Anyone in their 70s with High Blood Pressure taking Herceptin treatments?

[Bob B]

Hello All:

I have returned to ask a few more questions for my mother, who is trying to determine if Herceptin should be started. Any help/opinions are quite welcome and I thank you in advance.

In 2006, my mother (78 at the time) had a lumpectomy. The results were ductal carcinoma in situ (1.1 cm) with moderate to differentiated invasive ductal carcinoma (1.2 cm). Histolic, Nuclear and Mitotic grades were all II. Her margins were tumor free. Vascular invasion was not identified and the Scarf Bloom Richardson was moderately differentiated (I do not know what the S-B-R means).

She then 4 chemo treatments of Adriamycin and Cytoxan (which completely wiped her out/she ended up in intensive care), followed by 30 or so radiation sessions. She ended up with pneumonitis (plueral lung thickening, etc.) from the radiaton, which left her short-winded, tired. She has recovered fairly well from that now.

She is hormone receptor ER/PR negative, Her-2/neu was 3+ positive, Ki-67 was 18% positive. She has had about 4 blood tests since where the Chiron(?) level in her blood (CA 27-29) was 57-81-77-67 (normal something like under 30?). These tests were done by her original oncologist.

We were not satisfied with her oncologist's explanations/ideas concerning possible follow-up treatment. We finally convinced my mother to go to the Rena Rowan Breast Cancer Center in the Abramson Cancer Center at the Univ. Of Penn. Hospital for a second opinion.

While the doctor there spent about an hour with us (!) we still came away a bit bewildered as to whether she should try Herceptin, despite asking pretty definitive questions.

We were told that women over 65 with high blood pressure fare worse (about twice the possible incidence of heart failure) than the average patient without the age and BP concerns. It has been about a year since chemo was completed and seven months since radiation was completed.

My reading, research here and elsewhere, etc., had told me that the type of cancer my mother had can often return in the other breast; that it was an agressive cancer. The doctor we spoke with seemed to indicate otherwise, leaving us confused. She would not recommend whether my mother should try Herceptin but when asked what she would do under the same circumstances, she replied that she would try it (1 year/ 3 week intervals).

The doctor also told us they do not use the CA 27-29 markers at the Rena Rowan Center..

She also minimized possible side effects (other than the heart threat) but I have read many posts tonight with complaints about side effects. I have also read in other postings that many women seem to have trouble with the 3 week triple doses being a bit much.

So...my questions are:

1 - Are any of you in your 70s with high BP taking Herceptin?
2 - If so, how are you handling it?
3 - How has your Ejection Fraction held up?
4 - Have you had any problems with your blood pressure dropping to dangerous levels?
5 - Is the 3-week triple dosing a bit much for you at that age?
6 - Have any of you started Herceptin therapy so long after chemo/radiation?
7 - How is it determined whether MRI should be used to keep a watchful eye on things?

Sorry this is such a long post. Any advice will be welcome. If my mother is to start the Herceptin treatments, it must be very soon.

Thanks so much for your time,
Bob B

[Grace]

Dear Bob,

I am not your mother's age but I am over 65 with high blood pressure (identified when I was 50) and am on BP medication for life (Lotensin HCT 20-25). My cancer was very similar to your mother's, the invasive part was a bit smaller (5mm). We were both Grade 2. My 27-29 marker after surgery was elevated but not as elevated as your mother's. Normal range for CA 27-29 is anything below 37. My BC was also identified in the summer of 2006, and I just finished a year of herceptin. I also had chemo (taxol and carboplating) and had, as your mother did, a very bad reaction.

I did some exhaustive research on herceptin before I began and don't remember reading that high BP was a contraindication. My first LVEF reading was 59, and my last, a few weeks before I finished my year, was 60. I did develop a very small pericardial effusion while on herceptin, but neither of the two cardiologists I visited in the year seemed concerned. I am very easily winded these days, but I'm not sure what caused it. I exercise very little so I'm out of shape. My BP went down a few times so I was dizzy but nothing to worry about.

I can't advise your mother; that only her doctors can do, but my experience is that I weathered herceptin well, with lots of minor side effects but nothing major. My markers (both 27-29 and HER2 serum) both came down in the course of a year.

