Radiation and Cardiac Risk
A new study shows it's real, but not huge, still, it means everyone who is getting radiation--especially to the left side--should discuss the planned dose to the heart
Radiation Raises Women’s Risk of Heart Disease Only Slightly, Study Finds
By DENISE GRADY
Radiation treatment for breast cancer can increase a woman’s risk of heart disease, doctors have long known. But the size of the added risk has not been clear.
Now, a new study offers a way to estimate the risk. It finds that for most women the risk is modest, and that it is outweighed by the benefit from the treatment, which can halve the recurrence rate and lower the death rate from breast cancer by about one-sixth.
According to the study, a 50-year-old woman with no cardiovascular risk factors has a 1.9 percent chance of dying of heart disease before she turns 80. Radiation treatment for breast cancer would increase that risk to between 2.4 percent and 3.4 percent, depending on how much radiation hits the heart.
“It would be a real tragedy if this put women off having radiotherapy for breast cancer,” said Sarah Darby, a professor of medical statistics at the University of Oxford in Britain, and the lead author of the study, published Wednesday in The New England Journal of Medicine.
Dr. Silvia Formenti, the chairwoman of radiation oncology at New York University Langone Medical Center, said she worried that women with cancer would misconstrue the findings to mean that radiation is dangerous and that they should have their breasts removed instead of having lumpectomies, in order to avoid radiation.
“There is a wave toward mastectomy in this country,” Dr. Formenti said.
But at the same time, she and other experts say that the cardiovascular risk is real and that when radiation is given, every effort should be made to minimize exposure of the heart.
In addition, women who have had radiation treatment need to be especially vigilant about controlling other factors that increase the odds of heart disease, like high blood pressure and cholesterol.
Dr. Lori Mosca, the director of preventive cardiology at NewYork-Presbyterian Hospital/Columbia University Medical Center, who was not involved in the study, said the findings meant that a history of breast irradiation should be added to the list of risk factors for heart disease and taken into consideration by all doctors who are treating such patients.
“We absolutely need to put on our radar screen that prior radiation to the breast may be a new and important risk factor for women,” Dr. Mosca said.
But she and other experts also warned that the results needed to be verified because the study was not a controlled experiment, but was based on an analysis of records and estimates of radiation exposure to the heart.
Dr. Javid Moslehi, co-director of the cardio-oncology program at the Dana-Farber Cancer Institute in Boston and the author of an editorial accompanying the study, said the research was the first to provide risk estimates correlated with doses in breast cancer treatment, over a long time period.
“This is a huge paper, both in terms of how many women it impacts, and how it opens the door for new studies that need to be done,” Dr. Moslehi said.
He said the study reflected the fact that many people with cancer are now living long enough to encounter long-term effects of both radiation and chemotherapy.
They have given rise to a new and fast-growing field in medicine, cardio-oncology.
About three million women in the United States have been treated for breast cancer, and the majority have had radiation.
Although doctors try to spare the heart, it still gets some of the dose, especially when the left breast is treated. Radiation can damage the linings of blood vessels and scar the heart muscle.
Dr. Darby’s study is based on the records of 2,168 women who had radiation for breast cancer from 1958 to 2001 in Sweden and Denmark; 963 of the women had “major cardiac events” sometime after their cancer treatment, meaning a heart attack or clogged coronary arteries that needed treatment or caused death.
From the treatment records, the researchers estimated the radiation dose to the women’s hearts. They found that the risk began to increase within a few years after exposure, and that it continued for at least 20 years. The higher the dose, the higher the risk, and there was some increase in risk at even the lowest level of exposure.
“It was certainly a surprise to us that the risk started within the first few years after exposure, as radiation-related heart disease has traditionally been thought of as usually occurring several decades after exposure,” Dr. Darby said.
Radiation is measured in units called Grays, and the researchers found that for each Gray to which the heart was exposed, the odds of heart attack or another coronary events rose by 7.4 percent. The average dose to the heart over an entire course of radiation treatment was 5 Gray, they said. For an individual woman, the net effect would depend on her baseline initial risk of heart disease and the total radiation dose to her heart.
Women who already had risk factors, especially those who had had heart attacks in the past, would have seen the largest absolute risk from radiation.
Some radiation oncologists say that nowadays, the dose to the heart is lower than 5 Gray.
