As cardiologists and oncologists swap cross-fire about the conditions they treat and how they do so, here’s hoping that, above all, their female patients end up helped and not harmed, getting vital information about risks and benefits of therapies for two of the leading killers of women: heart disease and breast cancer.
What’s behind the medical specialists’ cross currents? Cardiologists and the American Heart Association are pointing to a major therapeutic statement published in the medical journal Circulation.
On the one hand, it provides what many see as an important, needed call to doctors of all kinds to recognize that heart disease among women goes “dangerously under-diagnosed and under-treated,” due in no small part because practitioners still fail to see that women suffer heart attacks in different ways than do many men. They do not, for example, suffer stabbing chest pain, radiating into the arm. Instead, as they experience clogs in tiny veins and arteries, they may feel a constant exhaustion and a discomfort as if they were having their chest squeezed or crushed.
As they treat women for their heart disease and its different manifestation, the scientific guidance also urges cardiologists and oncologists to better recognize and reckon with the reality that current radiation treatments and chemotherapies can cause cardiac failure and other cardiovascular woes. These may not show up for years after treatment.
Women and their doctors should not see this information as a deterrence to getting urgent, recommended, and appropriate breast cancer treatments. Their doctors should work to minimize the harms that these can cause, and they must provide women with more information and context about breast cancer and heart disease, the statement urges.
The heart association, in its own information about the statement, has emphasized that risk factors overlap for cardiac and breast cancer woes, including “age, tobacco use, diet, obesity and sedentary lifestyle.” But the group adds this pointed language:
As medical experts find overlapping care and treatment issues [for heart disease in women and breast cancer], the result is that a new emerging medical specialty is evolving for patients. At the heart of the issue is that many women believe breast cancer poses a bigger risk than heart disease. They are wrong. For women overall, heart disease poses a bigger risk than breast cancer. About 40,000 women die of breast cancer every year in the U.S., according to the Centers for Disease Control and Prevention. Meanwhile, roughly 10 times that number die from heart disease, according to heart disease and stroke statistics released in January and published in Circulation.
Oncologists, the Washington Post reported, long have known about risks their treatments for breast cancer may pose to women patients. They need to keep them in mind, and to provide patients with ample information about this potential peril in their care, the newspaper said, quoting Otis Brawley, chief medical officer of the American Cancer Society and a longtime critic of overtreating breast cancer. He noted:
It isn’t unusual … for a breast-cancer patient who underwent chemo years earlier to wake up one day with swollen ankles and shortness of breath, symptoms of congestive heart failure. Yet when such a patient ends up in the hospital … doctors tend to look for signs of a heart attack or pulmonary embolism while overlooking breast cancer treatment as a possible culprit. That’s a problem because heart failure caused by a chemo drug like doxorubicin is treated differently than heart failure from a heart attack.
The Washington Post also quoted other cancer specialists who said they feared that women might fail to catch the nuance of the cardiologists’ statement, leading them to forego beneficial care. Breast cancer treatment continues to advance but some of its difficult therapies, evidence shows, change and save lives.
The Wall Street Journal, meantime, reported that harsh chemotherapies have come under question among breast cancer specialists, especially for early-stage tumors. A newer approach seeks to determine, for example, by genetic tests if a tumor, detected early and relatively small, can be treated with surgery, radiation, and other less aggressive means — what some practitioners describe as a “de-escalation.”
These advocates note that:
Among the chemotherapy drugs commonly used against breast cancer are Cytoxan, Adriamycin, Taxol and Taxotere, administered intravenously. In addition to nausea, side-effects can include hair loss and fatigue. The de-escalation debate … isn’t about these drugs, which oncologists generally agree can be effective. Rather, it is about which patients would benefit from such regimens.
On the other hand, other experts quoted by the Wall Street Journal, while agreeing that radiation and chemotherapies can be “toxic,” as one argued: “The worst toxicity is death.”
In my practice, I see the not only the significant harms that patients suffer while seeking medical services but also the importance of giving them clear, credible, detailed information about how they will be treated before doctors do anything to or with them. This vital issue of quality medical care is called informed consent, and it is a concept at the core of any free society: People have the right to decide what to do with their bodies, as long as they don’t hurt someone else. This right includes their medical care, for which patients must receive all important facts so they can make intelligent decisions about what treatments to have and where to get them. Doctors don’t need to scare them to death, then to plunk a pile of papers in their faces to get them to waive crucial rights.
Cancer and heart care can be some of the most involved, invasive, costly kinds of treatment that men and women undergo. They need and deserve to know every scrap of pertinent information about potential medical services they might receive, including their full costs, benefits, and risks — including how, especially for older women, these might be more extensive than even they had thought.