ATTENTION ALL PERSONS CONCERNED ABOUT HEART AND ARTERY CHANGES AFTER TREATMENT FOR HODGKIN'S DISEASE AND OTHER LYMPHOMAS

CHECK SOME OF THE LATEST DATA (April 2005) ABOUT USING HIGH DOSE STATIN THERAPY AND WHAT ELSE CAN BE DONE ABOUT TREATING OR PREVENTING HEART AND ARTERY CHANGES IN LONG LIVING SURVIVORS

A SHORT HISTORY OF CARDIAC COMPLICATIONS AFTER TREATMENT FOR HODGKIN'S DISEASE

ALSO SEE ADDITIONAL UPDATED STATIN DATA in THE SEPTMEBER 2005 LYMPHOMA FOUNDATION NEWSLETTER

AN IMPORTANT EMAIL MESSAGE FROM PAULETTE D. ABOUT HEART AND ARTERY CHANGES AND TREATMENT AFTER RADIATION TREATMENT
The following email (redacted appropriately and printed with permission by Paulette D.) dramatically  illustrates a ‘story’ that physicians are hearing with more and more frequency as they and their patients become aware of the dangers of some of the late occurring complications of their initial treatment.

From: "Paulette D"
To: <lymphoma@aol.com>
Subject: good warning
Date: Mon, 25 Oct 2004 21:16:57 -0400

Dr. Lacher,
I just wanted to let you know that after you sent out a warning this year about increased incidence of atherosclerosis in patients treated with radiation therapy, I acted based on the information you presented.  My cholesterol has been high for at least the last 12 years but my liver enzymes have also  been high due to a fatty(whatever that is) liver.  Anyway, no one wanted to prescribe statins because of the liver.  I had been to a cardiologist a few years ago who detected some valve damage/murmur that he thought was caused by the radiation but he gave no recommendations on the cholesterol levels.  After your letter, I called my internist and went to see her to put me on a statin.  Once again she hesitated because of the liver so  she also sent me to a cardiologist.(Dr. Erica J----).  Unfortunately I had to wait 2 months  to see her, but when I did she immediately put me on a statin.  But while she was examining me she put the stethoscope against the carotid arteries and found/heard a bruee (bruit).  A Doppler showed that one artery was 50% blocked and the other over 90%.  My radiation treatment was in 1987-two years before I came to you with re-occurrence.  Dr. J---- got me in immediately to see neurosurgeon Philip S---- at Cornell and (Dr.) Y----G---- (intervention radiology)  Because of the prior radiation treatment they recommended stenting which they did last Thursday.  I am fine now, but I have to tell you that had you not sent that letter I would not have sprung into action.  I told each doctor I saw about the letter I received from you and made sure that they were aware of my prior radiation.  I was on a mission to do what needed to be done to address this situation instead of the usual "wait and see if the levels come down" attitude.  Thank you so much. Keep up the information flow.

Peace and love,

paulette d----

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DATA ABOUT USING HIGH DOSE STATIN THERAPY IN TREATING OR PREVENTING HEART AND ARTERY CHANGES IN LONG LIVING HODGKIN'S SURVIVORS AND THE GENERAL PUBLIC

The concept that follow-up care is unnecessary after a ‘cure’ is declared at the five year bench mark is not applicable to lymphoma patients… These patients should not be dropped from careful continuing follow-up care and with the advent of a growing body of knowledge concerning the value of high dose statin therapy (e.g. 80mg daily of atorvastatin – Lipitor)* it is more imperative that each patient review their special need for high dose statin therapy with their physicians and they may refer their physicians to the continuing additional data published on this subject such as the latest study by LaRosa, et al published in April 2005 in the New England Journal of Medicine.

Intensive Lipid Lowering with Atorvastatin in Patients with Stable Coronary Disease by LaRosa J. C., Grundy S. M., Waters D. D., Shear C., Barter P., Fruchart J.-C., Gotto A. M., Greten H., Kastelein J. J.P., Shepherd J., Wenger N. K., the Treating to New Targets (TNT) Investigators N Engl J Med 2005; 352:1425-1435, Apr 7, 2005; published at www.nejm.org on Mar 8, 2005

“In summary, our findings demonstrate that the use of an 80-mg dose of atorvastatin to reduce LDL cholesterol levels to 77 mg per deciliter provides additional clinical benefit in patients with stable CHD that is perceived to be well controlled at an LDL level of approximately 100 mg per deciliter. These data confirm and extend the growing body of evidence indicating that lowering LDL cholesterol levels well below currently recommended levels can have clinical benefit.”

*See additional data about the value and use of the 'statins' and general 'guidelines' of use... published in 2004

*Also see important statin data as noted in the Lymphoma Foundation September 2005 NEWSLETTER

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WHAT ELSE CAN BE DONE ABOUT TREATING OR PREVENTING HEART AND ARTERY CHANGES IN LONG LIVING SURVIVORS

The best management for radiation induced cardiac damage is prevention. Therefore...

1) It may be possible through more sophisticated methods of delivering the radiation by using IMRT (Intensity Modulated Radiation Therapy)…  such as the research and practical application of IMRT by Dr. Joachim Yahalom** at Memorial Sloan Kettering Cancer Center…  that excessive damage to the heart and the blood vessels could be minimized. The problem is that only a very small number of radiation therapy units throughout the USA are equipped to do this and at this time there is no short or long term follow-up data to verify the value of this approach.

