Scott Webb (Host): Newly diagnosed cancer patients who will be receiving chemotherapy or chest radiation therapy may experience heart complications as a result of their treatment. And experts like my guest today work to prevent, detect, and treat these complications. I'm joined today by Dr. Roland Njei. He's a board-certified cardiologist who specializes in cardio-oncology and practices at Franciscan Health.

This is the Franciscan Health Doc Pod. I'm Scott Webb. Doctor, it's great to have your time today. We're going to talk cardio-oncology and maybe what, you know, cancer patients should know about their heart during and after treatment. But let's just start here. What is cardio-oncology, and why is it such an important field?

Dr. Roland Njei: Well, that is a great question because, you know, cardio-oncology as far as cardiology is concerned and cardiovascular disease in general. Cardio-oncology is a newer branch of cardiology that really focuses on patients who have a new diagnosis of cancer, are undergoing treatment. And we focus on preventing, detecting, and treating any complications, any heart or vascular complications from chemotherapy and also chest radiation.

Now, why is it important? I look at it in three different steps. I look at before treatment, I look at during treatment, and I look at after treatment. So before treatment, the question becomes, is this patient really, you know, based on this patient's risk factors, does the patient have any cardiovascular disease? Does the patient have any risk factors that we think might be a major hindrance or might complicate their treatment? Then, the goal prior to treatment is can we optimize these risk factors? Can we optimize their cardiovascular and heart health prior to them having treatment?

Now, during treatment, we also want to monitor and treat these patients for any cancer-related side effects, right? Also during treatment, one very important aspect that a cardio-oncology does is to help the oncologist determine if it's okay, is it still safe for this patient to continue treatment even after heart problems develop? Because sometimes a patient can be responding very well from chemotherapy, and then they develop a cardiovascular complication. Now, they're caught between a rock and a hard place. Do we stop this really life-saving therapy, because this patient has developed cardiac complications, or is there something else that we can do?

And most of the time, in that case, we do a joint decision-making. There is something we call permissive cardiotoxicity, where we say, "You know what? You are benefiting from this therapy. We see that you're responding really well. Even though your heart muscle is weak, we're going to let the oncologist continue with the treatment, and then we're going to put you on medications to protect the heart."

Then, after treatment, it is very important to keep monitoring these patients because once you're done with treatment, some of the side effects of chemotherapy do not all of a sudden disappear because you're completely cured from disease. Depending on the kind of therapy that you were treated with, you can have long-term complications, from cancer therapy, especially someone who got treated with radiation. Sometimes you might not see any side effects, you know, anywhere ranging from say seven to 21 to 22 years.

Host: Wow. Okay. So then, Doctor, which patients are at risk for heart problems during and/or after cancer treatment?

Dr. Roland Njei: I think in the beginning there are a couple of things I look at. So, number one is, what is this patient's functional capacity at baseline, right? If you have someone who is very active, has no functional limitations from a heart standpoint, they're probably going to tolerate treatment very well.

Secondly, I say, do they have any baseline risk factors, you know, cardiovascular risk factors? Like, is their diabetes well-controlled? You know, cholesterol is well-controlled, blood pressure is well-controlled. Are they a smoker? You know, do they have these risk factors prior to treatment?

And prior to treatment, again, we want to say, "What is your heart function like?" Right? Because someone with a very normal and good functioning heart is more likely to tolerate treatment better than someone who has a weak heart at the time of us starting this patient on chemotherapeutic agents.

Host: Yeah, it's really interesting. And you touched on earlier that it's sort of shared treatment, shared decision-making, obviously patients, families, but also cardiologists, oncologists, and other cancer providers. So, how do you all kind of work together to protect patients' hearts?

