Transcription:
Managing Treatment Related Cardiovascular Side Effects

Melanie:  Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole and joining me today is Dr. Nausheen Akhter. She's the Director at the Cardio-oncology Program at Northwestern Medicine and a member of the Robert H. Lurie Comprehensive Cancer Center at Northwestern University.

She joins me today to discuss her research and clinical focus on cardio-oncology and provide comprehensive cardiovascular care for cancer patients. Dr. Akhter, I'm so glad to have you join us again. And how fun is your name to say, Dr. Akhter? I just love that, so I may say it a few times today. Tell us a little bit about the field of cardio-oncology or onco-cardiology. What are the goals of this field? What is this like right now?

Dr Nausheen Akhter: Well, thank you so much, Melanie. I'm very excited to also be on this podcast today with you and discussing. This is truly a passion of mine, cardio-oncology or onco-cardiology. There's some internal debate even within the field as to the name of this sub-specialty. But I will go by cardio-oncology. It's really a bridging field that has grown alongside cancer survivorship. And I would say that it has two primary goals. One is to advocate for better patient care by providing really seamless management for our patients between cardiology and oncology; and two is to identify, prevent and minimize early and late cardiovascular effects of cancer therapy. So I would say those are the two overarching goals of this field.

Melanie: Tell us about the training and background of cardio-oncology. So really this is a newer field, right? It hasn't been around for that long, but we're learning more and more about the cardiovascular effects of cancer and cancer treatments and all of the things that go along with cancer, right? So tell us a little bit about extra training and background that you have.

Dr Nausheen Akhter: A little bit about the history of this sub-specialty, you know, cardio-oncology, I would say, really started as a practice within large cancer hospitals like MD Anderson, where they were employing cardiologists to provide the cardiovascular care for their patients, but I would say there's been an explosion in this space, and there's been this need for closer support between these two sub-specialties and that's really grown due to the development of many new cancer therapies that can cause a variety of cardiovascular effects.

And so from cancer hospitals, then you'll now start to see that there are cardio-oncologists at most academic centers, and even now into community practices. And so our program here at Northwestern, although it started really as a fluid clinic where I have had an interest primarily in taking care of these patients, has now grown into a formal program. I would say that that's, you know, transpired, especially that growth has happened over the past couple of years.

There's really at this point no formal training for cardio-oncologists, although there are some institutions that are starting fellowship training. We here at Northwestern incorporate our general fellows into our cardio-oncology class as well as our advanced fellows who are interested in both imaging or heart failure, so they can rotate through cardio-oncology clinic and receive training that way.

There's also a lot of didactic training through lectures, and there are several national programs, that are devoted to cardio-oncology, that you can attend. There's even a journal, JACC CardioOncology, which is a subspecialty journal of the Journal of the American College of Cardiology. And that started about 2019. So as you can see, it's really a newer area, but it's growing very fast.

Melanie: Well, it certainly is. And what an interesting subspecialty. We don't often think about all of the side effects that affect other organ systems. So as survivorship continues to grow, Dr. Akhter -- see there, I said it again -- where do you see the coordination? Because I think this is one of the most important aspects of your field, is this coordination, this multidisciplinary coordination of care between cardiologists and other healthcare providers, such as the oncologist, the medical and radiation oncologists, the patient's own providers. Tell us a little bit about this multidisciplinary approach that would help compliance for the cancer followup care, routine health maintenance, all of those things that would help to alleviate some of those cardiovascular complications.

Dr Nausheen Akhter: So, Melanie, as you touched on the cancer survivors right now in the US are estimated at over 17 million, but that number has actually projected to grow over 30% by 2029. We're expecting to have approximately 22 million cancer survivors in the United States. And that's over 5% of the US population. And that's really because of early diagnosis and advancement in treatment.

With that increase in survivorship, cardiotoxicities then become the primary determinant of quality of life and mortality, particularly the longer into survivorship a patient is. So that partnership between cardiology and oncology, in terms of really thinking about patients from the cardiovascular prevention perspective is becoming very central to patient care. And that really starts even before cancer treatment starts.

When we have patients referred to us, we tried to develop a very collaborative plan with oncology with every new patient to really discuss the risks and benefits of their treatment even before treatment starts. The majority of our patients, however, are referred for treatment side effects on treatment. So I would say the majority of the patients that we receive referrals for come from our breast oncologist, patients with lymphoma, leukemia, lung, and myeloma. But we do see patients from across the cardiovascular spectrum. And the primary reasons we see patients are for decrease in heart function, so heart pumping function or heart failure. That I would say the majority of the patient group, is about 40%. We also see patients for arrhythmia and other reasons.

