Intro: This is Weekly Dose of Wellness, brought to you by MemorialCare Health System. Here's Deborah Howell.

Deborah Howell (Host): Ever wonder how radiation therapy and other cancer treatments can impact heart health? In this podcast, Dr. Peyman Kabolizadeh, Medical Director, Radiation Oncology at MemorialCare Todd Cancer Institute in Long Beach, and Dr. Fernando Mendoza, Medical Director of Non-Invasive Imaging and Cardiac Rehabilitation at the MemorialCare Heart and Vascular Institute at Long Beach Medical Center, will delve into the critical intersection of Cardiology and oncology to unravel the intricacies of heart health during cancer treatment. Welcome, Dr. Mendoza and Dr. Kabolizadeh.

Dr. Fernando Mendoza: Thank you, Deborah. Pleasure to be here.

Dr. Peyman Kabolizadeh: Good afternoon.

Host: Dr. Kabolizadeh, may I call you Dr. K from time to time?

Dr. Peyman Kabolizadeh: Yes, please.

Host: Okay. How can radiation therapy and other cancer treatments impact heart health?

Dr. Peyman Kabolizadeh: So to answer that question, cancer treatments, especially radiation and some chemotherapy drugs can unfortunately have unintended effects on the heart, especially in the left-sided breast cancer patient and lung cancer patient as the heart lies close to the radiation field. And even low-dose radiation can raise cardiac risk. This is pretty much from a study, landmark study in 2013 from the New England Journal of Medicine that showed increase in radiation toxicities. A type of radiation-induced heart disease can be due to acute inflammation and chronic inflammation after radiation and can be involving coronary artery disease, pericarditis, valvular heart disease, and myocardial fibrosis.

Host: Thank you for that. Dr. Mendoza, what symptoms arise that show heart complications have been detected after cancer treatment?

Dr. Fernando Mendoza: Well, first, I'm going to say that actually you want to detect this stuff before there are symptoms, okay? So, you know, in general, if you look at the expert consensus from the people that. Look into this field, they actually recommend that if you have had radiation, for example, to your left breast or to an area near your heart that you should be screened with heart tests every five years. That would include an echocardiogram and typically a stress test.

In addition to that, you're going to want to make sure that you have your heart risk factors assessed for on an annual basis, meaning do you have high blood pressure? Do you have high cholesterol and all those things? Because if you get radiated in the area next to your heart and you have those other risk factors for diabetes, high blood pressure, high cholesterol, then your risk is even higher, got it? So, we don't look at just, "Did you get radiated or not?" But we look at it in terms of you, as a patient, what other risk factors do you have? And so, those are the kind of the two screening tests that we would normally recommend. And we would want to find things before you had symptoms.

But supposedly, you didn't get those screening tests and the symptoms that you would look for could be shortness of breath. It can be as subtle as, "Hey, I'm tiring it out more than I think I should, based on my aging alone," chest discomfort, swelling in your legs. Those are the kinds of things that you would normally think about.

Host: Got it. Dr. K, back to you. Why is it important to choose a hospital that has programs and/or technology that can protect the heart from cancer treatments?

Dr. Peyman Kabolizadeh: Cancer survival is improving, but we want patients to survive well without long-term complication like heart disease. So, it's very important to choose a center that has very up-to-date technology, new technologies that are decreasing the dose to the adjacent critical structures like heart. So, those technology like deep inspiration breath hold dictate the treatment just to the breast tissue rather than the surrounding structure or using intensity-modulated radiation treatment or image-guided radiation treatment, these significantly reduce the heart exposure to radiation.

And most importantly, as Dr. Mendoza said, having a Cardio-Oncology program is very important to screen for hearts risk before the treatment, monitor heart function, during the therapy. This is very important, especially in patients with heart condition with pacemakers or defibrillators.

Host: And Dr. K, what specific technologies and techniques are available at MemorialCare Todd Cancer Institute to monitor and manage heart health in cancer patients?

