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Role of cardiologist with history of heart disease

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Posted 1/8/2014 7:12 PM (GMT -5)
I have read a lot about how some treatments increase the risk of heart attacks, etc but I was wondering if any of you who have been diagnosed with PCa, were already suffering from some form of heart disease. I haven't read much about how the cardiologist fits in the 'team' needed to fight PCa.
Posted 1/8/2014 8:17 PM (GMT -5)
In my case the cardiologist wasn't part of my PC treatment plan. I have hypertension and other risk factors that I've consulted a cardiologist about. All that information has been recorded in my medical charts and when the URO and RO were considering what treatment to recommend they took that information into account.

Which is one of the reasons why the URO I had didn't recommend surgery for me, she thought it would introduce too many cardiac risks. Radiation didn't have the same heart risks.

Also, once I started down the treatment path, I didn't consult my PCP much until the RO and URO decided my primary treatment was over.

Andrew
Posted 1/8/2014 9:07 PM (GMT -5)
I think you are thinking the right way. It just makes sense for various medical disciplines to communicate with each other regarding how one treatment may impact the other disease. There are treatments that have a positive impact on heart disease and may benefit prostate cancer. For example, statins, such as Lipitor benefits cardiac patients and MAY benefit prostate cancer. Metformin used in diabetics and pre-diabetics may benefit both cardiac and prostate cancer patients.
Hormone treatment, sometimes utilized in prostate cancer patients, may increase the risk of cardiac disease. Having a cardiologist that emphasizes proper diet and exercise makes good sense. Some may add metformin to reduce the weight gain associated with hormone therapy. There are other examples of this so it makes sense for your cardiologist to work with the physicians that are treating your prostate cancer.

Paul
Posted 1/8/2014 10:05 PM (GMT -5)
Thank you for your replies. Also, due my poor typing skills, in my original message I meant to write "fight PCa" and not "fit PCa". Maybe I was subconsciously thinking of the word "fix" rather than "fit".
Posted 1/8/2014 10:30 PM (GMT -5)
Traveller - we knew what you meant, typos are are easy to make. In case you didn't know, you can edit your own posts by clicking on the pencil icon in the upper right hand corner of your post.

and, yes, we'd all like to 'fix' this PC thing.
Andrew
Posted 1/9/2014 12:56 AM (GMT -5)
No, I didn't notice the pencil and I have learned something new today. Thanks.

Hannah
Posted 1/9/2014 2:10 AM (GMT -5)
Surgeons and anaesthetists are often reluctant to perform major surgery on people with cardiac issues, so treatment choices may be restricted for a PCa guy with a "Dicky Ticker". (Robot surgery can be about four hours and for most of this the body is at 45° to the vertical head down which can put a fair bit of strain on the heart)

Father-in-law has PCa and bad heart, he has had quadruple bypass, he is also diabetic. Not a good candidate for surgery so he started with watchful waiting, PSA has not gone too high (sorry I have no details). He has been doing watchful waiting for so long now that I have forgottten how long it was since he was diagnosed, it think it may be as long as 14 years ago. (he's nearly 78)

I'm no expert, but I think a cardio doc's opinion should be included in the decisions about treatment if the patient has heart issues.

Alf
Posted 1/9/2014 3:49 AM (GMT -5)
As Alf pointed out, a cardiac history may make surgery considerably more risky or even out of the question. My history is fairly mundane; I had a stent implanted in 2004 at age 47 and have been fine since with statins and blood pressure meds. But my surgeon required a full cardiac workup including a stress test prior to surgery. With your history, a robotic might be out of the question (Note: I am not a doctor) because as Alf also pointed out you'll be head down for the entire procedure.
Posted 1/9/2014 9:19 AM (GMT -5)
I discussed my PCa with my cardiologist from the start. He was most interested in the side effects of the lupron relative to metabolic syndrome. After our intial discussion on this topic he did some research to be sure I was not bsing him. The blood sugar rise began at about the second year and he told me then I was prediabetic. Most recently my PCP has put me on Metformin due to extremely high blood sugar. It seems to be helping.... along with diet and exercise. (the last phrase is obligatory) :)

Don
Posted 1/9/2014 3:03 PM (GMT -5)
I have not had any serious heart issues, just regular check ups, and statins for prevention..

But since the Lupron aggravates cardio metrics, I made the cardiologists aware, and vice versa with the medical oncologist.

Heart issues are more fatal than prostate cancer, so cardiologist insights would outweigh medical oncologists if they were not in agreement, which has not been the case so far.

LupronJim
Posted 1/11/2014 12:06 PM (GMT -5)
My husband is still mulling over his options. I posted his whole story in another thread, "Choices with Gleason 8". Because of his pre-existing cardiovascular disease and his dread of surgery, he is leaning towards radiation as his primary treatment choice. Knowing that HT is inevitable as are the resulting SEs, their effect on cholesterol/blood sugar levels are worrying. He is currently taken 40mg Lipitor which I gather combined with various HT drugs can be bad news with respect to the liver.

