Radiation for breast cancer can increase heart risks

Telling the difference between run-of-the-mill sore throat caused by a virus, which doesn’t require medication, from strep throat caused by a bacterium, which should be treated with antibiotics, is a tricky thing at any age.

As a mom to three school-aged kids, I have schlepped off to the pediatrician many times to check out a variety of colds, fevers, and sore throats. Many of these appointments included the drama and trauma of the much dreaded (at our house) throat culture. Until recently, the results were always negative.

I was taken aback when our 7 year old actually had strep throat. In the middle of summer.  Twice. The first time involved a very sore throat, fever, and what I thought was a heat rash (it was 90 degrees all that week), that turned out to be the classic rash associated with strep. The second time, we saw similar symptoms, minus the rash. When the next sore throat rolled around, I was convinced it was strep—similar symptoms, plus some little white spots in the back of his throat. Rapid test: negative. Culture: negative.


It can be just as tricky in adults. Current guidelines say there is little benefit for throat swabs for most adults, and they should be limited to high-risk adults. How do you know if you’re at high or low risk? One way is to visit your doctor. She or he will evaluate your symptoms and medical history and do an exam. Based on those assessments, your doctor will come up with a clinical score. If the score says you are at low risk, neither a throat culture nor an antibiotic is required. If you are at high risk, the throat culture is a good idea.

In tomorrow’s Annals of Internal Medicine, physicians from Harvard Medical School, MIT, and the Skaggs School of Pharmacy in California described an “at home” scoring approach that could save folks a trip to the doctor for what would most likely turn out to be a garden variety sore throat.

Here is how it would work. You have just developed a sore throat. You call your doctor’s office and answer a number of questions—for example, do you have a cough or are you running a fever. Your score is then calculated by a formula that accounts for the answers to those questions, your age, and the percentage of people in your area who have tested positive for strep within the last two weeks. If your score is high, then head to your doctor’s office. If it indicates that you are unlikely to have strep, then there is little need for you to rush in for an exam or throat culture. Fluids, rest, and pain relief are the first orders of business. If your symptoms persist or get worse, then you would need to see your doctor.

“We wanted to combine information on how prevalent the infection is in the community, what we call biosurveillance, with two specific patient-reported symptoms in order to identify people who are at such low risk for strep that they are unlikely to be tested even if they do seek care,” said Dr. Andrew Fine, the study’s lead author who is also an attending physician in the emergency department at Boston Children’s Hospital and Assistant Professor of Pediatrics at Harvard Medical School.

This approach could certainly save physicians and patients the time and expense of unnecessary visits to the doctor for a non-strep sore throat. The researchers estimate that use of this kind of score could prevent 230,000 office visits in the United States each year and keep 8,500 men and women from getting antibiotics they don’t need.

There are a few drawbacks to the home score. First, data on how many people have tested positive for strep may or may not be available in your area. Second, this kind of testing would likely miss a few cases of strep throat. However the chances of getting very ill very quickly from strep are small. With appropriate follow up for continued symptoms, it is unlikely that a missed case of strep would lead to severe complications. Third, if this system were in place, it is possible that over time, fewer folks would get tested which might skew how prevalent strep actually is in the area.

In theory, the score could be bundled into an app, avoiding the need for a call to the doctor’s office.

Dr. Kenneth Mandl, professor of medicine at Harvard Medical School and senior associate in medicine at Boston Children’s Hospital is one of the study authors. He points out how important the ability to do biosurveillance is to making a score like this work. “The basic idea is that if a lot of people around you have strep, you’re more likely to get it,” says Dr. Mandl. “This information is so powerful that if you know that strep ‘is going around’ it only takes a few additional facts from a person to come up with a reasonable risk assessment—without that person ever walking into a doctor’s office or clinic.”

Keep in mind that the home score was designed with adults in mind, and won’t cut back on trips to the pediatrician for kids. The American Academy of Pediatrics recommends that all children under age 15 who have a sore throat get tested for strep.

A home score for adults would reduce urgent or emergency visits, save time, dollars, and potentially unnecessary antibiotic use. One for kids would be even better. Daylight Saving Time officially ends at 2:00 am on the first Sunday in November. In theory, “falling back” means an extra hour of sleep this weekend.

Winston Churchill once described Daylight Saving Time like this: “An extra yawn one morning in the springtime, an extra snooze one night in the autumn… We borrow an hour one night in April; we pay it back with golden interest five months later.”

