Selected Podcast
Northwestern Medicine’s Cardio-Oncology Program
In this episode of the Better Edge podcast, Nausheen Akhter, MD, associate professor of Medicine (Cardiology), gives us an inside look into Northwestern Medicine’s Cardio-oncology program. She discusses the importance of this program and the advances that are on the horizon for cardio-oncology.
Featured Speaker:
Learn more about Nausheen Akhter, MD
Nausheen Akhter, MD
Nausheen Akhter, MD has both clinical and research interests in Cardiac-Oncology, to provide comprehensive cardiovascular care to every cancer patient. This spans screening cancer patients for cardiovascular disease to treating those who develop cardiovascular complications from cancer therapy. General interests also include cardiac imaging, valvular heart disease, and heart disease in women.Learn more about Nausheen Akhter, MD
Transcription:
Northwestern Medicine’s Cardio-Oncology Program
Melanie Cole (Host): Welcome to Better Edge, a Northwestern Medicine Podcast for physicians. I'm Melanie Cole. And joining me today is Dr. Nausheen Akhter. She's an Associate Professor of Medicine in Cardiology, and she's the Director of the Cardio-Oncology Program at Northwestern Medicine. She's also a member of the Robert H. Lurie Comprehensive Cancer Center at Northwestern University. She's here to highlight the subspecialty of cardio-oncology today.
Dr. Akhter, thank you so much for joining us today. I'd like you to start by just telling us a little bit about yourself, how you came to Northwestern Medicine, and your role as the director of the Northwestern Medicine Cardio-Oncology Program.
Dr Nausheen Akhter: Thank you so much, Melanie. I'm so excited to be here with you this morning. Yes, I have been at Northwestern now for 13 years. I did my advanced imaging fellowship here and then have stayed on as an attending physician since that time.
My interest in cardio-oncology really started as a junior attending at Northwestern when I looked around and I saw that there was a large unmet need for taking care of our oncology patients and their cardiovascular concerns. Cardio-oncology is a newer subspecialty within cardiology that is growing alongside the development of new cancer therapies and prolonged cancer survivorship. And currently, there's estimated to be about 18 million cancer survivors in the US, and this number is just steadily growing.
And so, I saw there's this large patient group. And so, I thought it might be interesting to kind of look a little bit further into this area. I would say this field has about 10 to 15 years now been growing. But the initial sites in which cardio-oncology started were really cancer hospitals. And so, there was a meeting at MD Anderson. One of the first meetings in cardio-oncology. And I attended that meeting to see what was it that was being discussed and what were the issues in this patient population, what was the latest in research, and just came back from that really excited about this area and wanting to help develop it here at Northwestern.
It also fit very neatly with my training in imaging. Because at that time, there are some advances in imaging that were happening too with earlier detection of cardiotoxicity in our cancer patients, and some of these things we were not yet doing at Northwestern. And so, this all fit very well together, and this is where I first took a dive into cardio-oncology.
I felt that patients really needed and advocate who could speak both languages, both in cardiology and oncology, in order to help them get through their treatment and to advise from sort of the big picture in terms of whether or not the patients can tolerate treatment, but really to help build a partnership between cardiologists, oncologists and patients to provide the best care for them.
Melanie Cole (Host): Well, thank you for that. And this is such an interesting topic, doctor. So as you're telling us how these two things interact physiologically and how treating one condition can affect the other, tell us some of the key elements of a program when you're looking at these cardiotoxicity complications of cancer treatments what makes you and Northwestern Medicine so uniquely qualified in this area. What makes this program so unique? Speak just a little bit about how you work at the juncture of cardiovascular disease and cancer.
Dr Nausheen Akhter: Well, Northwestern Medicine is committed to patient-centered, multidisciplinary, and collaborative care, and this is really at the heart of cardio-oncology. So, our staff in both the divisions of cardiology and hematology oncology, we work very closely together to really try to provide seamless care to our cancer patients.
We are a referral center for patients with complex and advanced cancer, and there are numerous clinical trials that are happening here in oncology, which are providing the latest therapies to our patients, such as CAR T-cell treatment or combinations of immunotherapy and chemotherapies. And so, these patients do require cardiology oversight and management, which can be provided by cardio-oncology.