Good luck to both of you in your decision making.

[Grace]

Bob,

I did herceptin every three weeks and had no serious reactions. I much preferred the three-week routine, particularly as my veins were not very cooperative.

I have never read that the type of breast cancer your mother had (same as mine) is likely to occur in the other breast. There is such a type of breast cancer, but it is not, to my knowledge, IDC.

Also, the most recent research indicates that very few women benefit from Adriamycin. It is also very toxic to the heart. Recent research suggests that taxol is particularly beneficial to women who have HER2 positive cancers.


Also, a KI67 of 18% is not bad. I believe that number is still in the low range. Mine was 20% and that put me in the medium range. I'm not sure of my numbers here as it's been a while since I did my research. I know that some doctors in Italy, after reserching this marker, identified 19% as a cut-off number, with anything above having a higher liklihood of recurrence.

There has been much controversy on this board regarding tumor markers and if you do a search you can find many posts on the reliability (or not) of such markers. Mine, as I mention in first post, were elevated. I had many scans and we found no additional cancer. It's now fourteen months since I had the elevated markers and I'm doing well. Also, my markers last time checked were all within normal range. Many things can push up markers that are not concerned with cancer, including chemotherapy, infections, etc. I will say, although this is not advice as it concerns myself alone, that I am happy I did herceptin for a year. It gives me a feeling of confidence that without, I wouldn't have.

To other members. If any of the information I am giving Bob is incorrect, please feel free to correct.

[Becky]

I will respond to the "cancer in the other breast" question.

There is a difference between local recurrence (the same cancer coming back in the same breast) and contralateral cancer (a new cancer in the opposite breast).

Women who have had breast cancer are obviously at the highest risk of developing a new breast cancer (what I mean is a completely new and different one). For invasive ductual carcinoma (IDC - cancer in the milk ducts), the risk of a new cancer in the opposite breast is 1% per year with a 10% - 12% chance over 10 years. For invasive lobular carcinoma (ILC - cancer in lobes which is the milk producing site) the 10 year risk is 20%.

The current cancer can spread to the other breast. This is why it is important to get biopsies done but it is not as common as one might think. A new lump in the other breast (if cancerous) is probably a brand new cancer. So U Penn is right about what they told you. Did you see Dr. Fox there?

Herceptin does not have a side effect of increasing BP (Avastin does) but your mom's heart should be in good shape prior to using Herceptin. Side effects tend to be more like Hayfever - runny nose etc. Very tolerable.

[BonnieR]

It is not clear to me if your mother has pre-existing cardiac problems?? I believe a base line reading (Echocardiogram, for instance) is first done so they can compare subsequent cardiac function tests which are preformed periodically during the Herceptin treatment.
Obtaining second opinions is a frustrating business. I got THREE different opinions!! No one has the definitive answer for us, it seems.
Your mother is lucky you are doing research on her behalf. It is daunting. Be sure to write your questions and answers when you visit the doctors.....
Keep the faith.

[Lani]

Here is some info:
J Clin Oncol. 2007 Aug 10;25(23):3525-33. Links
Trastuzumab-related cardiotoxicity: calling into question the concept of reversibility.

Telli ML, Hunt SA, Carlson RW, Guardino AE.
Department of Medicine, Division of Medical Oncology, Stanford University, Stanford, CA, USA. guardino@stanford.edu.
PURPOSE: To assess the spectrum and reversibility of the cardiotoxicity observed in the adjuvant trastuzumab trials. DESIGN: The design and efficacy of the major adjuvant trastuzumab trials was assessed, including the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-31, North Central Cancer Treatment Group N9831, Herceptin Adjuvant, Breast Cancer International Research Group 006, and Finland Herceptin trials. The cardiotoxicity data were evaluated with a focus on the follow-up cardiac evaluations of women who were diagnosed with cardiotoxicity. Proposed mechanisms of trastuzumab-related cardiotoxicity were considered. The natural history of congestive heart failure (CHF) was reviewed with the goal of placing the trastuzumab experience in context. RESULTS: Up to 4% of patients enrolled onto the adjuvant trastuzumab trials experienced severe CHF during treatment. In these trials, early stopping rules that identified an unacceptable level of cardiotoxicity were never reached. Despite this, a large number of patients on these trials experienced some form of cardiotoxicity that ultimately required discontinuation of trastuzumab. Approximately 14% of patients in the NSABP B-31 trial discontinued trastuzumab because of asymptomatic decreases in left ventricular ejection fraction (LVEF). Results of follow-up cardiac evaluations of patients diagnosed with any degree of cardiotoxicity in the NSABP B-31 trial document that a clinically significant proportion of patients have sustained decrements in their LVEF to less than 50%. CONCLUSION: Adjuvant trastuzumab provides substantial benefits to patients with human epidermal growth factor receptor 2-positive breast cancer, however, competing immediate and long-term cardiovascular risks are a great concern. Continued cardiac follow-up of these women is of critical importance.
PMID: 17687157 [PubMed - indexed for MEDLINE]