That’s an overly optimistic view. In reality, many people don’t, or can’t, take advantage of this weekend’s extra hour of sleep. And the resulting shift in the body’s daily sleep-wake cycle can disrupt sleep for several days.

Research teams around the world have tried to determine if losing or gaining an hour of sleep because of Daylight Saving Time make a difference in health. Michigan researchers, writing in the American Journal of Cardiology, showed a small increase in heart attacks on the first day (Sunday) of the spring transition to Daylight Saving Time, when we “lose” an hour of sleep. This echoed a Swedish study published in the New England Journal of Medicine showing a small increase in heart attacks after the start of Daylight Saving Time and a small decrease at its end.

Other researchers have looked at driving accidents, workplace safety, and even school performance, with mixed results.
Daylight Saving Time and sleep

The focus on gaining or losing an hour of sleep overlooks the bigger picture—the effect of Daylight Saving Time transitions on the sleep cycle. An excellent review in the journal Sleep Medicine Reviews by Dr. Yvonne Harrison, a senior lecturer at Liverpool John Moores University in England, concludes that a seemingly small one-hour shift in the sleep cycle can affect sleep for up to a week.

In the Fall, only a minority of people actually get that promised extra hour of sleep. During the following week, many people wake up earlier, have more trouble falling asleep, and are more likely to wake up during the night. People who tend to be so-called short sleepers, logging under 7.5 hours a night, and early risers (also known as larks), have the most trouble adjusting to the new schedule.

Similar problems are seen in the Spring. Again, the adjustment is harder for larks and short sleepers.
Springing back

Each of us experiences predictable physical, mental, and behavioral changes during the course of a day. These are called circadian rhythms. The daily cycle of light and dark keep them on a 24-hour cycle.

Sleep is a component of circadian rhythms. It is affected by outside influences, like light or Daylight Saving time. It can also affect the body’s other rhythms.

It’s difficult to side-step the effects of Daylight Saving time on sleep. My advice is to be aware that it can take your circadian and sleep rhythms a week or so to get adjusted to the new clock. Regular exercise, preferably at the same time each day, may help get your sleep cycle back on track. Going to bed and getting up on a schedule can help. And giving in to brief afternoon nap or two during the week may be a pleasant and relaxing way to restore lost sleep. Most people take balance for granted. They navigate without thinking, effort, or fear. For millions of others, though, poor balance is a problem. Some struggle with long-term dizziness or imbalance. Others suffer balance-related falls and injuries. A new study concludes that exercise can reduce not only the odds of falling but the odds of sustaining fall-related injuries.

French researchers analyzed the results of 17 trials that tested the effect of fall-prevention exercises on seniors’ risk of falls and fall-related injuries. Overall, exercise programs reduced falls that caused injuries by 37%, falls leading to serious injuries by 43%, and broken bones by 61%. The report was published online in the BMJ.

Some of the exercise programs were specifically aimed at improving balance. Others were general exercise programs. Two focused on tai chi.
Balance and injury

When a toddler or child falls, he or she usually shakes it off and keeps moving. But when an older adult falls, there are often consequences. Broken bones limit mobility. They can also lead to a downward health spiral. Each year, thousands of older Americans die as a result of breaking a hip. Broken bones and head injuries can knock confidence, engender a fear of falling, and undermine independence.

We’ve known for some time that structured exercise with balance training helps reduce falls, and assumed that such programs would also help prevent fall-related injuries. The BMJ report supports that assumption.

Although balance training is the mainstay of fall prevention programs, any exercise that improves endurance, muscle strength and flexibility can help prevent falls and related injuries.

Beyond better balance, the other benefits of multi-component exercise programs include:

    Faster reaction time. This can help you keep yourself upright if you start to fall by putting out an arm quickly to grab something stable.
    Improved coordination. This can directly help prevent falls but can also help you roll rather than crash as you go down.
    More muscle. Stronger and larger muscles can buffer the impact of a fall, providing some protection to bones and joints.
    Stronger bones. Resistance exercises strengthen bones, and stronger bones are more resistant to fractures.
    Better brain function. Regular exercise helps maintain brain function with age. Clearer thinking may help you avoid situations that increase fall risk.