Northwestern also has an inpatient multidisciplinary immunotoxicity team to monitor immunotherapy-related adverse effects, and cardio-oncology is part of that team. We also provide specialized advanced imaging in many things beyond echocardiography, CT, MR, PET CT to help monitor for early and late adverse effects on the heart. And we also provide specialized cancer survivorship clinics, and this is through the Robert H. Lurie Cancer Center, but there are multiple cancer survivorship clinics here in breast, leukemia, lymphoma, and a childhood cancer survivorship clinic. We are also in the process of expanding our cardio-oncology program to regional hospitals. So, there are many things that make Northwestern unique for taking care of this patient population.
Melanie Cole (Host): So, how do you identify the needs of these cancer survivors? I'd like you to speak a little bit about the testing that's done pre-treatment or during treatment or post to warrant that referral to cardio-oncology. As you're speaking to other providers and they are counseling their patients on some of these complications, what would you like referring physicians to look for to determine if their patient is going to be a high risk patient or would benefit from a pre-chemo cardiac evaluation?
Dr Nausheen Akhter: I think that this is our hope, is to sort of shift cardio-oncology care into this pre-chemo evaluation. There are really three time points in which patients are getting evaluated and the bulk of patients are sent after a problem happens during treatment or after treatment. But if we can identify the patients upfront and start thinking about a pre-chemotherapy cardiac evaluation, very similar to how we approach preoperative cardiac evaluation. This would be very valuable for patients.
Our oncologists and our primary care physicians are really the ones who need to determine who are these patients who are at high risk for cardiovascular complications. And this is primarily based on the patient themselves. What are their cardiovascular risk factors? Do they have diabetes? Do they have hypertension? Are there other factors that will make tolerating cancer treatment poor? Also, the baseline cardiac function is important and the type of cancer treatment obviously being given to the patient needs to be taken into account.
So, these patients would then establish with cardio-oncology before starting treatment. And in that visit, we would inform the patient of their risk, counsel them on symptoms to watch for how to monitor for these things, address any kind of modifiable risk factors such as blood pressure management control, and to come up with a surveillance plan. There are algorithms and guidelines for surveillance. And just as an example of a high risk patient, so if a patient already has a history of heart failure or a low baseline heart function and they're to start cancer treatment that can further affect their heart function, then this patient will need to be seen in cardio-oncology, so that we can discuss the further heart failure risk, optimize their medications, and then recommend clinical and echo surveillance. And for that patient, which is really one of the highest risk patients, they would probably need evaluation frequently during their treatment, at least every other cycle of their treatment. So in general, if a patient has two or more cardiac risk factors and is receiving high doses of cardiotoxic cancer treatment, those patients should be the ones identified as high risk and referred for a pre-chemo evaluation.
Melanie Cole (Host): Thank you so much for going over that really important information. What are the Chicago Citywide Cardio-Oncology Rounds?
Dr Nausheen Akhter: So, the Chicago Citywide Cardio-Oncology Rounds is an initiative with other institutions in Chicago, both academic and non-academic institutions. It's a platform for all of us to get together and discuss interesting and complex patients and management and share our expertise. It is really an educational platform. This was started in 2019 and it is endorsed by the Illinois ACC as well as the Illinois Society of Medical Oncology. We bring cases to front. Really, these cases are presented by our trainees, and then have both cardiology and oncology experts there to discuss management of patients. And this is unique to Chicago and we are really fortunate to have this platform here and have quarterly events.
Melanie Cole (Host): So, I'd like you to wrap up, Dr. Akhter, with advances that Northwestern Medicine has made in this area, where you see this going in the future of cardio-oncology because it's really such a burgeoning field and such an important field as well. This subspecialty is really attracting a lot of attention. So, I'd like you to speak about blueprint for the horizon and where you see this going and any research that you're conducting at Northwestern Medicine that you would like other providers to know about.
Dr Nausheen Akhter: You're absolutely correct, Melanie. This is a very exciting field and there's a lot of excitement and advances on the horizon for our patients. We at Northwestern have recently completed a randomized prospective clinical trial on HER2-positive breast cancer patients, evaluating the utility of an advanced echo imaging parameter called strain and starting treatment at an earlier phase and waiting for patients to develop changes in their heart function, and that analysis is currently ongoing. We've also studied the use of the pre-treatment echocardiogram in various cancer therapies such as ibrutinib, which is used in patients with CLL and CAR T-cell treatments in risk assessment for cardiovascular complications. So, incorporating the cardiac imaging phenotype in patient risk assessment before starting treatment. We're also hoping to join some multi-center international cardio-oncology registries.