These trials did not include patients with preexisting hypertension not controlled on medication or with valvular or arrhythmia problems. Few included patients up to 70 as I understand it.

I can only tell you about 1) an 84 year old with preexisting heart problems and 2)Tom's mother, also in her mid 80s as I recall(Tom posted frequently so you should be able to look him up under the members list). Tom's mother got quite a few months, but not the entire year of herceptin behind her before her LVEF went down sufficiently low that they stopped it. She died of problems unrelated to her heart or breast cancer according to Tom before her herceptin could be resumed.
The 84 year old I am referring to had had valve repair surgery 10 years before getting breast cancer and had diabetes and was being treated for high blood pressure. She was able to get 6 months of herceptin before her LVEF decreased from 55% to somewhere between 40 and 45%. It did not come back up 4 months later, but now 7+ months later it is back to baseline and a decision is to be made whether to resume herceptin. No medications were given and a serum test for heart failure was negative.

I have posted several articles on cardiotoxicity and herceptin on this site. I recommend you utilize the search function and search for them. I believe one was from MD Anderson.

AS Regards your questions--the 84 year old I refer to received herceptin every three weeks. Perhaps look up Tom's posts to see how often his mother got hers.

You don't say how long it has been since the chemo, radiation just listing 2006. Has it been over a year?

THE ARTICLE WHOSE ABSTRACT I POSTED ABOVE THOUGHT IT MIGHT BE HELPFUL TO GIVE ACE INHIBITORS TO THOSE ON HERCEPTIN AT RISK FOR CARDIAC FAILURE. IT DESCRIBED ACE INHIBITORS AS BEING HELPFUL FOR PREVENTING CHEMO=INDUCED CARDIOTOXICITY AND ALSO DESCRIBED THOSE PATIENTS ON HERCEPTIN WHO ALSO TOOK ACE INHIBITOR FOR HIGH BLOOD PRESSURE AS HAVING A DECREASED INCIDENCE OF HEART PROBLEMS ON HERCEPTIN AS I RECALL

HOPE SOME OF THIS HELPED

[Lani]

Links
Reversibility of trastuzumab-related cardiotoxicity: new insights based on clinical course and response to medical treatment.

Ewer MS, Vooletich MT, Durand JB, Woods ML, Davis JR, Valero V, Lenihan DJ.
Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, 77030, USA. mewer@mdanderson.org
PURPOSE: Trastuzumab is an important biologic agent with significant activity in breast cancers that overexpress the HER2/neu marker. However, trastuzumab is associated with cardiotoxicity that has not yet been fully explored. We present our experience with patients who developed trastuzumab-related cardiotoxicity. PATIENTS AND METHODS: Over a 4-year period, 38 patients with HER2/neu-positive breast cancer were referred for suspected trastuzumab-related cardiotoxicity. All patients had previously received anthracycline-based chemotherapy. Results After doxorubicin but before trastuzumab, the mean (+/- standard deviation) left ventricular ejection fraction (LVEF) was 0.61 +/- 0.13, and the LVEF decreased to 0.43 +/- 0.16 after trastuzumab (P < .0001). After withdrawal of trastuzumab, the LVEF increased to 0.56 +/- 0.11. Mean time to recovery of LVEF was 1.5 months and was temporally associated with medical treatment in 32 (84%) of the 38 patients but occurred without treatment in six patients (16%). Increases in LVEF were noted in 37 of the 38 patients. Twenty-five of these patients were re-treated with trastuzumab; three patients had recurrent left ventricular dysfunction, but 22 patients (88%) did not. All re-treatment patients continued on their therapeutic regimen for heart failure when rechallenged with trastuzumab. Nine patients underwent endomyocardial biopsy. Ultrastructural changes were not seen. CONCLUSION: Patients who develop cardiotoxicity while receiving trastuzumab therapy generally improve on removal of the agent. The mechanism of trastuzumab-related cardiac dysfunction is different from that of anthracycline cardiotoxicity, in part, demonstrated by the absence of anthracycline-like ultrastructural changes. Reintroducing trastuzumab may be appropriate for some individuals who previously have experienced trastuzumab-related cardiac dysfunction.
PMID: 16258084 [PubMed - indexed for MEDLINE]