Dr. Roland Njei: Yeah. So to begin with, I always tell my patients in clinic that I try to group your treatment into three buckets. So before the patient is treated, it heavily depends on the therapy that they're going to get, right? Are they getting chemotherapy? Are they getting immunotherapy? And then, we kind of like group, and there is something we call type 1 cardiotoxicity, right? These are chemotherapeutic agents that you're treated with. You could be completely cured from your cancer. And if nobody is monitoring, you could present anywhere from one to, you know, 10, 15, 20 years down the road with heart failure or some kind of complications. Then, there is something we also call type 2 cardiotoxicity, which means these, you know, patients who they have a cardiovascular risk while they're on therapy.

But once they're done with their therapy, that risk is significantly decreased. So, the way we look at it, we say before a patient even gets treatment, we say, "Where do you fall in this bucket?" And based on that, we kind of like formulate a plan together, a long-term plan for you between myself, the oncologists, and other providers as well.

Host: Right. I want to get a sense from you as best we can here in audio form, right? Which tests are commonly used in cardio-oncology?

Dr. Roland Njei: I would say pretty much most of the tests that will be ordered in someone who doesn't have cancer, at some point in cardio-oncology, it is ordered. Pretty much when someone is on chemotherapy or immunotherapy, they do check their electrolytes there. So, they'll order CBC. They will check their liver function, they will check their kidney function, they will check the blood cell counts. Standard. That is always.

Now, in cardio-oncology, most of the tests that we use to monitor complications from chemotherapy, we use high-sensitivity troponins. Sometimes we use a BNP, which is these are heart markers that we use to see. When someone has treatment, normally, yeah, these markers are probably going to be a little bit elevated in the blood. What I want to see is that, well, one, two, three, four weeks out, they should have normalized. If they're still lingering around, then that is concerning that there might be some subclinical injury going on.

The regular EKG we use all the time because some of these medications can cause arrhythmia. Some of them can prolong something we call the QT interval. And so, we do use EKGs pretty much. The big one is a transthoracic echo. Most of the time before a patient starts, if you're being treated with a medication that we know that can affect heart function, we want to get that baseline transthoracic echo, and then kind of like repeat them depending on what you're on at different intervals to make sure that your heart function is still the same.

Sometimes a basic chest X-ray is needed. Sometimes there are some patients who just because of their body habitus or the way they are built, we don't get really good echo images. And so, most of the time in those patients, we use something they call a MUGA scan. Sometimes, you know, there are some patients who we really need to do an MRI not in every patient. But, you know, most of the time, you know, basic labs like a high-sensitivity troponin to BNP, a regular EKG, echo, a chest X-ray, sometimes even outpatient event monitor or Holter monitor we use all the time, and a MUGA scan. I think those are the tests that we mostly use pretty often.

Host: Yeah. Yeah. And you kind of said earlier, gave us a sense that having a healthier heart going into this, going into cancer treatment, is a good thing. But maybe you can give us a sense specifically, like what can we do maybe to lower our risk of heart issues during and after cancer treatment? I'm assuming you touched on some of the greatest hits there of, diabetes management, blood pressure, cholesterol, those kinds of things. But just kind of go through the list for us. What can we do to help ourselves?

Dr. Roland Njei: Yeah. I think the key is not really waiting until you're diagnosed with some kind of, you know, cancer or some kind of catastrophic disease to say, "Hey, what should I do?" I always say, you know, the key is when you are healthy and strong, the key is knowing what risk factors you have. What are your risk factors, you know, if you have high blood pressure, is it well controlled? If not you have to keep your doctors on their toes to make sure your blood pressure is well controlled. If you have diabetes, most of the time we would like for your A1c to be less than 7, because we know that most of the complications of diabetes occur if your blood sugars are poorly controlled. We want that well controlled. If you're a smoker, highly recommended that you quit smoking. I know sometimes it's easier said than done just because, you know, sometimes people smoke for like 20, 30, 40 years. But we do have agents that we can help these patients kind of like transition from being a smoker to a non-smoker. If your cholesterol numbers are high, we want to get them low.