So in terms of the advancements on the horizon, the European Society of Cardiology just came out this summer in August with a guideline statement, a cardio-oncology guideline statement. And this is the first cardiology society to come out with a guideline statement. We see in this guideline statement there are a lot of areas that require more research. There's a need for cardiologists and oncologists to work together in clinical trial design, whether specifically for cardio-oncology or oncology. There's also a need for better mechanistic understanding of the adverse effects of cancer treatments that can lead to improvements in understanding why these adverse effects happen and potentially drugs to prevent the adverse effects. There's also a need for a better understanding for risk stratification by separate cancer types and separate cancer therapies and incorporating our imaging parameters into that risk stratification.
And finally, the registry data will be very useful in understanding this population from a larger perspective, population science and to understand maybe equity initiatives. And so, there's so many exciting areas and we're just very fortunate to be a part of it.
Melanie Cole (Host): Well, thank you so much and please join us again anytime and update us as these programs and initiatives continue to accelerate and really head towards advancements in the field of cardio-oncology. Just fascinating. Thank you so much for joining us.
To refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/cardiovascular to get connected with one of our providers.
That concludes this episode of Better Edge, a Northwestern Medicine Podcast for physicians. I'm Melanie Cole. Thank you so much for joining us today.
Northwestern Medicine’s Cardio-Oncology Program
Melanie Cole (Host): Welcome to Better Edge, a Northwestern Medicine Podcast for physicians. I'm Melanie Cole. And joining me today is Dr. Nausheen Akhter. She's an Associate Professor of Medicine in Cardiology, and she's the Director of the Cardio-Oncology Program at Northwestern Medicine. She's also a member of the Robert H. Lurie Comprehensive Cancer Center at Northwestern University. She's here to highlight the subspecialty of cardio-oncology today.
Dr. Akhter, thank you so much for joining us today. I'd like you to start by just telling us a little bit about yourself, how you came to Northwestern Medicine, and your role as the director of the Northwestern Medicine Cardio-Oncology Program.
Dr Nausheen Akhter: Thank you so much, Melanie. I'm so excited to be here with you this morning. Yes, I have been at Northwestern now for 13 years. I did my advanced imaging fellowship here and then have stayed on as an attending physician since that time.
My interest in cardio-oncology really started as a junior attending at Northwestern when I looked around and I saw that there was a large unmet need for taking care of our oncology patients and their cardiovascular concerns. Cardio-oncology is a newer subspecialty within cardiology that is growing alongside the development of new cancer therapies and prolonged cancer survivorship. And currently, there's estimated to be about 18 million cancer survivors in the US, and this number is just steadily growing.
And so, I saw there's this large patient group. And so, I thought it might be interesting to kind of look a little bit further into this area. I would say this field has about 10 to 15 years now been growing. But the initial sites in which cardio-oncology started were really cancer hospitals. And so, there was a meeting at MD Anderson. One of the first meetings in cardio-oncology. And I attended that meeting to see what was it that was being discussed and what were the issues in this patient population, what was the latest in research, and just came back from that really excited about this area and wanting to help develop it here at Northwestern.
It also fit very neatly with my training in imaging. Because at that time, there are some advances in imaging that were happening too with earlier detection of cardiotoxicity in our cancer patients, and some of these things we were not yet doing at Northwestern. And so, this all fit very well together, and this is where I first took a dive into cardio-oncology.
I felt that patients really needed and advocate who could speak both languages, both in cardiology and oncology, in order to help them get through their treatment and to advise from sort of the big picture in terms of whether or not the patients can tolerate treatment, but really to help build a partnership between cardiologists, oncologists and patients to provide the best care for them.
Melanie Cole (Host): Well, thank you for that. And this is such an interesting topic, doctor. So as you're telling us how these two things interact physiologically and how treating one condition can affect the other, tell us some of the key elements of a program when you're looking at these cardiotoxicity complications of cancer treatments what makes you and Northwestern Medicine so uniquely qualified in this area. What makes this program so unique? Speak just a little bit about how you work at the juncture of cardiovascular disease and cancer.