But our goal is really to partner with and be a part of -- like you said, the patient with cancer has so many different providers that they're dealing with. And as a cardio-oncologist, we're part of that team. And we're really there to partner with the patient. So they're able to get the treatment that they need. And that requires a lot of discussion with all the members of their team. And what's very nice to have that all housed under one roof. Our clinic although is physically located in the cardiology clinic. We discuss every patient with oncology and have a wonderful relationship with all of our oncologists or radiation oncologists, the nurse practitioners, both the oncology nurse practitioners as you said, the many, many different providers patient interacts with. But really kind of thinking about the prevention piece even before starting cancer therapy, knowing that cancer therapy has really advanced is critically important to now in cancer care.

Melanie: Well, it certainly is, which leads us very well into our next question. Tell us a little bit about the structure of Northwestern Medicine's cardio-oncology clinic. You mentioned it a little, tell us how you're shifting referrals upstream because pre-chemo cardiac evaluation for those high-risk patients is so important as you said, so that you can anticipate or know ahead of time what to be aware of. So you're working with the patient and their other physicians. Just tell us a little bit briefly about the structure.

Dr Nausheen Akhter: Even though we're housed in cardiology, we have a very fluid clinic where we do try to work with our patients, so that understanding they have multiple appointments with oncology as well, and try to time their appointments and their testing, so it's really to minimize their time to travel and understand that convenience is very important for our patients.

We have ongoing discussions with our oncology colleagues about what is considered to be a high risk. And that is an area that there's quite a bit of research and that we are learning more and more about the patients with known cardiovascular disease, patients who are older, and who are known to be undergoing cancer therapy that can affect the heart or if they're starting already with a lower heart function going into treatment. Those patients certainly are seen by cardio-oncologists before treatment.

And so although we're not capturing probably the complete group of patients that can be seen before treatment, I would say that we are getting really kind of the highest risk group of patients. And it's critically important to see these patients beforehand so that we can really optimize their care and come up with a surveillance strategy during treatment as well as provide education to both the patient and the provider for what kind of side effects, what kind of symptoms to watch for during treatment and to already establish that connection with the cardiologists. So that if these symptoms transpire, then they're connected with cardiology and can more quickly and directly connect with us so that we can address these issues without a delay.

Melanie: So before we wrap up, Dr. Akhter, your background is also in imaging. So tell us how cardiac imaging is used in cancer therapy surveillance because as we learn more about survivorship and followup care becomes even that much more important, right? So tell us a little bit about your background in imaging and how this is used in cancer therapy surveillance.

Dr Nausheen Akhter: Cardiac imaging is central to our assessment of our patients because the majority of our patients are referred for changes in their heart function. And that is generally thought of as the primary toxicity of cancer therapy. And so when we think about cardiotoxicities, you may hear a term called cancer therapy-related cardiac dysfunction. And essentially, that is a change in heart function by greater than 10% from the baseline heart function to a value less than lower limits of normal. And this has primarily been studied in traditional chemotherapies, such as anthracyclines and trastuzumab or Herceptin, but there's a lot of newer treatments, novel agents and immunotherapies that can also cause these changes on heart function. And so imaging surveillance is critical and we don't have it really well worked out in terms of followup, but except for traditional chemotherapy.

So traditional chemotherapy, as we know, to get a baseline heart function assessment, and then reassess depending on the type of therapy during treatment, after a certain dose of treatment and then afterwards within the first six to 12 months. But that area is also an area of research where we are learning in terms of long-term how best to surveillance our patients. I think that the patients who've had childhood cancer and childhood treatment, there's a little bit better worked out algorithm than for adult cancer survivors. But that is an area that I see that we'll have a better understanding of in the future.

Melanie: As we wrap up, where do you see this field going in the future?

Dr Nausheen Akhter: There are so many exciting developments in cardio-oncology. And I think that this area just will continue to grow and it's very exciting to be In this field right now. There is a lot of growing understanding of the overlap and risk factors between oncology and cardiology. For example, obesity, we know obviously is a risk factor for cardiovascular disease, but also for certain types of cancers, such as colon cancer. And so, you know, understanding the pathophysiology of the risk between both and to be able to sort of prevent both of these entities is exciting.

There'll be a growth in precision medicine as we better understand the mechanisms for cardiotoxicity. There'll be a growth in the use of artificial intelligence within imaging and understanding that artificial intelligence will also be a part of a patient's surveillance in the future, as well as an understanding of disparities in both cancer care as well as cardiovascular care, cardio-oncology can lead in understanding that area as well. So I think there's a lot of potential for growth here and the cardio-oncology can lead in many ways.

Melanie: Absolutely true. And thank you so much for telling us about this fascinating important field, Dr. Akhter. And to refer your patient or for more information on managing treatment-related cardiovascular side effects, please visit our website at nm.org to get connected with one of our providers.

That wraps up this episode of Better Edge, a Northwestern Medicine podcast for physicians. For updates on the latest medical advancements and breakthroughs, follow us on your social channels. I'm Melanie Cole. Thanks so much for listening.