The major one that sometimes we overlook is obesity, right? You know, obesity is this big, huge risk factor. If you're overweight or obese, we would like to work with you to try to get your weight down. Again, it's something that is easier said than done. And I always tell my patients, "You know, I don't want you to beat yourself up. You didn't just gain this weight overnight. It's going to be a slow and steady process wins the game," versus thinking that, "Oh, this is something you will quickly do overnight."

And most of the time when we talk in clinic, I say, "We have to set what we call realistic expectations," right? If I say, "Okay, we are on a journey for you to lose weight. What is your goal? How many pounds do you want to lose a week?" If you tell me, "Well, I want to lose a pound a week," that is a very realistic goal.

Because if at the end of that week you lose a pound, you are motivated to keep going, right? If you tell me, "Oh, I want to lose five to 10 pounds a week," I'm going to be very frank and say, "I don't think we can attain that. So, let's try to set more realistic goals." Because if at the end of that week you didn't lose five pounds or you actually gained a pound, you're going to be demoralized and pretty much, you know, give up.

So yeah, most of these risk factors are the things that we can like recommend even in people who are not sick, who are healthy. We say, "Hey, try to make sure that if you have any one of these risk factors, they're well controlled."

Host: Yeah, well-controlled, but obviously be realistic. Five to 10 sounds nice, but one sounds more realistic to me.

Dr. Roland Njei: Exactly.

Host: Yeah. So, Doctor, then after cancer treatment ends, how long do patients need to monitor their heart health? Is this a lifelong thing? Is it six months? Somewhere in between? How long generally speaking?

Dr. Roland Njei: Again, like I said, it all depends on the type of treatment that you received, right? Remember when I said you have, what we say, were you treated with medications that can cause type 1 or type 2 cardiotoxicity, right? If you were treated with a medication that causes type 1 cardiotoxicity. You could develop heart failure from this therapy at any point, right? We don't know when. So, these patients, we really recommend that they should be monitored very closely for the rest of their lives, right?

Now, patients who are treated with other medications that cause type 2, where the risk is just when they are under therapy, or patients who are on therapy that we know that can cause blood pressures to be high, increase your risk of arrhythmias and all that. While we say once you are off the medications, that risk significantly decreases. But it's not like it's 100% gone. So, we still recommend that every patient gets some level of follow-up, even if it's just yearly follow-up long term.

Host: Yeah. I want to get a sense from you, I know cardio-oncology isn't necessarily a new specialty or field, if you will, but just how much has the research changed patient outcomes in recent years?

Dr. Roland Njei: That is a fantastic question, because it's really come a long way. One of the things that cardio-oncology research has really done is, number one, is early detection of heart injury, right? In the past, sometimes a patient gets treated with a medication that long term can lead to heart failure. We didn't know how to follow up until patient then shows up with heart failure and then, you know, being reactive.

But I think through cancer research, we're now more proactive rather than reactive. Why? Because we can monitor these patients and have early detection, you know, through, like I said, we use the troponins, we use the BNP. One of the things that we really use in echocardiography that is very important is something we call global longitudinal strain or GLS, right? It looks at the twisting motion of the heart. And we can use these markers to say, "Hey, though your heart is not weak yet, but we're seeing changes at the subclinical level, that gives us a red flashing light that, you know, down the road, your heart can get big or something bad may happen." And so, through research, it has been able to help us to detect this early, you know, through these markers and testing.

Secondly, research has also made it very possible for us to now use preventative heart medications, right? So, take, for example, if I see a patient who's on therapy and I'm seeing evidence based on the testing that there is some kind of subclinical cardiomyopathy, well, we have all these medications now based on research that we can put this patient on to prevent their heart from progressing to full-blown heart failure, right? Beta blockers, ACE inhibitors, angiotensin receptor blockers, ARNIs, which is basically Entresto with statins. So, this is only possible through cardiology and cardio-oncology research.

Now, the other thing that cardio-oncology research has also really, you know, enlightened us is better risk stratification, right? So instead of treating all patients as one-size-fits-all, I can look at a patient and say, "Okay, based on your age, based on your existing heart disease, your risk factors, you have diabetes, hypertension, and the dose of chemotherapy or chest radiation you're going to get, that you're going to receive," I can stratify each patient into different groups, right? And this is made possible through cardio-oncology/cardiology research.

