impulses of the heart
are then recorded.
An echocardiogram (ECHO; heart ultrasound) is used to test the muscle function of the heart and how well the heartpumps. The person lies on a table and has conductive jelly applied to the chest. Then a transducer (device that emits
the ultrasound waves) is placed on the chest to obtain different views of the heart. Slight pressure is applied on thetransducer and can sometimes cause discomfort. The test results are displayed on a monitor for the doctor to study
later. Many measurements are done during this test to help find out if the heart muscle is pumping blood well. The
ultrasound test also looks at the valves of the heart to see that they open and close normally. Electrodes are usuallyplaced on the chest to monitor the heart’s electrical impulses during the test.
Cardiac magnetic resonance imaging (MRI) uses a large magnet, radio waves, and a computer to create detailed
images of the heart. Radiation is not used during the MRI. The person lies on the scanning table, which slides into thecircular opening of the MRI machine. Jewelry, eyeglasses, hearing aids, or other objects that may interfere with the
MRI must be removed prior to the test. If contrast is needed, it will be injected into a vein. The scanner can be noisy,
so you will be given earplugs to wear or music to listen to during the test to help block out the noise. Because of thestrong magnet, people who have metal devices (such as a pacemaker, implanted infusion pump, or iron-based metal
implant) cannot have MRIs.
A cardiac stress test measures heart function during periods when the heart is working hard. During this test, theheart and blood pressure are usually monitored while the person walks on a treadmill.
What happens if a problem with the heart is detected?
Your healthcare provider will advise you about the follow-up care you need. Sometimes, a referral to a cardiologist isneeded for additional evaluation and/or treatment with medications.
What can be done to prevent heart problems?
With increasing age, the risk of certain types of heart disease (such as heart attacks and hardening of the arteries) also
increases. Lifestyle factors that may increase the risk of heart problems include smoking, being overweight, eating ahigh fat diet, and not exercising. Medical conditions that increase the risk include diabetes, high blood pressure, andhigh blood cholesterol. You can reduce your risk of heart problems by:•

Avoid smoking and excessive alcohol intake.

•

Maintaining a healthy body weight.

•

Limiting the fat in your diet to no more than 30% of calories.

•

Exercising regularly for at least 30 minutes on most days of the week.

Medical conditions that increase the risk of heart problems include obesity, high blood pressure, high cholesterol or
triglyceride levels in the blood, and diabetes. If you have any of these conditions it is important to take medications or
adjust your lifestyle as recommended by your healthcare provider.

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Written by Debra L. Friedman, MD, Vanderbilt University/Ingram Cancer Center, Nashville, TN; Melissa M. Hudson, MD, St. JudeChildren’s Research Hospital, Memphis, TN; and Wendy Landier, PhD, CPNP, Children’s Hospital of Alabama, Birmingham, AL.
Reviewed by Linda Rivard, RN, BSN; Kayla L. Foster, MD, MPH; and Melissa Acquazzino, MD, MS.

Additional health information for childhood cancer survivors is available atwww.survivorshipguidelines.org
Note: Throughout this Health Links series, the term “childhood cancer” is used to designate pediatric cancers that may occur during childhood, adolescence, or young adulthood.
Health Links are designed to provide health information for survivors of pediatric cancer, regardless of whether the cancer occurred during childhood, adolescence, or young
adulthood.
Disclaimer and Notice of Proprietary Rights
Introduction to Late Effects Guidelines and Health Links: The Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers and accompanying Health
Links were developed by the Children’s Oncology Group as a collaborative effort of the Late Effects Committee and Nursing Discipline and are maintained and updated by the Children’s
Oncology Group’s Long-Term Follow-Up Guidelines Core Committee and its associated Task Forces.
To cancer patients (if children, their parents or legal guardians): Please seek the advice of a physician or other qualified health provider with any questions you may have regarding a
medical condition and do not rely on the Informational Content. The Children’s Oncology Group is a research organization and does not provide individualized medical care or treatment.
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