Melanie Cole, MS (Host): There are so many advancements in cancer care and we're learning more and more about the effects of cancer treatment on the cardiovascular system. We are here today to highlight AHN Cardio-Oncology Center of Excellence.

Welcome to AHN Med Talks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices, ensuring you stay at the forefront of your field. I'm Melanie Cole. And joining me today is Dr. Valentyna Ivanova. She's a certified cardio-oncologist at AHN. Dr. Ivanova, thank you so much for joining us today. I'd like you to start by telling us a little bit about the field of Cardio-Oncology. It's new-ish, and tell us a little bit about what you do and how it comes together to affect patient care.

Dr. Valentyna Ivanova: Good morning, Melanie. Thank you so much for having me on your program. So to answer your question, it's a very broad one, but let's just start from what Cardio-Oncology is. It's a close collaboration between hematologist, oncologist, and cardiologist, that leads to improvement in patient care who were diagnosed with the cancer.

So, what we do, first of all, we're trying to determine out of all the patients that Oncology is seeing, who is the higher risk to develop cardiovascular dysfunction or cardiovascular disease-- based on patients, who they are based on their own medical history, preexisting medical history, cardiovascular and others-- and also based on the therapy that these patients are going to be receiving. So, we did develop special risk factors, based on these two categories to aid the oncologist in determining who would be at the higher risk while they're seeing these patients. And that would determine their referral to the Cardio-Oncology program. Because as you can imagine, as many Oncology patients as we have, we will not be able to see every single Oncology patient, and it's not the goal Cardio-Oncology.

Melanie Cole, MS: Well, thank you for that. And that leads well into my next question. What are the goals of the AHN Cardio-Oncology Center? What does it mean, Dr. Ivanova, to be a center of excellence? And what does that mean for patients?

Dr. Valentyna Ivanova: So when a patient's referred to Cardio-Oncology Program by our Oncology colleagues, the first thing when we are meeting the patients, we're trying to determine which preventive strategies would minimize their risk before initiation of therapy. That's our first goal. We see this patient as a whole, not only just what their cardiovascular risk factors are, what their cardiovascular diseases are already preexisting, but we are assessing this patient from the patient itself and also the therapies they're going to receive. So, the role of the cardio-oncologist, knowing Cardiology, plus the Oncology therapies that are existing and knowing their effects on the patient's cardiovascular system, either immediate one or down the line.

The next step is we determine the preventive strategies prior to initiation of therapy. We usually follow these patients throughout the therapy and have strategies that minimize risk during potentially cardiotoxic therapy. And based on all our armamentarium of testing from Cardiology, we definitely determine what surveillance or monitoring would be appropriate for this specific patient throughout the therapy. So, the goal, the main goal is not to interrupt cancer therapy or minimize the interruptions of cancer therapy, and especially the goal is not to completely stop the cancer therapy because of the side effects from cardiovascular system.

Melanie Cole, MS: Really so important, this work that you're doing. Tell us a little bit about the type of care that you do offer in Cardio-Oncology for these patients.

Dr. Valentyna Ivanova: So, we offer outpatient and inpatient care, obviously for all our Oncology patients across the AHN network. A majority of our work is concentrated on the outpatient, providing consultation to Oncology patients, and having all the preventive strategies for cardiovascular disease while they are in treatment. Although, you know, the cardiovascular effects of chemotherapy or even not only cardiovascular, but other systems effects of chemotherapy lead to our patients to be admitted to the hospital. And that's where we also provide the care by seeing these patients inpatient and using all the necessary cardiology testing and procedures to help them overcome the cardiovascular effects of chemotherapy and immunotherapy if they're receiving those concomitantly.

Melanie Cole, MS: I'd like to get into a few of those effects in a minute. But before we do, Dr. Ivanova, speak about the multidisciplinary need for these patients. You are a cardio-oncologist and then there's Hematology and Oncology. Tell us a little bit about the team that's working with these complex patients and why that's so important that you all work together.

Dr. Valentyna Ivanova: Yes, it is very important to altogether because Oncology seeing the patient that determine all the necessary treatments based on the cancer itself. And when they determine that the patient is higher risk for cardiovascular complications during the therapy we see in these patients.

But if we are disconnected completely, we don't talk to each other, there is no good outcomes for this patient, right? So, as we see in the patient and we are determining the strategies to follow with this patient, what strategies we need to do from Cardiology standpoint, we usually communicate with our Oncology colleagues, Hematology-Oncology colleagues. And by close communication, we're making sure that patient has a clear plan on how to reach the goal. And the goal is usually to beat the cancer, right? So, that is the main goal. Or patients who are on palliative chemotherapy, and their cancer is at bay and not growing and not progressing. So, this is the patients that are long term on chemotherapy so we don't interrupt their therapy, and making them stable and making them in remission.

So, communication is the key, especially during complications and changing of Oncology strategy, changing of Cardiology strategy is very important. And if we don't communicate in real time, these patients don't do well, they're doing much more poorly.

Melanie Cole, MS: What are some of the most common side effects that you see from chemotherapy, from radiation, immunotherapy, any of these things that might affect the cardiovascular system? What's the scope of what we're talking about here today?

