Cancer patients get help with matters of the heart

Cardio-oncologist Lavanya Kondapalli, MD, specializes in cardiac problems caused by some oncology drugs
January 23rd, 2017
A patient pose with her oncology team.
Ellen March (second from left) is cancer-free, thanks to collaborative care from medical oncologist Elena Shagisultanova (far left), cardio-oncologist Lavanya Kondapalli and clinic nurse Sanaya Sturm.

Ellen March credits her breast cancer diagnosis to an unlikely source – her infant twins.

March, then 37, noticed that the 15-month-old babies began rejecting her left breast when they nursed. She thought the breast wasn’t producing milk and decided to stop using it. She expected the breast to get a little harder for a short time after that, then soften. But instead it stayed harder and got larger.

March decided to ask her primary care physician about it at her upcoming annual physical. That led to a breast biopsy and the discovery of a stage 3, 13-centimeter tumor.

“My twins discovered my cancer pretty much before anyone else did. They are probably the reason that I found it,” March said.

Her treatment at University of Colorado Cancer Center began two weeks later. She received chemotherapy treatments along with Herceptin, a drug that targets and blocks the receptors of the HER2 molecule, which was driving her cancer. March also underwent a double mastectomy and removal of her ovaries and five-and-a-half weeks of radiation. After completing her final Herceptin infusion Oct. 31 at the Cancer Center, March is cancer-free, said her medical oncologist Elena Shagisultanova, MD.

But Shagisultanova is quick to point out that March’s lifesaving cancer treatment could have been derailed by the very drugs that saved her. That’s because Herceptin has been shown to damage the heart muscle in 4 to 6 percent of breast cancer patients – a problem in and of itself. But heart problems can also disrupt and delay cancer treatment, decreasing the chances of survival.

Unintended consequences

Because of Herceptin’s known cardiac-related risks and those associated with the anthracycline chemotherapy she received, March’s standard of care included regular echocardiograms to evaluate her heart’s blood-pumping ability. But when the tests detected a decrease in cardiac function, Shagisultanova had an additional resource – the state’s only fellowship-trained cardio-oncologist, Lavanya Kondapalli, MD. Kondapalli and nurse Sanaya Sturm, RN, see oncology patients with varieties of heart issues during full-day Tuesday clinics in the Cardiac & Vascular Center at University of Colorado Hospital and half-days on Fridays in the Cancer Center.

In March’s case, Kondapalli prescribed beta blockers and ACE inhibitors to manage her blood pressure and decrease stress on the heart muscle. Thanks to her quick support and treatment, March had to skip just one cycle of her Herceptin treatment, Shagisultanova said. That was essential to treating her large and aggressive tumor successfully.

“To cure breast cancer we must administer the full program of treatment,” Shagisultanova said. “That’s the gold standard.” Indeed, she added, Herceptin “melted” March’s cancer, which had spread to her lymph nodes but are now clear, Shagisultanova said.

The medications Kondapalli prescribed, meanwhile, appear to have restored March’s heart function to normal levels, and Kondapalli said she believes that any damage to her heart is reversible. Still, March’s heart health will continue to bear watching. As part of her ongoing treatment to keep the cancer from returning, March must take Aromasin, a drug that blocks the estrogen-producing enzyme aramostase, daily for at least five years, Shagisultanova said. Aromasin, too, has been linked to an increased risk of heart problems in breast cancer patients.

Staying on track

March’s case illustrates a medical irony. As the arsenal of cancer-fighting treatments grows, patients are surviving their disease longer. Thousands of kids lost to lymphomas and other cancers are now surviving into adulthood and many adults are managing their cancers as chronic diseases. Yet that pharmaceutical success has in some cases opened the door to long-term cardiac problems that weren’t much of a concern a decade or two ago when many more cancer patients succumbed to the disease.

Kondapalli and Sturm, who trained in critical cardiac care but also has worked in oncology, confront the dilemma in their clinics, where they see about 20 patients combined each week. For example, drugs that fight renal cell carcinomas and other cancers by choking off a tumor’s blood supply can also attack the entire cardiovascular system, leading to problems like high blood pressure. Radiation treatment for breast cancer and Hodgkin disease may cause collateral damage to heart muscle. Other cancer treatment-related problems include inflammation of the sac surrounding the heart muscle, chest pain, arrhythmias, atrial fibrillation, and coronary artery disease.

“The question is how do we deal with the side effects from the cancer treatment?” Kondapalli said. “We don’t want an existing cardiovascular problem, cardiotoxicity or [injury from] radiation to prevent the patients from getting their treatment.”

Cancer doesn’t wait during treatment delays, so schedule backups in the clinic aren’t an option. “Everything that happens is urgent,” Sturm said. A new patient visit typically lasts 60 minutes. Sturm checks for symptoms, such as shortness of breath, fatigue and swelling; takes vital signs; reviews the results of echocardiograms, stress tests, and labs; and goes over the plan of care Kondapalli develops for the patient.

Sturm also helps to coordinate communication between the clinic and the referring oncology provider and nurses. The goal is to provide a reliable resource for oncologists and their patients, she said.

Kondapalli aims to contribute research in a comparatively new field that is dynamic because of the fast pace of oncology drug innovation. In an effort to establish clearer clinical guidelines, she is involved in work to create a patient registry that can be used to measure outcomes in patients with oncology-related cardiac issues and “inform the future.”

For example, Kondapalli said, “We don’t know a lot about the side effects of chemotherapy on the heart.” She recently authored an analysis of cardiotoxicity as an “unintended consequence” of HER2-targeted breast cancer therapies and advocated that patients receiving chemotherapy receive counseling on the cardiac risk the drugs may pose “as an important part of survivorship care.”

A straight line to life

For Ellen March, the future is now. Cancer was a formidable bump in the road for a mother of three small children who also built a successful career exposing people to the skills and satisfactions of sewing. March hosted nine seasons of a PBS show on the subject and continues today as an editor and writer for a variety of sewing and crafts-oriented publications and websites.

Her love of sewing extends to her childhood in North Dakota, where her grandmother taught her the seamstressing skills that have stayed with her all her life, including during her years at the University of Southern California, where she studied humanities, English and theater along with business administration.

“My current job combines all of those things,” March said. She’s incorporated in her work the skills of her father, who worked as an editor for the Des Moines Register and Los Angeles Times.

“I’m a chip off the old block,” she said. “I’m both sewing and editing.”

March is also carrying on tradition. “Sewing is nostalgic for me,” she said. “It makes me think of my grandmother, and it’s important for me to continue it.” Her five-year-old son, she said, can sew a straight line.

Having traveled a hard road the past year, March is ready to move toward, strengthening the fabric of her life in new ways – and with the help of her mother, who quit her job to help with the kids when Ellen became ill, and her coworkers.

“I feel like a different person in that I look at the world in a different way,” she said. “I still love what I do. It’s my dream job. But what is most important is my family and watching my kids grow up and get married and enjoying my life with them.”

That’s the outcome Sturm and Kondapalli are striving for by working closely with cancer patients and the oncologists who treat them.

“We’re trying to help patients get through their treatments with coordination and monitoring. We want them to be able to get back to their families,” Sturm said.

About the author

Tyler Smith has been a health care writer, with a focus on hospitals, since 1996. He served as a writer and editor for the Marketing and Communications team at University of Colorado Hospital and UCHealth from 2007 to 2017. More recently, he has reported for and contributed stories to the University of Colorado School of Medicine, the Colorado School of Public Health and the Colorado Bioscience Association.