2) It may be possible to treat only with chemotherapy and avoid the use of radiation therapy as indicated by the recently published research (in December 2004) of Dr. David Straus**, et al from the Memorial Sloan Kettering Cancer Center.

Results of a prospective randomized clinical trial of doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) followed by radiation therapy (RT) versus ABVD alone for stages I, II, and IIIA nonbulky Hodgkin disease David J. Straus, Carol S. Portlock, Jing Qin, Jane Myers, Andrew D. Zelenetz, Craig Moskowitz, Ariela Noy, André Goy, and Joachim Yahalom  Blood, 1 December 2004, Vol. 104, No. 12, pp. 3483-3489.

At the same time enthusiasm for chemotherapy treatment as the sole primary therapy must take into account the potential early and late cardiac damage caused by certain chemotherapeutic agents and particularly ‘Adriamycin’ and its analogues.

3) CONSIDER ADDING A STATIN TO THE MEDICAL REGIMEN OF PATIENTS TREATED WITH RADIATION THERAPY EARLY AFTER THE TREATMENT IS CONCLUDED. Now that there is a general consensus of the value of adding a ‘statin’ to the medical regimen to help prevent and treat coronary artery disease… all physicians and especially medical oncologists and radiation oncologists… should insist on meticulous cardiac monitoring of their long-lived patients. The case for the use of statins such as atorvastatin (Lipitor) in the general population is made more clear with each succeeding analysis and the latest report (LaRosa, et al in the New England Journal of Medicine noted above) once again reiterates the potential value of high dose (80 mg) atorvastatin in both preventing and even reversing coronary arteriosclerosis.

4) And if prevention of damage has not been achieved then, in addition to the potential reversible value of high dose statin therapy... surgical replacement of damaged heart valves and coronary artery and carotid artery stents have also been effective in correcting the damage or bypassing the obstructions.

*****

** Research by Dr. David Straus (Chemotherapy vs Radiation and Chemotherapy for Hodgkin’s Disease) and Dr. Joachim Yahalom (IMRT) has been supported by grants from the Lymphoma Foundation.

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A VERY SHORT HISTORY OF CARDIAC COMPLICATIONS AFTER RADIATION TREATMENT FOR HODGKIN'S DISEASE

We have known about the potential danger of the late effects of radiation therapy for a long time… In 1982 Applefield, et al, reported (in Cancer Treatment Reports 66:1003-1013) that radiation induced pericarditis, coronary artery disease, and cardiomyopathy could occur in a fourth of the patients treated with radiation to the upper mantle field. But the importance of this observation was subject to much controversy especially because the acute side effects of radiation therapy were usually reversible…and the immediate goal of long survival was still elusive.

It took some time for physicians to appreciate that in the long-surviving patients the serious late developing effect of radiation on the coronary and carotid arteries would decrease their chances for a truly ‘normal’ life expectancy.  Seeking to focus attention on the late side effects of treatment that were impinging on the survival of their Hodgkin’s patients Dr. Mortimer J. Lacher and Dr. John Redman of the Memorial Sloan Kettering Cancer Center compiled and edited Hodgkin’s Disease: The Consequences of Survival (published in 1990 by Lea & Febiger) consisting of expert analyses by a wide range of dedicated physicians caring for Hodgkin’s patients. In that volume the importance of the late occurring cardiac changes was not fully appreciated as Drs. Gerling, Gottlieb and Borer of various cardiology divisions of the Cornell University Medical Center stated: “The occurrence and clinical importance of radiation-induced coronary artery obstruction continues to be a widely debated issue” and Dr. Jay S. Loeffler and Dr. Peter Mauch of the Joint Center for Radiation Therapy, Department of Radiation Therapy, Harvard Medical School and Dr. Samuel Hellman, Dean, Pritzker School of Medicine in Chicago, Illinois commenting on the cardiac effects of mediastinal (central chest area) radiation therapy concluded: “Fortunately, the vast majority of late effects are not severe and only a very small proportion of patients develop major complications leading to permanent disability or death.” However, with the passage of time and greater awareness of the late developing side effects after radiation therapy… this is clearly not the conclusion that they would draw today… and in fact Mauch and his colleagues continued to record follow-up data and in a publication twelve years later in April 2002 noted:

“After 12 to 15 years, treatment-related mortality, including death from second malignancies, cardiovascular or pulmonary diseases, and infections, begins to exceed the mortality from Hodgkin’s disease in patients with initially early-stage disease.” (Long-Term Survival and Competing Causes of Death in Patients With Early-Stage Hodgkin’s Disease Treated at Age 50 or Younger by A. Ng, et al … and Mauch - Journal of Clinical Oncology, Vol 20, Issue 8 (April), 2002:2101-2108)

It should be obvious to all observers that in the 1960s, seventies and eighties our primary goal was to stop the early deaths in patients with Hodgkin’s disease and other lymphomas and attention to late occurring side-effects was not at the forefront of physicians’ concern

Now it is clear that long life can be achieved and because patients can be expected to survive twenty, thirty or more years after treatment…  it is necessary for all physicians to continue to monitor their patients to see if they can possibly prevent or properly treat late occurring life threatening cardiovascular side effects and to monitor their patients with early mammograms to catch breast cancer at the earliest possible moment and recommend colonoscopy and other follow-up measures to reduce the mortality associated with the late onset of various malignancies that are more common in the treated lymphoma patients.

Continue to conduct careful follow-up examinations for a lifetime...  long after the five-year mark has been achieved.

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