Dr. Valentyna Ivanova: Okay. So, going a little bit back, by 2025, we have like five pillars of cancer treatment. Those were just surgery, initial ones, right? That was offered way, way back. Radiation therapy, chemotherapy, targeted therapy and immunotherapy. Those five pillars are used by oncologists, either simultaneously or separately based on the cancer. And all the intertwining side effects of these therapies, targeted therapy, immunotherapy, there's multiple cardiovascular effects that we see from cardiomyopathy to whole heart failure symptoms as a presentation. Also, effects on endothelium of coronary vessels with their coronary vasospasms with myocardial infarction. Especially with patients who are on immunotherapy, they are more prone to myocarditis, and also atherosclerotic heart disease. So, arrhythmias are very common also based on the medications patients do receive. And radiation therapy, not to forget about that, people were thinking that radiation therapy is not as affecting as maybe chemotherapies. But radiation therapy affects every single part of cardiovascular system. It affects directly cardiomyocytes, causing cardiomyopathy and declining in LV systolic function. It can cause diastolic dysfunction. It affects valves, causing down the line, in cancer survivors especially, valvular disease, stenotic valvular disease or regurgitation. It does affect the conduction system, and causing arrhythmias or AV nodal blocks. And it also affects coronary disease and increased atherosclerotic process leading to myocardial infarction down the line.

Melanie Cole, MS: Wow. So many possible side effects. It's really is. I'm so glad that we're learning so much more about this, and we're able to look ahead and try and prevent some of these, or mitigate some of those effects. Dr. Ivanova, what's exciting in the field of Cardio-Oncology right now? Tell us about some of the research and innovations at AHN right now.

Dr. Valentyna Ivanova: There is lots of excitement in the field of Cardio-Oncology, obviously. JACC Journal has all the publications, newest in the research. Although in Allegheny General Hospital, we also participate in research programs. Our center here is a part of the ATRIUM Study, which is abatacept for immune checkpoint inhibitor-associated myocarditis. We are one of 52 centers that participate in this phase III investigator-initiated and randomized double-blind, placebo-controlled study, which studies the abatacept efficacy in patients who are on immune checkpoint inhibitors and develop myocarditis. It's a disease that's very rare. I mean, the rate of myocarditis is probably less than 1% out of all the patients that receive immune checkpoint inhibitors, although the complications rate or actually death rate is up to 50% with the immune checkpoint myocarditis.

So, it's very important to investigate what other treatments these patients might have, like steroids. At this point of time, steroids are the main treatment, but they have lots of complications down the line and, especially steroids decrease the sensitivity for the patient for further treatment with chemotherapy. So, cancer has become less sensitive to chemotherapy if patients receive high-dose steroids.

So, this study allows us to see if abatacept would be the agent that we can initiate for these patients for treatment, and not using very high-dose steroids at the same time. So, that's one of the researches we do participate. Also, we recently received the grant from Glimmer of Hope Foundation to start retrospective study to investigate patients, breast cancer patients, younger age, below age of 65. In this population, if they do receive chemotherapy, 16% of these patients would develop cardiovascular disease in about 10 years after treatments is finished. And it's very important because this is younger patients, they have lots of life ahead of them. And we're trying to make sure we investigate and see what could be the reasons. Do they have preexisting conditions or they don't? And we are trying to see what can we do to mitigate this risk for this younger patients with breast cancer. So, those are the two main things that right now in AHN, our Cardio-Oncology Center, participates in and doing research in.

Melanie Cole, MS: What an exciting time in your field, Dr. Ivanova. As we wrap up, I'd like you to speak to other providers about what you feel are the key takeaways, referral criteria, your vision for the program, and how this care model will really improve the way that patients receive care for comorbid conditions, how it will affect their outcomes. Wrap this all up for us with truly your best information.

Dr. Valentyna Ivanova: Thank you so much. It is a very important point. I just wanted to say to all my colleagues across the network, not every single Oncology patient is seen by cardio-oncologists. And now, with our close collaboration with oncologists, we do know Cardio-Oncology Program exists. We collaborate between two specialties, although lots of patients just seen by other specialists, which for example, they did have a history of cancer and they received the treatment, especially treatment with anthracyclines, especially treatment with a whole chest radiation in the past when they were younger. And now, they're seeing just with primary care physician or seeing with any other specialist for any other reason. Please pay attention to their history, the cancer history. That could have affected their cardiovascular system or down the line has affected the cardiovascular system, these patients are more vulnerable. And please do send them, refer them to us. We will be happy to see them. We will be happy to determine all their risk factors or help you manage their cardiovascular conditions that they might have now, because previously they were not properly having plan of management and treatment and seemed like, "Okay, cancer's treated. We beat the cancer." Cancer survivor, good. Oncologist to stop seeing patients in a certain period of time or follow with them remotely or maybe once in one year or five years. But cardiovascular disease is brewing underneath and we need to be aware of that. More and more cancer survivors we have these days and Cardio-Oncology job is not finished at the chemotherapy finishing line. We are really seeing a lot of patients who are survivors and making sure that they live their life fully without succumbing to cardiovascular disease after they beat the cancer.

Melanie Cole, MS: Dr. Ivanova, thank you so much for joining us today and really sharing your incredible expertise in a profession and a field that not everybody knows about. And it's so important the information that you gave us today. So, thank you again for joining us. And to learn more or to refer your patient to Dr. Ivanova, please call 844-MD-REFER, or you can visit ahn.org. Thank you so much for listening to this edition of AHN Med Talks with the Allegheny Health Network. I'm Melanie Cole.