Under the Microscope: Life After Cancer

An estimated 16 million cancer survivors are living in the United States today. This large and growing number is a remarkable testament to the power of today’s cancer therapies. But it also reflects a growing health concern: How can we help ensure people live long, healthy lives after they’ve won their battle with cancer? 

Cancer and its treatments can have lifelong effects on a person’s health. In 2018 the V Foundation, with a generous donation of $3.7 million from the Bristol-Myers Squibb Company, launched an ambitious initiative to improve life after cancer through its Robin Roberts Fund for Cancer Survivorship.

A key goal of these efforts is to improve the outlook for children who beat cancer. Survivors of childhood cancer potentially have decades of healthy life ahead of them—particularly if we can minimize the long-term toll of their cancer treatment and help them continue to get the care they need.

Thinking beyond the cure

Smita Bhatia, MD, Director of the School of Medicine Institute for Cancer Outcomes and Survivorship at the University of Alabama, Birmingham, got hooked on cancer survivorship during her medical training as a pediatric oncology fellow. Working with some of the pioneers in the field along with her patients and their families, she was struck by the opportunity to help kids not only beat cancer but stay healthy in the long run.

“Their biggest desire is to be cured and put the cancer behind them, and indeed, that should be the topmost priority,” says Bhatia. “But when that happens, it is important to sit down with a survivorship counselor to take a look forward and make sure they are living a healthy and productive life. Often, that second part doesn’t happen, and it’s a missed opportunity.”

A double-edged sword

Skipping recommended follow-up care has important consequences. Bhatia’s research focuses on anthracyclines. Used in more than half of children treated for cancer each year, anthracyclines have been key to the dramatic improvements in survival rates for many childhood cancers and are also among the most common drugs used in adults.

But these drug can have serious side effects. One of the most devastating is heart failure, a life-threatening condition in which the heart cannot pump enough blood to meet the body’s needs. While anthracyclines works against cancer by damaging the DNA of cancer cells, they sometimes travel to the heart where it damages heart cells, causing scar tissue to form and permanently weakening the heart’s function as a pump.

About 7-10 percent of children treated with an anthracycline develop heart failure, which is a leading causes of premature death in children cured of their cancer. The first wave of heart failure is seen in the first year after treatment, but a second wave emerges about 5-7 years later.

Learning how to lessen the risk

Receiving regular follow-up care from a doctor knowledgeable about these health risks is crucial to recognizing and treating heart failure symptoms. But preventing it in the first place would be better still. With a grant from the V Foundation, Bhatia is looking for ways to do just that.

“If you expose 100 people to anthracyclines, 10 will develop heart failure and 90 won’t. The question is, why do these 90 people escape? To find out, we’re systematically looking at the DNA to see if a certain gene increases or decreases the risk of toxicity from anthracyclines,” Bhatia explains. “I’m extremely grateful to the V Foundation for giving us these funds to advance our goal of truly understanding the mechanisms for how an anthracycline causes these heart problems.”

Bhatia and her colleagues have established a large study to collect blood samples from childhood cancer survivors at 141 hospitals. They are comparing samples from 300 children with heart failure to 300 children without heart failure in hopes of zeroing in on genes—along with RNA and other factors that affect gene expression—that could hold the key to anthracyclines’ heart-damaging effects.

By looking for leads in this giant genetic haystack, Bhatia aims to give doctors a way to identify which children may be more likely to develop heart failure. With that knowledge, doctors may be able to adjust a child’s treatment regimen to minimize the risk. Such insights could also potentially lead to new treatments that counteract the activity of an anthracycline in the heart.

Raising awareness

As this and other promising research projects move forward, there is plenty patients and their families can do to prevent and address health problems after cancer. Bhatia urges all patients to continue to regularly visit a doctor with specialized knowledge in cancer survivorship, especially as they grow into adulthood and establish the habits that will determine their quality of life for years to come. “Those who are in their late teens and early twenties often consider themselves invincible and don’t feel the need to go back and be seen by their oncologist or survivorship specialist,” says Bhatia. “It’s very important to make sure that they are made aware of the long-term health issues that can happen and what they need to do to stay on top of that.”