Cheryl Martin (Host): On this episode of HeartSpeak, we're talking with a very special guest who has a unique subspecialty in cardiology. We welcome Dr. Courtney Campbell. She's a Cardio-Oncologist on the medical staff at Baylor Scott White Heart and Vascular Hospital Dallas and Baylor University Medical Center. This is HeartSpeak, the podcast from Baylor Scott and White Heart and Vascular Hospital, Dallas and Fort Worth, joint ownership with physicians. I'm Cheryl Martin. Dr. Campbell, delighted to have you on and to learn more about your specialty.

Courtney Campbell, MD, PhD: Thank you so much Cheryl. I'm happy to be here.

Host: So first, what is cardio-oncology?

Courtney Campbell, MD, PhD: Absolutely. So cardio-oncology is about caring for the heart before, during, and after cancer therapy and care.

Host: And what is a cardio-oncologist?

Courtney Campbell, MD, PhD: A cardio-oncologist is a cardiologist. So they've trained in internal medicine and trained in an additional cardiovascular medicine fellowship who does additional training in cardio-oncology. So I trained at Ohio State for my internal medicine and cardiology training, and then I did an additional year of training at Washington University in St. Louis, which is one of the largest cardio-oncology programs in the country. There are just a handful of fellowships that are training this specialized field, but it is a growing field, and we are eager to have more people come into this specialty.

Host: So, are cancer patients at higher risk for developing heart problems?

Courtney Campbell, MD, PhD: Some of them are, and that is really what the foundation of cardio-oncology is. So, over the last 20 years, this field has emerged, and part of that is that we've gotten really good at treating cancer. There are over a thousand new drugs for cancer in the last 20 years, and they are a lot more specialized.

So, initially, 20 years ago, our mainstay of cancer treatment was chemotherapy. And we do know that some chemotherapy can affect the heart, both in short and long term, and then radiation therapy. But it's really expanded beyond that. We now have targeted therapy. So oncologists look for specific mutations in someone's cancer, and they're able to use really precise medicines to target that cancer.

Sometimes with these targeted therapies, though, there are other side effects, and these can affect the heart, whether from a heart rhythm standpoint, a heart failure, it gets weaker, or even causing heart attacks. Other treatments, like immune checkpoint inhibitors, are really new. They take the brakes off the immune system to allow it to, uh, attack the cancer.

These have been game changing. People that had metastatic disease that originally would have been told they had weeks to live are now living years later with this therapy, but sometimes that same treatment that turns on the immune system against cancer can turn it on against the heart as well. So, with this we find, you know, there's a growing need to be able to care for this specific population.

Host: Do you think a lot of cancer patients are aware of this, especially if are focusing on fighting the disease? How many of them really know that I really need to focus on my heart and there may be some complications there as well?

Courtney Campbell, MD, PhD: I think it depends on the type of treatment they're receiving. It can be really overwhelming when people get information about their new treatment, because there's a long list of side effects and some of those can be heart related. Some of them are common, and some of them are less common and not big factors.

For certain treatments, there will be of planned monitoring that oncologists will do, like looking at ultrasounds of the heart, echocardiograms every three months, but other side effects are much more rare, and it may not happen until they're in the hospital with an acute issue. The other thing is that people should rightfully be focused on their cancer treatment, and a role of a cardio-oncologist is to watch the heart so you don't have to worry too much about that.

 However, with cancer, a lot of the disease, since it's treatable or even metastatic disease, it becomes a chronic disease. And so, if you are dealing with cancer for years, we really can't forget about bread and butter cardiovascular disease and forget that we do need to make sure cardiovascular risk factors are controlled.

We can't forget about someone's cholesterol for 5 or 10 years, while they're on, you know, have stable cancer.

Host: So you're saying a potential heart problem as a result of cancer treatment can show up years later.

Courtney Campbell, MD, PhD: It depends on the type of cancer treatment and that's a really important point because some of what I do is letting people know that it's not their cancer therapy and that they can continue their cancer therapy and that's not what's causing the problem. You can, for instance, someone with lung cancer, a lot of them have some of the same risk factors for coronary artery disease; a smoking history, higher cholesterol, high blood pressure.

 I've been consulted on patients and they were worried about their heart and that they couldn't keep their cancer therapy going, but it ended up that they had a blockage in the blood vessel that supplied their heart that we could fix with a stent and they could continue their cancer treatment. So a lot of what we do is try to make sure they can get the cancer treatment they need and care for the heart in the interim.

Host: Now Dr. Campbell, you're a Medical Director for the Cardio-Oncology Center in Dallas at Baylor Scott & White Heart Vascular Hospital and Baylor University Medical Center. Tell us about the Cardio-Oncology Center at Baylor, Scott & White Heart and Vascular Hospital, Dallas.

Courtney Campbell, MD, PhD: Absolutely. So really proud of this new center. We've been open for about a year now and for patients, if they're coming to us from an outpatient setting referred by an oncologist, they will have a nurse navigator that will help make sure they get the testing and appointments needed in a really timely manner.

