Cardio-Oncology Care Emerges as a Specialized Need

Erica L. Mayer, MD, MPH

There was a time when a cancer diagnosis brought a single-minded focus on fighting the disease, with less thought to quality of life afterward. But the sheer number of survivors— nearly 15 million in the United States, or 4% of the population—has brought greater attention to ensuring that cancer treatment does not cause other harms, since cancer patients are not only living but also living longer. The National Cancer Institute reports 41% of cancer survivors live 10 years or more, and 15% live 20 years or more.¹

After secondary malignancies, cardiovascular(CV) issues are the leading cause of late morbidity and death among cancer survivors.² The need for oncologists and cardiologists to be more proactive in developing strategies to work together to prevent heart problems for cancer patients—and later, survivors—was the force behind the half-day Cardio-oncology Intensive, which featured more than 60 presenters and panelists across 6 hours at the American College of Cardiology’s 64th Scientific Session & Expo, held March 14-16 in San Diego, California.

The need for collaboration was summed up by Jean-Bernard Durand, MD, medical director of Cardiomyopathy Services at The University of Texas MD Anderson Cancer Center in Houston, who told attendees that to be “fully engaged” every cardiologist should attend at least one cancer meeting a year. Bertrand was a co-author on a 2012 profile of a group of cancer survivors who took part in a Cardiovascular Prevention in Cancer Survivors clinic, which found that the mean vascular age was 8.4 years older than the mean chronological age.² Some risk factors those patients faced are well-known: three-quarters had received anthracycline chemotherapy, while half had received radiation.²

Much can be done, however, in areas of prevention and diagnostics. Some presenters focused on more precise assessment of a patient’s CV condition before proceeding with chemotherapy, on the use of molecular diagnostics in cancer treatment, which have reduced reliance on anthracycline chemotherapy, and on better assessment of a patients CV and lipid profile before cancer therapy begins. Too often, presenters said, patients should have been taking cardioprotective therapies anyway for hypertension or diabetes.

Erica L. Mayer, MD, MPH, a breast oncologist from Dana-Farber Cancer Institute, said many years ago, treating a very young woman with anthracycline for triple--negative breast cancer was a fairly straightforward decision. “It likely had substantial benefit,” and probably saved the woman’s life, she said.

If the woman develops a second cancer, however, her options are much more limited, said Mayer. Today, weighing the risk-benefit ratio of cancer treatment with cancer survival offers many more choices, especially in an age of precision medicine. Mayer said that like many other oncologists, she uses the diagnostic test Oncotype Dx to determine which patients would not benefit from certain more toxic therapies; overall, the use of anthracyclines has declined.

Jean-Bernard

Durand, MD

When tests offer prognostic and predictive information that the cancer will not respond to chemotherapy, she said, endocrine-based therapy is used instead.

Mayer said, however, that oncologists would benefit from more understanding of how biomarkers are changing the diagnostic process on the cardiology side, so that they would make more referrals instead of simply ordering an echocardiogram. It’s time, she said, for the oncologist to partner with the cardiologist, “hopefully someone with knowledge of oncology, on how to best co-manage the care.”

Lee Jones, PhD

During a discussion of cardioprotective strategies, exercise physiologist Lee Jones, PhD, director of the Cardio-Oncology research Program at Memorial Sloan Kettering Cancer Center in New York City, emphasized the importance of getting an initial assessment of a patient before treatment starts. When he is asked, “How much should I exercise during chemo?” the answer in highly personal, because it depends upon the patient’s activity level and condition before treatment began.

It’s not well understood, Jones said, that patients need exercise at different levels of intensity, and some low-intensity exercise is important and beneficial.

In discussing patient cases, presenters noted how often cancer patients arrived with underlying untreated diabetes or hypertension that had to be addressed. Not only do therapies like beta blockers provide treatment for cardiovascular issues, but they may improve survival, according to research cited by some presenters.

Susan Dent, MD, a medical oncologist at The Ottawa Hospital Cancer Centre in Canada, said there is a great need to expand the evidence base on cardioprotective medications in cancer care. “There’s no consensus on what is the best approach,” she said.

References

1. Office of Cancer Survivorship. Statistics.National Cancer Institute website. http://cancercontrol.cancer.gov/ocs/statistics/statistics. html. Updated May 30, 2014. Accessed March 17, 2015.
2. Daher IN, Daigle TR, Bhatia N, Durand JB. The prevention of cardiovascular disease in cancer survivors. Tex Heart Inst J. 2012;39(2):190-198.