Dr. Louis S. Constine, vice chairman of radiation oncology at the University of Rochester Medical Center, said that 2 Gray was more common and that doctors could now put shields in front of the heart and “curve radiation around the chest wall instead of shooting it through the heart and lungs.”
Dr. Formenti thinks that for most patients, the best way to protect the heart is to treat them while they are lying on their stomachs, instead of the usual way, lying on their backs. Women lie on a table or a mattress with openings that let the breasts drop away from the chest.
Anatomy differs, but in most women this prone position helps keep the radiation beams as far as possible from the heart and lungs. The heart still receives some radiation, but significantly less than when women lie on their backs, especially when the left breast is being treated.
“If you can keep it below 1 Gray, which is what we are doing, you are probably O.K. with the majority of patients,” Dr. Formenti said.
During the past 15 years, she said, she has treated several thousand patients this way.
Dr. Formenti and her colleagues also teach the technique to other doctors. But, she said, it is taking a long time to catch on.
Comments
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Kira- I read this article this morning and have to admit it is a concern to me because I had 33 Rads treatments to the left breast which apparently is the breast at the most risk esp for rads. Bottom line is though what choice to we really have? Refuse treatment? Go an alternate route? I am just not willing to play Russian roulette with my life. I knew that radiation scars the lungs and there could be heart issues but apparently it is more of a problem than first thought.
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All of us who have opted for radiation are, for the most part, aware of the risks. They are real. None of us really dispute that. What I take issue with are those who insist on posting their opinions that ALL women who have radiation WILL develop heart/lung/other cancer issues and that, simply, isn't the case. Does the risk exist? Yes. We learn more about it with each study that comes out and we need to learn more about it if we are to make good treatment decisions. But - and this is huge - using these studies and the projected risk to further one's own bias and, possibly, using fear to influence someone away from a treatment that would benefit them hugely in comparison to the real risk involved is reprehensible.
Thank you for posting a more balanced look at the risks vs. benefits and how radiologists actively seek to minimise those risks as far as possible. It is much more informative for women deciding on whether- or not radiation will benefit them.
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Recently there was an article that women who do lumpectomy with rads had a better survival rate than mastectomy--I have to find the abstract--and they postulated that it was the rads.
I worked for a rad onc for 3 years and they primarily did IMRT, and there were "dose histiograms" that showed the doses to the surrounding tissues. I never fully understood them, but clearly the heart did not get the full 5 grays that the breast did.
For me, because I had lymphedema develop early on, the fact that much of my axillary nodes got a big dose--it's standard, even when they're not radiating the axilla--was a concern and my rad onc told me "not to worry": wish I'd known more and she'd been more willing to have a detailed discussion.
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I was worried before I began radiation because it is my left breast, I talked to my RO about my concerns and he showed me the scans. The rads will get to a small part of my heart and lungs, and it is under the number that is "medically acceptable". It was a tough choice, but I feel the treatment has more benefit than risk right now. I am going to be proactive and take care of my heart and keep watch on my cholesterol and think positive that everything will be fine.
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I think we all know most risks involved in all we are going through... but ..ladies please research and be your own advocate. I have left sides breast cancer and am having what is called ABC radiation. this is a technique where a breathing device is used to control your breathing and thus moving the chest wall far away from your lungs and heart. my heart touches my chest wall.. thus breathing in and holding my breath with this machine.. which i know dates back to at least 2003 .. moves vital organs away from the beams. this radition is used for other cancer also.
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PLEASE PLEASE ask your doc to do ABC radiation... it moves your heart completely out of the way! Using this device has moved my heart way out of the way so that none of it nor my lungs are involved!! I had my first one today. It involves a breathing device. Active Breathing Control (ABC) coordinates radiation delivery with the breathing cycle to more precisely target radiation and avoid vital organs. In patients with left-sided breast cancer, ABC can reduce the volume of heart muscle in the radiation field (in my case it moved the heart completly out of the way). Your radiation oncologist will tell you if you are a candidate for ABC.
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I'll definetely inquire on Monday about this, it is my "Dr" day.
Thanks!
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hmm, something I question at the start but the docs reassured me
however, I am now almost 5 years from rads and have several dif issues to deal with, need a talk to the docs it seems
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sigh...just one more thing to add to the list of worries. Left breast and a smoker. I am still likely to have rads due to the 50% reduction in recurrence rate, but sheesh. Is any of this stuff easy? Ah, don't listen to me...having a pity party today. Now that the lumpie and re-excision to get wider margins are done, next step is rads and I am terrified.