So a lot of folks, looking for cardiologists, they may have to wait weeks or months to see them. But with cardio-oncology, we recognize a lot of these issues really can't wait. Especially if your cancer treatment is being held until you get a cardiovascular opinion. So we try to see people quickly within a week.

And when you come to a cardio-oncology visit, there's really three main focuses of it. So the first is cardio-oncology monitoring. What treatment are you on or have you received in the past? What kind of risk factors are there? Is this one that doesn't affect the heart? Is this one where there might be heart rhythm issues or heart attack or heart weakening?

And what kind of monitoring do we need to do for that? Do we need to do labs? Do we need to do imaging? How frequently do we need to do those? The next is your CART care. So some folks might not have any cardiovascular disease at the time of evaluation and it's all just anticipatory. But others, like if you're on blood pressure medicine, some cancer treatment might increase your blood pressure. So we might have to think about changes. Some might decrease your blood pressure if you're not eating or drinking well. So how do we navigate your known hypertensive medicines. And then sometimes there might be drug interactions. So we need to switch to a different medication that won't interact with your treatment.

Sometimes we can switch like hypertension medicines to some that are cardioprotective, that have a protective effect from any risk that you might get from the treatment that you're receiving. The last part as we talked about, is cardiovascular risk factor control. So in the center, we take it really seriously that your cholesterol, your blood pressure, you know, your exercise, your nutrition, whether or not you have sleep apnea, diabetes, are all under good control, and that we're monitoring those and we're not forgetting about those, during and after your cancer therapy.

It's a really multifaceted evaluation. And we work really closely with oncologists. So I spend a lot of my day, I probably have spoken to four different oncologists today to talk about the nuances in care and make sure that this is shared decision making moving forward that we can treat both their cancer and heart disease as it arises, safely. We don't want to forget about either aspect of that, because it's really about improving the lives of patients with cancer and heart disease and help them live higher quality of life and longer lives.

Host: That's great. Now, any other benefits for patients from a specialized cardio-oncology program you want to talk about?

Courtney Campbell, MD, PhD: Yes, so with cardio-oncology, the knowledge of that treatment is really important, because some things can be missed. Some symptoms can be brushed aside. So, for instance, folks that are survivors, that had radiation therapy 10 plus years ago; I've seen cases where you know, a lot of these patients had a radiation in their 20s or 30s are presenting with some chest discomfort and they're really not a typical demographic for having coronary artery disease, but a cardio-oncologist, someone that knows what the risks are from that treatment and radiation 20 years ago does have a risk of affecting coronary arteries, particularly at the beginning part of those blood vessels, they're at higher risk for those.

And so, recognizing that this really could be coronary artery disease in a younger patient, not the typical demographic, and pursuing that, is important and can save someone from having to present in the ER and suddenly needing a bypass surgery after they've had a heart attack. And so that knowledge can you know, help address things sooner.

I think a lot of the impetus behind cardio-oncology is that a lot of folks presented too late to cardiologists when we had fewer options available than if we found stuff early. And people's cancer therapies were being held when they didn't need to be. There is a concept in cardio-oncology called permissive cardiotoxicity.

And that is, we recognize some treatments might have side effects, but in cardiology we can treat those. We can treat rhythm issues. We can treat the heart getting a little bit weak and help prevent it from becoming full heart, clinical heart failure. And having that perspective can make sure that you're able to complete the treatment you want.

Or if you have something like a heart attack, we can get you back on the cancer treatment that you need sooner. The knee jerk reaction to stop everything and not keep going and really can harm the, the long term outcomes.

Host: Any closing thoughts, sharing something that we did not talk about?

Courtney Campbell, MD, PhD: Yeah, so with cardio-oncology, it is a new field. The cancer treatments are evolving every day. There are new drugs being approved, and there are new side effects that we're learning about that can affect the heart. And so with the cardio-oncology center here, we work nationally on clinical trials and registries to help identify best ways to manage and what are the side effects of these medications. And so at a, at a center and a cardio-oncology specialist, you get that network of really across the country of trying to improve the lives for these patients.

Host: Dr. Courtney Campbell, thanks so much for enlightening us on the specialty of cardio-oncology. Thank you.

Courtney Campbell, MD, PhD: Thank you, Cheryl.

Host: For more information about the program, please call 214-820-7162. That's 214-820-7162. To learn more about heart and vascular care on the Dallas campus, just go online to BSWhealth.com/heartDallas.

Thanks for checking out this episode of HeartSpeak. To find a specialist at Baylor Scott and White Heart and Vascular Hospital in Dallas, call 844-279-3627 or visit BSWHealth.com/HeartDallas. If you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library for other topics of interest to you.

Thanks again for listening. Baylor Scott & White Heart & Vascular Hospital, Dallas and Fort Worth; joint ownership with physicians.