Improving balance

In many urban areas, there’s no shortage of classes aimed at improving balance. You can find them at senior centers, Y’s and Jewish Community Centers, health clubs, and the like. There’s also a lot you can do at home. The AmericanCollege of Sports Medicine Standing recommends standing with one foot in front of another, lifting a foot off the floor, and shifting weight in various directions as three examples of home exercises.

Here’s one from Better Balance, a Special Health Report from HarvardMedicalSchool:Single leg stand

    Single-leg stance

        Stand up straight with your feet together and weight evenly distributed on both feet. Put your arms at your sides.

        Lift your right foot a few inches off the floor, bending that knee slightly, and balance on your left leg. Hold this position for as long as you can. Five seconds is a good start; aim for 30 seconds.

        Lower your foot to the starting position.

        Repeat with your left leg. This completes one rep.

        If you can, repeat once or twice more.

As you do this exercise, focus on a spot straight ahead. Try to maintain good posture throughout by keeping your chest lifted, your shoulders down and back, and your abdominal muscles braced. And breathe comfortably.

If this exercise is too hard, hold onto a chair or counter for support. If it’s too easy, hold the leg lift for 60 seconds, or do it with your eyes closed.

Efforts to prevent falls are best started early in life rather than late in life. Even so, you are never too old or too frail to exercise. There are always routines that can fit your needs. When my mother was treated for breast cancer several years ago, she had just one objective in mind: to eradicate the cancer. For her, radiation therapy was the best way to do that.

Radiation, on its own or coupled with other treatments, has given many women like my mother the chance to survive their breast cancer. Yet years later, some of these women are encountering a residual side effect from their radiation—heart disease.

A new research letter published in JAMA Internal Medicine estimates that the increased lifetime risk for a heart attack or other major heart event in women who’ve had breast cancer radiation is between 0.5% and 3.5%. The risk is highest among women who get radiation to the left breast—understandable, since that’s where the heart is located.

The heart effects of radiation begin emerging as soon as five years after treatment, according to a large European study out earlier this year in The New England Journal of Medicine. That study also found that, for every 1 gray of radiation (a unit that measures the absorbed radiation dose), a woman’s heart risk rises by 7.4%. “Even small doses of radiation can cause trouble,” says Dr. Alphonse Taghian, professor of radiation oncology at Harvard Medical School and chief of breast radiation oncology at Massachusetts General Hospital.
Treat breast cancer, protect the heart

Future heart risks should not be the reason to abandon this important component of treatment. “I don’t think by any means it should make anyone forego radiation for breast cancer therapy,” says Dr. Javid Moslehi, instructor in the department of medicine at Harvard Medical School, and co-director of the cardio-oncology program at Brigham and Women’s Hospital.

“The ultimate goal is to minimize the exposure to the heart as much as possible,” Dr. Taghian says.

In the JAMA study, researchers found that having a woman lie on her stomach during radiation treatment reduced her exposure. Dr. Taghian uses a technique called the breath-hold with his patients. Holding a breath expands the lungs, which pushes the heart out of the radiation’s path. This technique can cut radiation exposure to different structures of the heart by 54% to 96%.

Protecting women from the side effects of radiation is not a one-size-fits-all approach. “I don’t think there is one method to fit all patients,” he says. “The bottom line is we have to try the optimal method for each patient to avoid exposing the heart.”

Proton therapy—a relatively new radiation treatment that uses particles instead of traditional x-rays—can also lower a woman’s exposure, but very few centers currently offer this treatment. “In the future, this will probably be the dominant way to spare the heart,” Dr. Taghian says.
Know your heart risks

Before having radiation for breast cancer, a woman should have a discussion with her oncologist—as well as her cardiologist. Ask the oncologist what dose of radiation you’ll be getting, and how your heart will be protected during treatment. Talk to your cardiologist about your existing heart risks, and how to reduce them.

It’s especially important to consider your heart if you’re also having chemotherapy, which is well known for its cardiotoxicity. “We can’t avoid the heart risks with chemotherapy, but with radiation we could lower them using better technology and better understanding,” Dr. Taghian says.

Though you may not be able to fully protect your heart from cancer treatment, there are other lifestyle-based heart disease risks you can control. In the JAMA research letter, women who were least likely to develop heart disease were those who were already at low risk based on their cholesterol, blood pressure, and C-reactive protein (a marker of inflammation) levels. “Make sure the blood pressure is under control, you’re not smoking, you have a healthy lifestyle, and you control your cholesterol,” Dr. Moslehi advises.


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