Doorway to a Heart

Cancer survivors can now take heart. Literally, that is, if they are unfortunate enough to need a new one. Previously, survivors who also suffered heart failure had to be cancer-free for at least five years before being considered for a heart transplant. But under new guidelines issued last year by the International Society for Heart & Lung Transplantation, if a patient’s cardiologist and oncologist agree that the likelihood of a cancer recurrence is low, the patient can be placed on the waiting list for a new heart.

If patients have survived their cancer for a certain number of years, says J. David Vega, MD, director of the Heart Transplant Program at Emory University Hospital in Atlanta, “whether that’s three years or five years, the likelihood of a recurrence of their cancer is fairly low, and they could potentially, if necessary, have a heart transplant.”

A lot of discretion is allowed, says Stuart Russell, MD, clinical director of the heart failure and cardiac transplantation program at Johns Hopkins Hospital in Baltimore and a member of the committee that drafted the new guidelines. “There are no hard-and-fast rules,” he says. “We didn’t come out and say ‘for this type you can wait one year and for this you can wait three years,’ anything like that.”

The biggest risk to cancer survivors is the lifetime immune suppression required of organ transplant recipients. “There is a little bit of the unknown there,” says Vega. “There aren’t a lot of data in patients out there who have had cancer and survived three to five years, who are then subjected to immune suppression.”

Russell says the immune system does a great job in fighting off cancer cells. So knocking out the immune system by immunosuppression could cause a fatal recurrence of a patient’s cancer, he says. But it really depends on the type of cancer.

A man who has localized prostate cancer could be considered cured and eligible for a heart transplant soon after the tumor is removed. But a lung cancer survivor with heart failure might not be considered a good candidate until he or she was cancer-free for several years, because of the high risk of metastasis.

Russell says that nationally, 2,000 hearts are transplanted annually, and he estimates that the new guidelines may add 200 patients a year to the waiting list.

The guidelines also allow older patients to receive new hearts—up to age 70, instead of the previous age limit of 65.

Adding eligible people to the heart transplant waiting list could increase the competition for already-scarce organs. But Russell says that more organs may become available as the criteria for donors expand as well. Regarding the older patients who now can be considered, he says the guidelines indicate that it might be better to give a slightly older donor heart to that person. Transplanting the heart of a 50-year-old into a 70-year-old patient, for example, could buy the recipient as much extra life as the heart of a 20-year-old might.

Emory University has already transplanted donor hearts into cancer survivors whose heart failure was brought on by one of the chemotherapy drugs they received to knock out their cancer, Vega says. So far, they’re doing fine. “It’s not large numbers, but they seem to do the same as other patients” who have received new hearts, he says.

To learn more:

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The International Society for Heart & Lung Transplantation’s guidelines for heart transplantation can be found on the organization’s website: www.ishlt.org.

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More information on how donor hearts are allocated can be found on the website for the United Network for Organ Sharing: www.unos.org.