The Dangerous Intersection of Breast Cancer and Cardiovascular Disease: A Call for Improved Prevention

Every 14 seconds, somewhere in the world, a woman is diagnosed with breast cancer.1 It is the most common cancer worldwide, with over 2.3 million diagnosed per year.¹ There are approximately 4.1 million female breast cancer survivors in the United States, representing over one-fifth of all cancer survivors in the nation.² Yet there are more strides to be made, as breast cancer is the second leading cause of cancer deaths, following lung cancer.

Meanwhile, cardiovascular disease (CVD) remains the leading cause of mortality among women and often intersects with breast cancer. This connection is most prominent in those undergoing treatments such as anthracyclines or HER2-targeted cancer therapy, due to their cardiotoxic effects.³ Furthermore, breast cancer survivors with CVD have a 1.24-fold higher risk of dying than those without a history of CVD.⁴ The junction between breast cancer and CVD underscores the importance of an integrated approach to improve overall survival rates and quality of life, especially as chemotherapy and radiation can lead to cardiotoxicity, exacerbating cardiovascular conditions and contributing to poorer survival rates.

This intersection becomes even more critical when considering gaps in health equity such as racial disparities, socioeconomic status, and geographic location. For instance, Black women in the United States are more likely to die from breast cancer than their White counterparts, despite having a lower incidence rate.⁵ Patients from lower socioeconomic backgrounds experience worse cardiovascular outcomes.⁶ Research shows that breast cancer survivors living in rural areas face a 24% higher risk of cardiovascular mortality than those in urban areas.⁷

The high prevalence and mortality rates of breast cancer, coupled with adverse CVD effects of treatments and pervasive disparities, highlight the urgency for an encompassing, equitable clinical framework. This strategy must aim to improve early detection, optimize treatment protocols, and ensure that all women have access to the care they need to achieve the best possible outcomes.

Cardio-Oncology Clinical Framework
A clinical framework to minimize cardiotoxicity in breast cancer patients supports an overarching mission to improve the patient’s quality of life and health outcomes, making strides to close gaps in health inequities by integrating multidisciplinary approaches to deliver comprehensive care.

Risk Assessment and Stratification
A clinical framework needs to assess and stratify patients based on their risk of developing cancer treatment–related cardiotoxicity. A comprehensive cardiotoxicity risk assessment is crucial to inform oncology therapy selection, preventive medicine appropriateness, and therapy monitoring.⁸ Cardiotoxicity, which is impacted by both the clinical assessment and oncology treatment plan, may change throughout the treatment journey. The clinical assessment includes gathering information such as cancer treatment and cardiovascular history, age, and genetic factors.⁸ The assessment is then coupled with complementary tests such as b-type natriuretic peptide (BNP), electrocardiogram (ECG), glycated hemoglobin A1c, estimated glomerular filtration rate, and a lipid profile.8 To stratify patients’ cardiovascular toxicity risk, the European Society of Cardiology (ESC) guidelines support the use of the Heart Failure Association and International Cardio-Oncology Society baseline risk stratification score with a class IIa recommendation, level of evidence C.^9,10 This is one of multiple risk stratification tools available that categorize patients’ risk levels, from low to very high, based on their clinical assessment. The assessment and subsequent risk level inform the development of a customized treatment pathway for each patient.

Prevention Strategies
Implementing preventive measures can significantly reduce the incidence of cardiotoxicity. According to the ESC guidelines on cardio-oncology, key pharmacological strategies include the use of cardioprotective agents such as dexrazoxane, beta-blockers, and angiotensin-converting enzyme (ACE) inhibitors to protect heart function.¹⁰ Adjusting chemotherapy doses and schedules to minimize cardiac exposure without compromising oncologic efficacy is another important approach.¹⁰ Additionally, encouraging patients to adopt heart-healthy lifestyles, including a balanced diet and smoking cessation, can further reduce the risk of cardiotoxicity. Exercise alone is associated with meaningful reductions in the incidence of cardiovascular events in women with nonmetastatic breast cancer.¹¹

Early Detection and Monitoring
Once patients are assessed and risk-stratified and applicable prevention strategies are implemented, ongoing monitoring and early detection of cardiotoxicity is crucial for timely intervention to minimize the adverse cardiovascular effects associated with treatment. Guidelines from ESC as well as the American Society of Clinical Oncology and the European Society for Medical Oncology emphasize the importance of regular monitoring during and after treatment once a baseline has been established. This involves scheduling periodic cardiac assessments for surveillance during and after treatment based on baseline cardiovascular risk.¹² Monitoring cardiac biomarkers such as troponins and BNP can provide early indications of cardiac injury. Utilizing advanced imaging techniques like cardiac MRI for detailed evaluation of cardiac structure and function can also aid in early detection.¹² Echocardiography and ECGs should be performed at regular intervals, with additional tests as needed based on patient risk and treatment selection.^12,13 By integrating imaging and biomarkers, providers can tailor surveillance protocols to patient risk assessments, ensuring that all patients receive the necessary attention. Ultimately, this helps maintain cardiovascular health, allowing patients to continue their cancer treatment with reduced risk of severe cardiac complications.