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Another option to look into is to see if doing the rads in the prone position (face down) is an option. The breast falls away from the body so there is minimal radiation to the heart/lungs. It won't work for everyone (need to have large enough breasts for one), but if it can work it is a good solution.
It's what I had done .... it's a relatively new technique so not all centers offer it, but is well worth looking into in my opinion.
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This is what Dr. Nancy Snyderman said on the news last about that radiation study:
"Women undergoing breast cancer treatment today need to know that the technology has evolved significantly since the study started back in 1958. It's not just the doses of radiation that are different now, but more important, how precise they are. Radiation oncologists now have pinpoint accurate techniques that minimize or almost completely avoid the heart, reducing the chance for damage while still irradiating the breast tumor. We have come a long way in breast cancer radiation treatments and women should be reassured. Today's take home is that cancer patients have to take care of the rest of their health as well and pay attention their health during treatment."
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Im trying to think about the positive aspects about leftsided radiation but when I read this I got a little nervous because the doses mentioned in the article 1 - 2 or even 5 Gy to the heart are much lower than the "acceptable" maximum doses where Im getting my treatment!...
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for those with concerns similar as mine ive just found some articles which made me feel better:
http://www.ncbi.nlm.nih.gov/pubmed/10543669 (and remember: this was BEFORE breathing techniques were used).
http://www.ncbi.nlm.nih.gov/pubmed/15770005
http://www.ncbi.nlm.nih.gov/pubmed/18376379
http://www.ncbi.nlm.nih.gov/pubmed/19423958 (smaller study but really uplifting results when gated radiation is compared with standard radiation) -
I am SOOOOOO glad I got a mastectomy instead of lumpectomy and rads. I specifically asked my doctor about this issue back in 2007 when I got my mastectomy. He wasn't overly concerned about it but did say, "Yes there is a risk of heart/lung damage" and I would have had to have the left side since that was where my cancer was. This announcement does NOT suprise me!
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Laying on your stomach does not move the heart away from the chest wall. it actually makes the heart fall forward and your chest wall too. please please look into the ABC....active breathing control. ask ask. Folks are flocking to the machine in richmond. I am giving a talk about it this next month at my support group. my Physicist .. who runs the device is giving me lots of info to share.. and pics of my own before and after to show how the heart and lungs are moved out of the way just by using this simple breathing machine.
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I almost did the double mastectomy but when my dna tests came back they showed that i would have to have the chemo and radiation anyway .. so opted to save my breasts.. for now.
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please do! there are places that do it but if not close to you .. worth the drive .. or "vacation" to have it done. i drive an hour each way. If not for this technique i would not be having radiation as the beam showed in the scan .. that was required before treatment. .. showed the beam going right through the middle of my heart. my heart is right up against my chest wall. this is not always the way with all hearts though. the breathing machine allowed me to move my heart way far away so there is a huge gap between.
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9Lives - my Rad Onc said that the heart only falls into the chest for SOME women, but does not for most, and that the purpose of the CT scan and simulations is to make sure that you don't fall into that group before proceding. For those few people that happens to, they do recommend using the breathing technique, but for others, such as myself without that problem the prone position can be very effective.
There is no one-size-fits-all solution that will work for everyone, but a good facility should be able to have multiple options available to ensure the safest treatment available for all patients.
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sorry for the delay. computer trouble.
my heart did not fall .. it was too close to the chest wall thus the breathing tech ABC moved my heart away from the chest wall so that the rad beams did not go through my heart.
SO you are lucky you had a pathway between your heart and chest wall. There is no way i would have done any radiation if it were not for this technique, and no there is nothing that works for all but for those whose heart is too close this works wonders. If i were to lay on my tummy for treatment as with most.. the heart would just get closer to the chest wall.. fall forward.
Unfortunatly the ABC breathing technique is new to our country and not available in most places. which makes no sense as the cost is so low.
I am blessed to have as my doc someone who was instrumental in getting our machine, and thank goodness because now so many folks are driving hours to use it, They have had to add a new RAD machine just to keep up and the ABC machine has only been there about 6months
He has to live somewhere and i am glad he picked Richmond Virginia
Doctor Arthur has lead the teams that have created most RAD Techniques used nationally and internationaly ..his most recent Brachytherapy and some other life saving techniques....one of which i am sure most RAD patients use...