Now, there has also been improved cancer treatment continuation, right? So before it was like, if you develop heart failure, boom, we take you off medication. Well, now we have this concept of we have joint decision-making where we say, "Well, can we do some kind of permissive cardiotoxicity? Let you continue with your treatment, and then we help protect the heart."

Now, the other thing that research has also done that is very good is that now we have a lot of cancer therapeutics coming out. And we are also well-equipped with the knowledge to also manage side effects of these medications, right? Take, for example, if a patient is being treated with an immune and checkpoint inhibitor, we're monitoring for any evidence of myocarditis, which is basically inflammation of the heart muscle, or pneumonitis, which is inflammation of the chest wall. If someone is being treated with something we call like VEGF inhibitors, we know that we have to monitor for high blood pressure and clots in the body. If someone is being treated with say, you know, a growth medication we call TKIs, which is like tyrosine kinase inhibitors, we monitor for risk, we monitor for heart failure, we monitor for arrhythmias. And even CAR T therapy that is used nowadays where they're basically taking your immune cells and train them to go back into the body and fight the cancer cells, right? We know how to manage, you know, some of those cardiovascular complications. So, this has been made possible, these points that I've enumerated made possible through research that has been done in the past, ongoing research. And I think there's still a lot of ongoing research and research to be done that, you know, we'll continue to refine and improve the field of cardio-oncology.

Host: Yeah. And Doctor, if a patient wants to see a cardio-oncologist, especially if it's, you know, maybe been a few years since their treatment, just broadly speaking, how best to get a referral?

Dr. Roland Njei: If you really wanted to be seen by a cardio-oncologist, I think the first thing is not everybody needs to see a cardio-oncologist, right? So, the key is first I would talk to my oncologist and say, "Hey, based on the treatment I'm having or based on the treatment I had in the past, do you think that it will be beneficial for me to see a cardio-oncologist?"

Sometimes I know people move, they had a relationship with an oncologist and that oncologist has changed practice, gone to different areas, then I would just have a conversation with your primary care doctor and say, "Hey, I had cancer in the past and I had this treatment. You think I deserve to see a cardio-oncologist?" So even if the primary care doctor is not, you know, familiar with the therapy that you had, I think he or she would do her due diligence and say, "You know what? I'm not too familiar with this medication, but I think it would be good for me to just—why don't we just send you to a cardio-oncologist for them to assess and then see if you do need to follow up or not?"

Host: Yeah, just do an assessment and see where folks are at. Great to have you on, great to benefit from your expertise. It's an exciting field. As you say, research is ongoing. I'll just give you a chance here at the end, Doctor, just final thoughts and takeaways. We framed here cardio-oncology and what that means and how folks can help themselves, all that good stuff.

Dr. Roland Njei: I would say that, you know, cardio-oncology is an exciting field. I love it, it's one of those things, you know, I love what I do. It makes my heart sing. And what I usually tell my patients, and I like others to know and to sensitize, is that most cardiovascular complications from chemotherapy, they can be prevented. And we can detect early. Most of them we can manage effectively when patients and the care team work together. And I also want patients to understand that protecting their heart is not something that we do against, you know, your cancer treatment. Both, you know, work hand in hand, and it's kind of like we have a complementary goal, not a competing one.

Host: That's perfect. We need to treat the cancer, but we have to maybe also help with some of these heart complications, everybody working together, working as a team. Love it all. Thank you so much.

Dr. Roland Njei: Thank you, sir.

Host: And for more information, visit franciscanhealth.org and search cardio-oncology. And if you found this podcast helpful, please share it on your social channels. And be sure to check out the full podcast library for additional topics of interest. This is the Franciscan Health Doc Pod. I'm Scott Webb. Stay well, and we'll talk again next time.