Heart failure
“But what about my heart?” she asked as I paused near the end of my recommendations for treatment of her breast cancer.
“Your heart?” I questioned, trying not to sound incredulous. She was 43 years old with a very aggressive Stage III breast cancer. Why in the world was she worrying about her heart?
“My dad got radiation for Hodgkin’s Disease. He survived the cancer, but the radiation killed his heart. Radiation killed my dad, and I do not want that to happen to me.”
Oh.
“Are we really going to do this?” my nurse asked me.
“Yes,” I answered, as we observed my dying patient and her husband holding hands, heads together, crying.
“It’s heartbreaking,” she said picking up the chart.
Yes, yes, it is, I thought, watching them opt for a second round of whole brain radiation instead of hospice with the hopes of giving her one more week, one more day with her children.
When I chose radiation oncology as my specialty, I did not realize how much I would think about the heart. A plane crashed into the first World Trade Center tower during our introductory lecture on EKG interpretation. Since then, I have generally avoided anything heart related.
The heart and I shook hands that week and respectfully parted ways: I promised not to injure her and she, in turn, would leave me alone. Radiation oncology is one of the few specialties I found where the heart really does not play a direct role. Or so I thought.
I began to hear about the heart as soon as I started my residency. Long term survivors of Hodgkin’s lymphoma were sprinkled through my attending physician’s follow up clinic and I was astounded at their list of complications – aortic valve replacement, early cardiovascular disease, cardiomyopathy. Each patient was managed by a combination of primary care physician, cardiothoracic surgeon, and cardiologist.
In addition to the abdominal scars where their spleen had been removed as part of Hodgkin’s treatment, spidery railroads of white scar tissue now ran down their chests. We could not take back the photons given 30 years prior. We could only bear witness to the steep price of surviving.
Pacemakers have also complicated my attempts to care for the heart. Battery packs filled with 10+ years of charge sit in perfect alignment with the edge of my radiation field. Their vital function and precarious positions taunt me to try to deliver 50 units of radiation to the breast and only 3 units to the adjacent battery unit.
Asking a cardiologist to flip a perfectly functioning pacemaker to the opposite breast so we can proceed with radiation is one of my least favorite calls to make to a colleague. Sometimes it cannot be moved, and the patient must be monitored by an ICU nurse with a code cart outside the treatment room. We hold our breaths – hoping the device does not go haywire, send an incorrect shock, and put the patient into cardiac arrest.
A large study published several years ago found that women with left sided breast cancers died at a slightly higher rate than women with right sided cancers. This did not seem to jive since cancers on the left side were not more aggressive or found at more advanced stages than those on the right. Turns out the slightly higher death rate was due to non-breast related causes, heart disease specifically.
The left anterior descending artery (LAD), commonly referred to as the “widowmaker,” supplies the main pumping chamber of the heart. The LAD lies beneath the ribs just behind the left breast and, unfortunately for women who develop cancer in their left breast, on the edge of the radiation field. Historically, radiation planning occurred without the ability to see the heart and therefore plan to avoid it. As a result, the LAD was included in many radiation fields, contributing to coronary artery disease and early cardiac death in some women with left sided breast cancers.
In the mid-1990s, CT scans were introduced to aid in radiation planning. Prior to treatment, each breast patient now has a CT scan. Now we outline the heart and modify our radiation fields to avoid it. Other treatment techniques like taking a deep breath and holding it during treatments to pull the diaphragm and heart down (known as “deep inspiration breath hold” or DIBH) as well as intricate physics calculation programs have allowed us to avoid significant heart exposure in almost all left sided breast cancer patients.
The difference between left and right sided breast cancer survival has almost disappeared. Technology has allowed us to take better care of the heart.
Heart. Cancer. Cancer. Heart.
A patient receiving radiation for prostate cancer does not show for his scheduled appointment. He had a massive heart attack while driving to the clinic we later learn.
And an ailing heart prevents my oldest, most favorite patient from coming in for a follow up visit. I miss her laugh and fresh baked bread.
The widower of a patient stops me in the grocery store and pulls me into a giant hug. I clutch a bag of tomatoes in my hand while my cheek rests briefly on his chest.
Radiation is electromagnetic waves delivered into a body to create irreparable harm to unwanted invaders. To reach their intended target, these photons must pass through normal tissue. Whether this normal tissue experiences a glancing blow or full exposure, we count on the body to repair the damage as it would a cut on the skin.
The heart is no different. Most of the time with current doses and modern treatment planning, there is no discernible, lasting damage to the muscle or electrical components of the heart.
Sometimes, I wonder if the electrical impulses of my patients’ hearts align with the passing photons I prescribe. Through some complicated vectors, the combined electricity bounces back and enters my heart. I feel the ache as it lodges beneath my sternum, somehow passing straight through the impenetrable barrier my white coat is supposed to provide.
Is this heart failure? The unintended pain that I feel as I watch the suffering of my patients.
I cannot keep my earlier promise to the heart as I watch cancer and its treatments devastate the hearts of so many who pass through my rooms. She and I have struck up an uneasy truce, it seems that is the essence of patient care.
It is the unbothered heart that I now fear most of all.
On my mind…
"It is the unbothered heart that I now fear most of all."
Absolutely beautiful article. So much empathy and love and care for your patients and so wonderfully written.
The pathos you articulate ought to remind each and every one of us (whether we be patient or physician) that we must empathize with patient AND physician AND respect none of us are miracle workers and we do what we can to our best ability.