External beam radiation
The MammoSite Radiation
3D Conformal External-Beam Radiotherapy
Hypofractionated whole-breast irradiation.
started and headed the NSABP B-39 clinical trial on Radiation Therapy in Treating Women Who Have Undergone Surgery For Ductal Carcinoma In Situ or Stage I or Stage II Breast Cancer
More than 4,000 patients from across the U.S. will participate in the NSABP B-39 clinical trial. It was designed by Massey’s Douglas Arthur M.D., in collaboration with surgeons and radiation oncology investigators from around the country, and compares the effectiveness of whole breast irradiation (WBI) to partial breast irradiation (PBI) in women with stage 0, I or II breast cancer who have undergone lumpectomies. Whereas WBI irradiates the entire breast, PBI works by targeting the site of the tumor using concentrated radiation applied either externally or internally. The targeted irradiation treatments occur twice a day for two to five days – a significant reduction compared to the seven weeks needed to complete WBI treatments
The NSABP B-41 trial tests the beneficial effects of a new targeted drug combination, lapatinib (also known as Tykerb) and trastuzumab (also known as Herceptin), on patients with HER2-positive breast cancer who have not yet had surgery. Conventional therapies for HER2-positive breast cancer often include chemotherapy involving paclitaxel (also known as Taxol) to kill cancer cells, combined with trastuzumab, which targets receptors on the surface of cells to block HER2 growth signals. Lapatinib also blocks the action of the HER2 protein, but does so through an inside-out mechanism within the cell as opposed to using surface receptors. After drug therapy, patients undergo surgery to remove any remaining tumor, and tissue samples are analyzed to compare the effectiveness of each treatment. Researchers hope this study can predict which tumors will be completely killed by these drug combinations.
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Hi everyone. Sorry this is going to be a book.. Haven't written on the boards in awhile! I'm glad I found this thread. I've been afraid of getting rads, mainly since mine is on my left side so I don't want heart/lung damage. Im in the grey area so ive been having second thoughts. I've been really stressed out the past 3-4 days waffling back and forth. my RO said he recommended rads but since I'm in the grey area, it's my decision... He did say though that if it were his family member, they'd be getting rads.
Ugh... I'm 52 and I'm kind of ready to be done with this! I had chemo, 6 rounds in 10/12, finished 1/13, started Femara after that, then had a dbl. mastectomy in march 2013... So I'm 4 weeks out from that. I just wanted an easy exchange to implants in June and be done... Then My ps said that the fail rate for implants after rads is around 95%... And can take one to two years to fail... typically capsular contracture... i looked it up and it looked bad. PS said it was painful. I was a bit upset by that but I really trust this doctor as about 94% of his patients are cancer patients and he mostly only does reconstruction. He's considered the best around here. I'm just bummed. I really don't want more serious reconstruction surgery like lat. Dorsi, don't think I could handle that. He said I don't have enough belly fat to make two boobies. He said something about taking fat out of my bum to put under the muscle where the implant would have gone, and then get skin and tissue from my back or tummy to fix my radiated side... Feel like ill be stitched up everywhere! Not sure what he will do to the non-radiated side. Sorry this is so long. Ever since I got diagnosed and thru chem, I've been told they really don't think I'll need radiation. Even after the path report, my team of Drs. Didn't think I'd need it. My path was good except for micromets in my SN, very tiny amount, a close margin (2 mm) at the deep margin by my chest wall, I'm HER2+, but still on herceptin for total of 1 year, stage 2a in left breast, 2.5cm tumor, no LVI, but I'm multi-focal and multi-centric, which means I have several tumors in each breast. My right breast is a stage 1c so no rads.
But I think I've always known I'm going with the rads. HER2+ is very aggressive and small cells like to hide out and with that close margin, I don't want to take the chance. I want to be able to tell my middle-schooler I've done everything to fight this monster!
I have been doing lots of research and also read that article about the radiation 'study', but I'm starting to feel better because it followed women from like 1958 till 2002, I think that's what I remember; and my RO said things have changed since then and the radiation center ill go to has state-of-the art machines. They have an IGRT (image guided radiation therapy). You don't have to hold your breath anymore to get your heart and lungs out of the way. It has "respiratory gating" where the machine monitors your breathing and respiratory cycle to determine the exact moment to deliver the most effective radiation while missing your vital organs. The machine can then make up for the movement from your breathing and will make the width of the treatment area much smaller, sparing more of your normal tissue. It's so cool... It gauges when you are taking a full breath and only delivers the radiation at that time, but stops when any movement from breathing puts the rads beam out of the pre-determined treatment area... So basically you just breath normally the whole time.
