October 23, 2019

Cancer Therapy and Cardiotoxicity

Practical considerations in post-treatment care
With increasing post-treatment cancer survival, integrative care physicians are able to help cancer patients shift from a focus on surviving to living well—but cardiovascular damage caused by cancer treatment can get in the way of optimal wellness.

This article is part of the 2019 Oncology Special Issue of Natural Medicine Journal. Read the full issue here

Over half of people treated for cancer can now expect to live 10 years or more after diagnosis.1 And while longevity is obviously important, optimizing wellness throughout survival may be of equal or greater importance. Unfortunately, an under-recognized detractor—cardiovascular damage—may get in the way of living to one’s fullest after a cancer diagnosis.

Diseases of the cardiovascular system are already highly prevalent, and traditional cancer therapies increase the risk.

Indeed, many commonly used conventional cancer therapies can have potent cardiotoxic effects and impart significant, long-term risk on the cardiovascular system.2 Awareness of this issue, along with implementation of thorough risk assessment and appropriate, evidence-based preventive care in cancer survivors is essential to help ensure long-term wellness in this patient population.

Risk Reduction in a Vulnerable Population

Cancer is the number one cause of death in higher socioeconomic populations within the United States, but cardiovascular disease is still the primary killer of men and women overall, accounting for approximately 1 in every 3-4 deaths.3,4 Traditional risk factors like family history, obesity, diabetes, high cholesterol, smoking, and high blood pressure make thorough risk assessment for most aging adults a necessity. When you also consider the prevalence of less recognized—but important—risk factors such as inflammation, nutritional deficiency, and mental/emotional stress, it’s clear that screening for the presence of cardiovascular diseases in just about everyone is warranted.5-7

Diseases of the cardiovascular system are already highly prevalent, and standard cancer therapies increase the risk. This issue is of particular concern in older cancer survivors, who may already have one or more cardiovascular comorbidities. It’s also relevant for younger adults who went through cancer treatment during childhood, as adverse treatment effects during that time can lead to an earlier onset of cardiovascular disease.8 In fact, surviving childhood cancer in general imparts a nearly 2-fold increased risk of multiple cardiovascular diseases on its own, including congestive heart failure and venous thromboembolism. Patients who survived childhood cancers are also at increased risk of having high blood pressure and dyslipidemia.9

Multiple Toxic Effects Lead to Multiple Pathogenic Sequelae

While previously noted circumstances may impart the most significant risk, review of the wide scope of negative effects that can be anticipated, depending on therapies applied, should spark concern for ruling out heart disease presence in anyone previously treated for cancer (Figure).


Figure: Cardiovascular toxicities associated with antineoplastic drugs in patients with cancer

Originally published in Frontiers in Psychology. Copyright © 2018 Varricchi, Ameri, Cadeddu, Ghigo, Madonna, Marone, Mercurio, Monte, Novo, Parrella, Pirozzi, Pecoraro, Spallarossa, Zito, Mercuro, Pagliaro and Tocchetti.

Commonly used individual therapies have the potential to cause a wide range of health effects. It is abundantly clear that heart disease following radiotherapy, chemotherapy, or hormone therapy may be due to direct cardiovascular damage caused by the treatment itself, or to the development and augmentation of cardiovascular risk factors related to those treatments.2

Cardiotoxic Side Effects of Commonly Used Cancer Therapies10,11


  • Loss of myocardium/cardiomyopathy


  • Myocarditis


  • Thromboembolism from endothelial damage

Anti-HER2 therapies (most likely when combined with anthracycline)

  • Mitochondrial dysfunction

Pyrimidine analogues

  • Myocardial ischemia from coronary vasospasm

Anti-(VEGF) therapies

  • Myocardial ischemia from arterial thrombosis
  • Thromboembolism from endothelial damage
  • Arterial hypertension

Arsenic trioxide

  • Myocardial ischemia

Some tyrosine kinase inhibitors

  • Myocardial ischemia
  • Thromboembolism from endothelial damage
  • Peripheral arterial occlusive disease
  • Pleural effusion


  • Damage to small and large vessels, valves, and pericardium damage

Practical Steps for Risk Assessment and Reduction

Typical follow-up care after cancer therapy consists mostly of monitoring for recurrence. But as life expectancy after cancer treatment continues to increase, this follow-up care is becoming inadequate.12 Cardiovascular screening is clearly necessary. However, the potential complexities involved from case to case, lack of universally accepted guidelines, and lack of sufficient long-term data to help predict cardiovascular outcomes in this patient population creates a situation that is still somewhat fluid and does not allow for a definitive, one-size-fits-all cardiovascular work up.

Nonetheless, after a patient has been treated for cancer, assessment of cardiovascular risk factors and symptom history is still advisable in the primary care setting. Some simple additions such as advanced cardiovascular biomarkers and imaging studies like coronary calcium scoring, carotid intima-media thickness, and echocardiography can help further ensure a more thorough approach to long-term cardiovascular health promotion in cancer survivors.

Categorized Under


  1. Quaresma M, Coleman MP, Rachet B. 40-year trends in an index of survival for all cancers combined and survival adjusted for age and sex for each cancer in England and Wales, 1971-2011: a population-based study. Lancet.  2015;385(9974):1206-1218.
  2. Albini A, Pennesi G, Donatelli F, Cammarota R, De Flora S, Noonan DM. Cardiotoxicity of anticancer drugs: the need for cardio-oncology and cardio-oncological prevention. J Natl Cancer Inst. 2010;102(1):14-25.
  3. Hastings KG, Boothroyd DB, Kapphahn K, et al. Socioeconomic differences in the epidemiologic transition from heart disease to cancer as the leading cause of death in the United States, 2003 to 2015. Ann Intern Med. 2018;169(12):836.
  4. Centers for Disease Control and Prevention. Underlying Cause of Death 1999-2017. CDC Wonder website. https://wonder.cdc.gov/wonder/help/ucd.html. Updated December 6, 2018. Accessed October 9, 2019.
  5. Packard RR, Libby P. Inflammation in atherosclerosis: from vascular biology to biomarker discovery and risk prediction. Clin Chem. 2008;54(1):24-38.
  6. Ginter E. Chronic vitamin C deficiency increases the risk of cardiovascular diseases. Bratisl Lek Listy. 2007;108(9):417-421.
  7. Brotman DJ, Golden SH, Wittstein IS. The cardiovascular toll of stress. Lancet. 2007;370(9592):1089-1100.
  8. Armenian SH, Armstrong GT, Aune G, et al. Cardiovascular disease in survivors of childhood cancer: insights into epidemiology, pathophysiology, and prevention. J Clin Oncol. 2018;36(21):2135-2144.
  9. Faber J, Wingerter A, Neu MA, et al. Burden of cardiovascular risk factors and cardiovascular disease in childhood cancer survivors: data from the German CVSS-study. Eur Heart J. 2018;39(17):1555-1562.
  10. Kirby M. Adding life to years: heart health and cancer. Prim Care Cardiovasc J. 2016. https://www.issuesandanswers.org/wp-content/uploads/MacMillanHeartHealthCancer.pdf. Accessed October 9, 2019.
  11. Ewer MS, Ewer SM. Cardiotoxicity of anticancer treatments. Nat Rev Cardiol. 2015;12(9):547-558.
  12. Siegel RL, Miller KD, Jemal A. Cancer Statistics, 2017. CA Cancer J Clin. 2017;67(1):7-30.