Because hubbie had a policy of avoiding all doctors like the plague, he hasn't seen a cardiologist in years. So, now, along with seeing RO/uro, we are trying to arrange a visit with a knowledgeable cardiologist.

Although weight gain can be an issue with HT, hubbie can probably afford to put on a few pounds. He is currently 135 lbs (height 5'7") and I sometimes think he is too thin!!!

Obviously, the policy of doctor avoidance is now being reworked.
Posted 1/11/2014 1:32 PM (GMT -5)
The link between ADT and cardiovascular events is controversial. In 2010, The American Urological Association, American Heart Association, etc. reviewed the evidence and decided that there probably is some link, but not enough to prevent its use where indicated. They recommended taking prudent measures (statins, antihypertensive, metformin, aspirin) and simply monitoring.

Androgen-Deprivation Therapy in Prostate Cancer and Cardiovascular Risk
A Science Advisory From the American Heart Association, American Cancer Society, and American Urological Association Endorsed by the American Society for Radiation Oncology

Since then, a report published in JAMA found that there was no association between ADT and risk of CV death.

Association of Androgen Deprivation Therapy With Cardiovascular Death in Patients With Prostate Cancer

However, a database analysis undertaken by researchers at Memorial Sloan Kettering found an association between ADT and a higher occurrence of thromboembolic events, that increased with ADT duration.

Androgen Deprivation and Thromboembolic Events in Men with Prostate Cancer

Interestingly, the effect may be linked to GnRH agonists (like Lupron) but NOT to GnRH antagonists (like Firmagon). So simply using a different ADT medication may be all that's needed.

Cardiovascular Morbidity Associated with Gonadotropin Releasing Hormone Agonists and an Antagonist

It is also controversial whether ADT is beneficial when high risk men are receiving primary therapy with dose-escalated radiation, combo radiation therapy or hypofractionated radiation therapy. In fact, I think the BC Cancer Agency recently completed a major clinical trial to determine this. The duration of ADT is also not set in stone. Two months before start of radiation seems optimal, and for high risk, up to 18 months in total IF it is a benefit at all.

Lots of treatment decisions to fully discuss with your RO.

- Allen
Posted 1/11/2014 3:18 PM (GMT -5)
Tall

According to Dr. Lam, it is the weight gain SE from ht that causes the other problems, such as heart disease/diabetid

Mel
Posted 1/11/2014 5:07 PM (GMT -5)
I'm sure he's right that that's a big part of it and that keeping weight down and other lifestyle changes can prevent most of the CV effects. There seem to be other changes as well, like loss of insulin sensitivity and increase in blood lipids. There's also the fact that Lupron has a greater CV effect than orchiectomy or Firmagon.
Posted 1/11/2014 7:48 PM (GMT -5)
Allen,

I am totally impressed by your vast knowledge on this topic and all the links that you provide. Hubbie and I are science research types so like to have tons and tons of information, even if it makes it that much harder to decide what to do. I will definitely chase down the the BC Cancer Agency's study that you mentioned.

Hopefully, the RO won't mind too much but I can always just say that "Tall Allen" on the Internet told us so :-)

From what I have read, it looks like it is the weight gain from taking the HT that seems to be a major contributing factor, especially around the belly. As we happen to know an awful lot more about heart disease than we do about PCa, at least, we will be able to keep on top of that issue.

Dr. Myers, on his blog, does say that Lipitor is bad when taking certain HT drugs and suggests switching to Crestor (as it acts differently on the body than Lipitor).
Posted 1/12/2014 12:30 AM (GMT -5)
I think he will be much more impressed if you whip out the research. That's what I do. Usually, I just email it to my doctor, who has often already seen it (he's at a teaching hospital where they're encouraged to stay abreast of the latest developments).

One of the ancillary benefits of taking statins and metformin for CV issues is that they may sensitize the cancer to the radiation. It's all just lab studies and a retrospective analysis at this point, but the risk is low and benefit is high. Here are some studies for you and your husband to pore over.

Metformin and Prostate Cancer Radiation Therapy: Improved Outcomes Due to Enhanced Tumor Oxygenation

Metformin kills and radiosensitizes cancer cells and preferentially kills cancer stem cells

Utilizing metformin as a radiosensitizing agent in the treatment of prostate cancer.

Statin Use and Risk of Prostate Cancer Recurrence in Men Treated With Radiation Therapy

Improved Biochemical Outcomes With Statin Use in Patients With High-Risk Localized Prostate Cancer Treated With Radiotherapy

Cell Killing and Radiosensitizing Effects of Atorvastatin in PC3 Prostate Cancer Cells

Radiosensitization of MYC-overexpressing prostate cancer cells by statins.

Statins may do double duty by protecting healthy cells:
www.ncbi.nlm.nih.gov/pubmed/19615773
www.ncbi.nlm.nih.gov/pubmed/17674978
www.ncbi.nlm.nih.gov/pubmed/16467108
www.ncbi.nlm.nih.gov/pubmed/15850408

Of course, we avoid supplementing antioxidants and free radical absorbers while taking radiation.

- Allen
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