Dr. Peyman Kabolizadeh: We have built a suite of tools at MemorialCare Long Beach to protect not only the heart but all healthy tissues around the tumor. We have all kinds of technology that is available to humans, new and also newest that is coming to us, that we would be the first centers in the country and even in the world to have them on the new machine we are just getting right now. We have deep inspiration breath hold, image-guided radiation therapies, CT-based treatment planning, motion management with 4D cone-beam CT, 4D CT scan, AlignRT, Vision RT, adaptive radiation therapy, which adjust treatments in real time as the patient goes through the radiation treatment, as their tumor start shrinking, then we can adjust the treatment in real time. There is DoseRT from Vision RT we're getting on the new machine, which we exactly know where the dose actually is going to reside. SimRT from Vision RT is also another technique, which give us the opportunity to deliver the dose very precisely and accurately. Also, we're getting RapidArc, Dynamic HyperArc, which are, again, newest technology. We will be the first centers in the United States having that. And that gives us the possibility of delivering the dose very accurately and precisely without giving the doses that are surrounding a structure, normal structures. And lastly, HyperSight, which is a beautiful technology that give us CT resolution on the machine so we would know exactly where the tumor is at all time during the treatment on the machine. Lastly is MapRT, also giving us the possibility of delivering precise radiation.

But in addition to those, we also follow guidelines and recent publications, and we try to reduce and omit radiation where it's safe. We try to use less number of radiation treatments. For example, three weeks instead of five to six weeks for breast cancer or try to do partial breast irradiation using IMRT or brachytherapy or even intraoperative radiation treatment, which is only giving one shot of radiation at the time of surgery.

Host: Well, let's continue the good news with Dr. Mendoza and talk about the advanced diagnostics and treatments that MemorialCare Heart and Vascular Institute uses to diagnose and treat these kind of heart conditions if they do show up.

Dr. Fernando Mendoza: Yeah. Well, I mean, one of the great things about working at MemorialCare Heart and Vascular Institute is they've shelled out a lot of money to make sure that we have the best high-end equipment, no matter what kind of heart testing you need. I don't think there's anything available that we don't have there.

The good news is that majority of what is needed out there to diagnose and treat these things, they're actually not super complicated for the most part. A lot of it is a heart ultrasound, an echocardiogram. We do have some ability to do additional high-level ultrasound. We do something called left ventricular strain, where we can detect whether your heart muscle is getting weak before the ejection fraction even drops. And that's one tool that we've added in the last few years. It's not necessarily available in all community cardiology offices, but certainly something that we have there. We have CAT scans that can detect whether you have a plaque in your arteries. Stress test, we have every stress test available. And of course, like I said, a lot of this stuff of what we are doing, and I think there's a later question more on kind of the preventative stuff, but it can be blood work, it can be checking blood pressure and things like those.

Host: Okay, appreciate that. Dr. K, how is individualized treatment plan to minimize the risk of heart complications?

Dr. Peyman Kabolizadeh: So, every treatment plan is unique, personalized to each patient's anatomy and medical risk. So, we use at our center all resources that is available to us, including advanced imaging treatment simulation techniques, motion management, including deep inspiration breath hold or gaiting, real time adjustment, which we can adjust the treatment plan in real time, along with treatment delivery techniques like using intraoperative radiation treatment or using BRCA therapy and risk assessment of each patient. And the most important is multidisciplinary planning. We work hand in hand with cardio-oncologists here at Memorial Cancer Institute.

Host: Got it. And that's really more good news for the patient. Dr. M, what role does advanced imaging play in preventing heart complications during cancer treatment?

Dr. Fernando Mendoza: If we're talking about during cancer treatment, then there are specific chemotherapies, that if you're getting, can be heart toxic. These are more commonly used in patients who have breast cancer, for example, Herceptin, or even some of the treatments for lymphoma like doxorubicin, or Adriamycin as it's commonly known. Those patients will typically get a heart ultrasound. And as I mentioned, we at Memorial have an ability to do an advanced echo where we do something called strain imaging where we can detect damage very early in the process before there's any permanent damage to the heart.

But I wanted to take you through a typical patient that I may see in my office a few years after their treatment, just get a sense of what patients can do and what's out there and what's recommended. So, this is all about trying to make patients the best advocates for themselves. So if you're a patient and you've had some treatment, for example, some radiation to your chest in the past. And typically, what will happen is when you go in, you see your doctor for, let's say the first time, if you're going to put that on your list on the piece of paper that you had breast cancer or you had lymphoma, I would say majority of the time, the doctors never do any follow-up questioning on that with your primary care physician or whether that be a cardiologist. So, I would say, in that case, it's your job to, if you had radiation, to make sure that you relay that to the physician.