Management of Current and Long-Term Cardiotoxicity
Effective management of cardiotoxicity requires a multidisciplinary approach involving oncologists, cardiologists, and primary care providers throughout the treatment journey.¹³ Key components include adjusting cardiotoxic treatment regimens based on the severity of cardiac dysfunction.¹⁴

Administering cardioprotective medications, like dexrazoxane, and managing heart failure symptoms with standard heart failure therapies, like ACE inhibitors and beta-blockers, are essential.¹⁴ (See Related Cover Story on new research.) Post treatment, long-term cardiac monitoring and lifestyle modifications, such as regular exercise and a balanced diet, are important for ongoing heart health. A multidisciplinary approach aims to balance effective cancer treatment with minimizing cardiovascular risks and supports recovery. Plans that outline ongoing cardiac monitoring and management strategies support the development of individualized survivorship care.¹⁵

Educating patients about the signs and symptoms of cardiotoxicity and the importance of regular follow-up ensures they remain vigilant about their cardiovascular health. Seamless communication and coordination among health care providers helps deliver comprehensive care, addressing both oncologic and cardiac needs.

Health Equity in Managing Cardiotoxicity
Supporting health equity in managing cardiotoxicity is imperative. All patients should have equitable access to cardiovascular assessments and ongoing treatments, regardless of race, socioeconomic status, or ethnicity. Ensuring that providers are educated about patient barriers to care in prevention, early detection, and treatment in underrepresented groups is an initial step toward reducing inequitable care. Furthermore, by addressing social determinants of health, such as access to health care, education, and support systems, providers and patient navigators can help mitigate disparities in clinical outcomes.¹⁶

Care pathways may also help overcome barriers to inequity by recommending evidence-based practices to all patients likely to benefit. For example, a pathway may highlight cardiotoxic regimens and prompt providers to seek a cardiology referral. A multidisciplinary approach that promotes awareness of these disparities can significantly improve cardiovascular health and cancer treatment outcomes for all breast cancer patients, fostering a more inclusive and just health care system.

A Call to Action
A clinical framework for evaluating cardiotoxic oncology treatments should be customized for the patient by integrating risk assessment and stratification, prevention, early detection and monitoring, treatment, and ongoing care underpinned by equitable health care for all cancer patients. By adopting a multidisciplinary team approach leveraging a clinical framework, clinicians and the health care team can more effectively mitigate the risks of cardiotoxicity, ultimately improving the quality of life and outcomes for breast cancer patients and survivors. A holistic approach helps ensure patients receive the best possible care while balancing the demands of cancer treatment with the need to protect and preserve heart health.

The Role for Health Plans
Health plans also play a crucial role in managing cardiotoxicity by extending comprehensive coverage and access to necessary cardiovascular assessments and treatments. Health plan care coordination teams may facilitate regular cardiac monitoring essential for early detection and management of cardiotoxicity. They also support the use of cardioprotective medications and interventions. Additionally, health plans can promote health equity by providing resources and support to underserved populations, ensuring that all patients have access to high-quality care regardless of their socioeconomic status. Evolent, a specialty and primary care management company, partners with health plans and providers to enhance outcomes for patients with complex clinical conditions, including cancer and CVD. Working across specialties and primary care, Evolent seeks to improve the care journey, facilitating more connected, higher-quality, and more efficient care for patients. Yet, it remains crucial for all stakeholders—health care providers, health plans, care coordination teams, patients, and their caregivers—to proactively minimize these risks, leading to improved quality of life and overall outcomes. This comprehensive approach aims to improve overall outcomes and quality of life for breast cancer patients.

Author Information
Terra Wonsettler, PharmD, MBA, is vice president of pharmacy for Evolent, a company specializing in connecting care. At Evolent, she is responsible for oncology medical policy, pathway, and provider education in both clinical and quality initiatives. Prior to Evolent, Wonsettler started her career as an oncology hospital pharmacist before serving over a decade leading health plan medical and pharmacy benefit administration. She serves on the board of directors for the Academy of Managed Care Pharmacy.

References
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