Don't Break My Heart – An AHA Statement on Breast Cancer and Cardiovascular Diseases

This American Heart Association Scientific Statement may come as a surprise, but written almost exclusively by women for women, it is an important and timely contribution. Most women in the United States and worldwide would not connect these two disease entities and have drastically different opinions of them. Especially minority women and women with a college or lesser education share the perception that breast cancer, rather than heart disease, is the leading cause of death among women(1). Furthermore, there is a lack of knowledge of how lifestyle behaviors affect the risks and outcomes not only of heart disease but also breast cancer (1). In this context, it is extremely noteworthy that media representation of breast cancer is 5 times higher than that of heart disease and mainly targets the older female population (2). While it is well known that women develop heart diseases later in life, they do not have much more favorable statistics. As many as 1 in 3 women die from cardiovascular diseases compared with 1 in 30 from breast cancer. Ninety plus percent of women are diagnosed with non-metastatic breast cancer and the 5-year survival rate is far better then that of patients with heart failure and even after first time hospitalization for myocardial infarction (3, 4). Accordingly, causing cardiovascular disease as a consequence of the treatment of breast cancer has significant prognostic implications. Women with pre-existing cardiovascular disease or risk factors have a higher likelihood to develop clinically manifest cardiovascular disease (“reduced cardiovascular reserve”) (5,6). Importantly, some risk factors are common to both cardiovascular diseases and breast cancer, and adhering to the seven health metrics of the AHA not only reduces cardiovascular diseases, but also the risk of developing breast cancer (7,8). Thus, in multiple dimensions, there is a very unique interplay between cardiology and oncology, and this has become known as “cardio-oncology” (9).

This AHA statement reviews all of the outlined aspects very comprehensively. It presents the scope of the problem, the risk factors common to these two disease entities, the adverse cardiovascular effects of cancer therapy, the monitoring for cardiovascular toxicity, cardioprotective and preventive strategies, and future directions. As it emerges from the beginning, it is directed to raising awareness for the importance of cardiovascular diseases in women in general as much as it is devoted to recognizing and mitigating the cardiovascular consequences of cancer therapy in women with a breast cancer in particular. As laudable as all of this enormous work is, one might ask though, who will be the recipient and whom is this directed to?

Clearly, this statement will go out to the entire community of cardiology, but should there be other recipients and who is the ultimate recipient? It would have been ideal for this very document to go out to the oncologists and ultimately to the patient. Thus, a joint statement with oncological societies and a summary page for patients would have been very welcome. These two groups are the crucial partakers, and in fact, they are the only partakers in the very beginning when breast cancer is diagnosed and a treatment plan is made in the framework of pre-existing and possibly evolving cardiovascular risk. It thus seems to be the best and most crucial time for this topic to emerge so that appropriate decisions can be made. Primary preventive efforts are clearly preferred, and cardiologists should be involved in the care as needed and as early as possible. They will, however, never be able to take as central of a figure as an oncologist. Similarly, in regards to the preventive aspects of cardiovascular disease and breast cancer, this is a domain of interest not only for preventive cardiology but also, and maybe even more so, for preventive medicine, general internal medicine, and family medicine. Hence, this AHA document is much broader in scope, spanning multiple disciplines and multiple aspects of medical care. It should serve to build roads, to lay foundations, and to strengthen existing cardio-oncology service lines. In truth, it is a statement, a statement for cardio-oncology, a statement for women affected by breast cancer, and a statement for women in general, at risk of cardiovascular diseases. “Don’t break my heart!” is the central call to and from women and the echo is to be heard in particular in women with breast cancer.