April 5th, 2013
Cardio-Oncology: Who Needs It?
John Ryan, MD
This post is the first in a series on Cardio-Oncology. Inspired largely by the recent publication of the study Risk of Ischemic Heart Disease in Women after Radiotherapy for Breast Cancer in the New England Journal of Medicine, we invited study authors Candace Correa and Kazem Rahimi; author of an accompanying editorial, Javid J. Moslehi; and Jerry Walker, who has appointments in both the Division of Cardiology and the Department of Radiology at the University of Utah School of Medicine, to discuss this important topic. John Ryan moderated.
Which patients with cancer should a cardiologist evaluate? And how broad should the field of Cardio-Oncology be?
Dr. Walker: The field of Cardio-Oncology is a relatively new but rapidly expanding sub-specialty of Cardiology. Oncologists, Radiation Oncologists, and Surgeons already work in collaborative efforts to increase the cure rates of cancer patients. Cardiologists can provide additional support in this effort. Chemotherapy and radiation therapy, as indicated in the article of discussion, can increase risk of cardiovascular disease. If a patient survives the cancer due to these treatment protocols, there is a risk of the patient suffering or even dying prematurely from a completely unrelated cardiovascular disease process.
We should be screening and following all patients who might receive any treatments that could result in higher risk of cardiovascular disease. Some patients don’t even know they might have cardiomyopathy until it is discovered as an incidental finding on an echocardiogram after chemotherapy has been completed. Our involvement should not hinder these treatment protocols but should help our Oncology and Radiation Oncology colleagues best avoid the pitfalls of treatment. This will eventually help bring about the best long-term outcomes for these patients.
Dr. Correa: The field of Cardio-Oncology should be broad. We have a great opportunity for oncologists and cardiologists to work together to investigate the mechanisms, clinical outcomes, and treatment of cardiac disease in the unique oncology population. The cross-fertilization via collaborative basic science and clinical efforts by multispecialty teams would likely yield very useful information that could ultimately lead to improved survival and quality of life.
Dr. Rahimi: Oncologists can handle most of these issues. Specifically in terms of our study, I don’t think these findings suggest any change to current practice in terms of who evaluates the patients. In most circumstances, it is perfectly reasonable for the oncologist to evaluate these patients. If there is uncertainty about further management, advice can be sought from cardiologists.
Dr. Moslehi: Focusing just on breast cancer, the treatments have changed significantly over the past decade. Women who are being treated for breast cancer may receive multiple therapies, each of which may have cardiotoxic effects. For example, a woman who presents with HER2+ breast cancer would receive anthracyclines, cyclophosphamide, radiation, and any number of HER2 targeted therapies, each of which may have cardiac sequelae. Just within the HER2 targeted group, there are now different therapies including an antibody that targets the HER2 receptor (such as trastuzumab – Herceptin), an antibody that inhibits HER2 dimerization (pertuzumab), a tyrosine kinase inhibitor that antagonizes HER2 from inside the cell (such as lapatinib, neratinib) or a conjugate drug (TDM-1). The specific cardiac issues with these drugs are not well known because of the drugs’ novelty. This does call for a cardio-oncologist to be involved in patients’ care.