[Lani]

around 77 years old.

A heart attack she had prompted discovery of lung metastasis of her breast cancer.

She first developed breast cancer 22 years ago, long before herceptin was widely used.

here is one of her most recent threads:
Good news!
I've had some rough times for awhile with cardiomyopathy and heart failure, most likely aggravated by 15 months of herceptin. The herceptin was stopped over a year and a half ago when my ejection fraction dropped to 30 and then I had a triple bypass a year ago in May. This spring the heart failure seemed worse and about 2 weeks ago I was referred by my cardiologist to a surgeon who puts in defibrulators for people with serious irregular heart rhythms that could cause sudden death. In talking to my husband and me, he said I would need to meet certain criteria before he would do the surgery: (1) he would have me wear a 24-hour heart monitor to record the electric rhythms of my heart, (2) he would carefully study my cardiac history, including records of my bypass, stress tests, ejection fraction and other heart tests, and (3) he would talk to my oncologist about my life expectancy as a stage IV cancer patient, since it would be foolish to go through the surgery if I only had a short time to live. Today I saw him again after he followed up on these things, and the first thing he said was "I don't often have such good news to give to someone with your history!" Then he proceeded to tell me that he wouldn't do the surgery to implant the defibrulator because (1) the heart monitor showed the electrical rhythms of my heart were much better than he feared they might by (2) my ejection fraction had improved from 30 to between 40 and 45, and (3) my oncologist told him that I was doing very well, had been NED for the past two years, and probably had an above average life expectancy for a stage IV patient. My husband and I went out for dinner to celebrate! He had a steak and I had crablegs, which I love. We even shared a rich and gooey dessert! I know how much I love to hear good news on this website, so felt I needed to share this with you. As most of you know, I'm 77, I've been fighting cancer for 22 years, first in 1985, then mets to my spine in 1990, and then her2 mets to my lungs in 2004, which were found because a heart attack put me in the hospital for a month. It's been a roller coaster ride for my husband and me but today was good news! My next CT scan will be in December. I'll be in touch! Hugs, Tricia

Feel free to look her up under Members, read her posts, threads and/or email or private message her if possible.

PS radiation therapy can cause heart problems, particularly if the left breast is the one radiated, but many years later--I add this because it may or may not be related to Tricia K's heart problems (she might have had them anyway, and she might not have left sided bc)

Hope this helps

[Bob B]

Grace, Becky, BonnieR and Lani:

Thank you for taking the time to respond in such exacting fashion. You have given us a good deal of important information.

Grace: You do appear to have similar factors to my Mom's. Her EF was 55-60 last year after her troublesome chemo episodes. Recent echo had her at about 65. You mentioned occasional dizziness from low BP even though you have high BP. I have some concerns here as my mother has some dizziness/balancing issues residual from the brain tumor she had removed several years ago. She has some blockage in one of her carotid arteries that they are watching now, so we're trying to factor that in as well but it's difficult for us to assess. I think that her BP occasionally drops too low now (even though she is on BP medication) and is the cause of some of her occasional dizziness.

Becky: Appreciate the reoccurance % information. This was one of the elements that I was trying to find more information about to help us decide. Mom saw Dr. Kaplan at the Rena Rowan Center. Is this where you had your treatment? We are in NJ as well.