 So, I will typically do that, for example, if I see somebody who's got a history of breast cancer, my question is, was it the left breast or the right breast? And then, I find out what kind of treatment you had. if you remember the chemotherapy, I'll write that down. And then, if you have a history of radiation, then I'll write that down as well. And then, the second steps I do is, again, to kind of look at what risk factors do you have, right? So, are you an older patient because older patients are more likely to have heart disease versus young patients? Do you have a history of diabetes? Did you smoke before? Did you have high blood pressure? Do you have high cholesterol? Is there a family history of heart disease. All those things combined. Because the way I look at it is I look at your treatment, whether it be radiation or if any of your chemo was potentially toxic to your heart. I look at that as another risk factor. So, let's say you don't have any of those others and you only had this radiation or this chemotherapy, then I'm not as concerned. Because let's say you had a slightly increased risk as a result of these therapies, your baseline risk is so low that I'm not super worried.

But again, if you already have all those other risk factors, you know, if you're obese and you have diabetes and high cholesterol and high blood pressure, then I'm more concerned because you're already higher risk than your average person and you had an additional risk on top of that. And so, what I'm going to do then is I'm going to treat those risk factors a little bit stronger. Let's say your cholesterol was on the fence, so whether I would treat it or not, I'm going to treat it now because if I was just looking at your risk in general for heart disease, a general estimate is going to underestimate it because it's not accounting for the treatments that you got during your cancer. And so, that's kind of the picture that I look at it. And then, again, the tests that are typically recommended, if you had radiation to the area near the heart, would be to do an ultrasound of your heart to detect if there's any valve disease as a result of that. And then, a stress test and, again, these are like every five years, so don't think that this is on an annual basis.

And there's different kinds of stress tests. But normally, it is still recommended to do it, even patients who don't have symptoms. I'll tell you, a lot of primary care doctors don't have this information. So, I would basically relate to them that you've heard that it was recommended to get an ultrasound and a stress test every five years in these cases. And then, sometimes what I'll do is I'll get a CAT scan. There's a test called a coronary calcium scan that can measure how much plaque you have in your heart arteries to give a sense whether the radiation may have aged your arteries to some extent, and whether it's time To do, a cholesterol treatment, whether to give you an aspirin to reduce your risk. And sometimes to guide me in terms of what kind of stress test to do, to tell me is it a high chance that they have blockages in their arteries or do they have very minimal stuff? And so, we don't have to follow them as closely. So, that's kind of my approach and the general approach in patients who are followed for Cardio-Oncology.

Host: Okay. This final question is for both of you and I'd like to start with Dr. Kabolizadeh. Are there lifestyle changes or preventive measures that cancer patients can take to protect their heart health during treatment?

Dr. Peyman Kabolizadeh: Absolutely. What people do outside the clinic is just as important. They can do heart-healthy diet, regular exercise, no smoking, and limit alcohol, manage health conditions, reduce stress, follow your care team's advice, and choose the right team. And I think Dr. Mendoza can comment on this further.

Dr. Fernando Mendoza: Yeah, Dr. K. I think, you nailed it. I want to be clear that a lot of the risk factors for heart disease overlap with the risk factors for cancers. For example, sedentary lifestyle makes you at higher risk for heart disease, makes you at risk for cancers. Being overweight or having obesity increases your risk for some cancers as well as for heart disease. So, you basically want to do the things that we should all be doing, which is doing regular aerobic exercise. It can be going for a walk. If you have knee problems, you know, going for a bike or doing some water aerobics. Whatever you can do on your end to make sure that you get going is great. You want to make sure that you're treating your risk factors. There are data that showed if you look at somebody who has cancer and who has high blood pressure, the ones who have their high blood pressure treated better during their cancer treatments actually do better overall.

I know it's tricky because I know one of the tricks when you have cancer is you go all in on the cancer and you want to combat that and go a hundred percent on that. But I want you to try to also keep in mind that it's still important for you to take care of the rest of you and make sure that you're eating well and exercising and do all those things because treatment for cancer now are so good that you have a very high chance you're going to survive it. We want to make sure you don't have any heart complications afterwards.

Host: I love the positivity so much. Thank you very, very much, Dr. Mendoza and Dr. Kabolizadeh, for your time and your expertise today. We learned a lot and we really enjoyed having you on the podcast.

Dr. Fernando Mendoza: Thank you so much, Deborah.

Dr. Peyman Kabolizadeh: Thank you so much, Deborah. And one last thing is treating cancer shouldn't come at the expense of the heart. Thanks to modern radiation techniques and imaging and multidisciplinary care, we can help patients not only survive, but also thrive with their heart strong and protected.

Host: I'm so glad you added that. And for more information about cancer treatments that safeguard your heart, you can visit memorialcare.org/lbcancer. That's all for this time. I'm Deborah Howell. Have yourself a terrific day.