I don't know if there are a lot of these machines out there, or not or if some of you already know about it. Definitely something to check into. I am lucky that this facility is about 10 minutes from my house. I just found out my facility has this IGRT technology and thought you might be interested in it. Anything to reduce heart damage and I'm in! -
Leigh, I'm more than a little angry since i was told in the beginning (like you) that radiation wouldn't be needed. Had double mastectomy with immediate direct to implant with alloderm. Surgery went well. Now that the BS has the post op report he wants me to get an RO consult. Seeing me MO on Tuesday who is more up on the research. Will post any comments from him here.
Peggy -
9 lives, I too did the ARM breathing...felt like a scuba diver must feel, but sooo glad that my RO (Head of the dept) called saying that she looked at cat scans and from that determined that I would need to do ARM due to heart being close to chest wall, and that I would need to come downtown vs getting rads in suburbs. Worth every mile!!
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Whats the standard amount of radiation necessary? I was told during chemo that I would be needing radiation even after a mascetomy bc of chest well infilitration. of course the breast cancer is on left side. a RO (family acquaintance) mentioned the IRMT technique.
I am wondering how much radiation I would need? I was told 5 or 6 weeks. Another RO told me she likes to do 7 weeks which I figure might be 33 and actually 6.5 weeks. It really stinks this whole breast cancer.esp for a person who was otherwise healty. I hate to take any medication and chemo has been really rough. kind of upsetting since my daughter is graudating from HS later this month and I've been away from my family (kids ,1715,13) so I could be with family. at the end of the day I want to do everything to avoid recurrence and be able to tell my kids that I did everything in my control. The risks are horrible....even worse for left side breast cancer patients but what choice do we really have? You don't want to regret not doing everything possible. I pray to god for minimal damage and side effects....but we are all well aware that the risks are very very real.
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Would you please write a little bit about the active breathing control (ABC)? I am in the middle of chemo, and radiation will start 1 October and my radiation oncologist wants me to do ABC. I see the benefits, so I'm definitely going to try, but I found out during my first and only MRI, that I am super claustraphobic, and I'm worried that having that machine control my breathing is going to be a real challenge for me. Thank you all for sharing so much - I have been reading the posts on chemo, and the shopping list & hints have helped me a lot.
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karibari,
The machine doesn't control your breathing, you are the one controlling the machine.
At least that is the way it worked when I did the ABC breathing to keep my heart out of the field. It wasn't hard. What they did was sit a very small clear box on my chest between my breasts. It had a sensor in it that the machine could read as my chest moved up and down as I breathed. They would say take a breath and hold it...right there (when my chest rose to the right area) for about 15 seconds. That's when the radiation would turn on. If I exhaled or moved out of that spot, then the radiation automatically turned off. Very, very precise.
I felt very good about having rads this way and being able to better protect my heart and lungs.
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sopjie786, the treatment I was prescribed was 45 grays at 3 per day (hypo-fractionated) for three weeks plus boosts afterwards, bringing it up to 56 grays. I have refused radiotherapy since I found out all sorts of things wrong here. Such as boosts should not be combined with the 3 grays a day regime and also that boosts aimed at the tumour bed are fairly irrelevant since the bed can no longer identified (the scar is not the bed site necessarily - surgery changes all that).
Also the boost offered just .08% improvement in recurrence rates for me at my age (50) but doubles the side effects.
No thanks to the whole lot. She warned me I had a 23% recurrence rate according to her stats, which means I have a 77% likelihood of no recurrence. I am going with that. But I did have a particularly low grade cancer, being Tubular, the lowest of them all, no lymph nodes and really big clean margins. I will preserve the one shot at radiotherapy should a recurrence occur sometime in the future.
I am taking my chances since I have informed myself. I had to gather all my thoughts and put it in one place, so I did this on my blog http://nzmermaid.blogspot.co.nz
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Thank you Lee7 - I appreciate your insight. I do feel optimistic about the precision ABC offers & it makes me feel better that the machine doesn't control the breathing! I think my radiation oncologist needs some tips on explaining how it works to newbies like me.
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