BonnieR: Mom's EF was 55-60 after her chemo meltdown last year. A recent Echo has her at about 65. She doesn't have a preexisting heart situation per say, but has had the dizziness situation I've mentioned above and her heart tends to race a bit at times.

Lani: Very informative information relating to Herceptin's effect on the heart and pursuant recovery percentages. I'm very concerned about the possible effects on the heart as the oncologist we just saw told us that most of the Herceptin studies were with women younger than my mother and that the % of heart failure would be higher with older women who had BP problems.

My Mom is a bit taken aback by the possible side effects she's read about in the medication's "cheat sheet," although a good many of the women on this site seem to think the effort is worth it and the general side effects tolerable.

I would welcome additional comments anyone may offer about your preferred treatment schedule, be it every week, two weeks or three weeks. I have read comments by some that the 3-week infusion may be a bit much, particularly if it is done too quickly.

Also, has anyone started their Herceptin treatments a substantial time after finishing chemo/radiation rather than simultaneous to or shortly thereafter? This would be the situation with my mother.

Mom does have a port-a-cath which was installed previous to her chemo treatments and was eager to have it removed before my sister and I were finally able to convince her to get a 2nd opinion on Herceptin before having the port removed.

Thanks again. Much appreciated, God bless you all.
BB

[Grace]

Bob,

My episodes of dizziness lasted for just a few weeks, some eight months after starting herceptin. It was unusual (so doctor ordered an MRI--with an all clear result), and the episodes stopped shortly thereafter, so it may have been an infection or something else happening that was not herceptin related. I should mention, though, that I never had dizzy episodes before cancer drugs came into my life, which appears not to be the case with your mother.

I had herceptin every three weeks, and it was always administered over ninety minutes, never thirty. Since I did not request the longer infusion, I assume it's the clinic's protocol. If your mother decides on herceptin every three weeks, she should ask for the ninety-minute infusion since she's already at the chemo center, and it does seem to cause fewer problems.

I'm surprised again by your comments concerning high BP and heart failure for older patients on herceptin. I visited two cardiologists during my year of treatment and neither of them had a similar concern, and I read every bit of research I could find before beginning herceptin and found no statistics indicating that women with high BP or older women had more issues with heart. Of course, that was seventeen months ago and more information should now be available.

I did find lots of research indicating that older women (over 65) fare less well on chemotherapy drugs, in particular Adriamycin, which is very hard on the heart. I decided before my first visit with oncologist that I would not do Adriamycin because there is a long history of heart disease in my family, but my doctor was there before me, and didn't recommend it, for the same reason. I believe (relying now on what I read months ago so I may be wrong) that women who take herceptin and Adriamycin have more probems with heart, and as I remember your mother took Adriamycin, so that may be the reason for her doctor's concern. You might want to do some research yourself on herceptin and heart failure to reassure your mother.

I began herceptin with chemo five weeks after surgery, so I can't answer your last question but I'm sure someone on the board will. I believe Becky started herceptin late, but my memory may be off on that. These decisions are so difficult to make so my sympathies are with you and your family, but I'm sure you'll come to the right decision in the end.

[rumki8]

Hi friends, my father is 58 years old and he too healthy. He has high blood pressure and takes some meds twice a day. Blood pressure seems under control with these meds, but the tension thing is the worst side effect. What can be done to help someone who's having difficulty sustaining an tension due to being on blood pressure meds? What blood pressure meds don't have this effect so much? Please advice.

[Marlys]

I will share my experience. I was almost 67 when I went on Herceptin. I had the same treatment as your mother. I was hospitalized after my 3rd A/C because my neutrophils were zilch. Otherwise did o.k. I started Herceptin right after I finished Chemo. I had had high blood pressure since age 53. Even with left ventricular hypertrophy. I received Herceptin every 3 weeks for a year. However after 2 Muga scans which were going down, I started Coenzyme Q10 and walking and water aerobics. My scan went from 63 to 72. <Y oncologist felt there was no need to do further Muga Scans. Incidentally, most of the women in my water
aerobics class were older than me.
I am not going to suggest what your mother should do becasue I don't know her cardiac history but based on my experience I certainly would not rule it out.Love & hugs,
Marlys