Dr Nausheen Akhter: Well, Northwestern Medicine is committed to patient-centered, multidisciplinary, and collaborative care, and this is really at the heart of cardio-oncology. So, our staff in both the divisions of cardiology and hematology oncology, we work very closely together to really try to provide seamless care to our cancer patients.
We are a referral center for patients with complex and advanced cancer, and there are numerous clinical trials that are happening here in oncology, which are providing the latest therapies to our patients, such as CAR T-cell treatment or combinations of immunotherapy and chemotherapies. And so, these patients do require cardiology oversight and management, which can be provided by cardio-oncology.
Northwestern also has an inpatient multidisciplinary immunotoxicity team to monitor immunotherapy-related adverse effects, and cardio-oncology is part of that team. We also provide specialized advanced imaging in many things beyond echocardiography, CT, MR, PET CT to help monitor for early and late adverse effects on the heart. And we also provide specialized cancer survivorship clinics, and this is through the Robert H. Lurie Cancer Center, but there are multiple cancer survivorship clinics here in breast, leukemia, lymphoma, and a childhood cancer survivorship clinic. We are also in the process of expanding our cardio-oncology program to regional hospitals. So, there are many things that make Northwestern unique for taking care of this patient population.
Melanie Cole (Host): So, how do you identify the needs of these cancer survivors? I'd like you to speak a little bit about the testing that's done pre-treatment or during treatment or post to warrant that referral to cardio-oncology. As you're speaking to other providers and they are counseling their patients on some of these complications, what would you like referring physicians to look for to determine if their patient is going to be a high risk patient or would benefit from a pre-chemo cardiac evaluation?
Dr Nausheen Akhter: I think that this is our hope, is to sort of shift cardio-oncology care into this pre-chemo evaluation. There are really three time points in which patients are getting evaluated and the bulk of patients are sent after a problem happens during treatment or after treatment. But if we can identify the patients upfront and start thinking about a pre-chemotherapy cardiac evaluation, very similar to how we approach preoperative cardiac evaluation. This would be very valuable for patients.
Our oncologists and our primary care physicians are really the ones who need to determine who are these patients who are at high risk for cardiovascular complications. And this is primarily based on the patient themselves. What are their cardiovascular risk factors? Do they have diabetes? Do they have hypertension? Are there other factors that will make tolerating cancer treatment poor? Also, the baseline cardiac function is important and the type of cancer treatment obviously being given to the patient needs to be taken into account.
So, these patients would then establish with cardio-oncology before starting treatment. And in that visit, we would inform the patient of their risk, counsel them on symptoms to watch for how to monitor for these things, address any kind of modifiable risk factors such as blood pressure management control, and to come up with a surveillance plan. There are algorithms and guidelines for surveillance. And just as an example of a high risk patient, so if a patient already has a history of heart failure or a low baseline heart function and they're to start cancer treatment that can further affect their heart function, then this patient will need to be seen in cardio-oncology, so that we can discuss the further heart failure risk, optimize their medications, and then recommend clinical and echo surveillance. And for that patient, which is really one of the highest risk patients, they would probably need evaluation frequently during their treatment, at least every other cycle of their treatment. So in general, if a patient has two or more cardiac risk factors and is receiving high doses of cardiotoxic cancer treatment, those patients should be the ones identified as high risk and referred for a pre-chemo evaluation.
Melanie Cole (Host): Thank you so much for going over that really important information. What are the Chicago Citywide Cardio-Oncology Rounds?
Dr Nausheen Akhter: So, the Chicago Citywide Cardio-Oncology Rounds is an initiative with other institutions in Chicago, both academic and non-academic institutions. It's a platform for all of us to get together and discuss interesting and complex patients and management and share our expertise. It is really an educational platform. This was started in 2019 and it is endorsed by the Illinois ACC as well as the Illinois Society of Medical Oncology. We bring cases to front. Really, these cases are presented by our trainees, and then have both cardiology and oncology experts there to discuss management of patients. And this is unique to Chicago and we are really fortunate to have this platform here and have quarterly events.
Melanie Cole (Host): So, I'd like you to wrap up, Dr. Akhter, with advances that Northwestern Medicine has made in this area, where you see this going in the future of cardio-oncology because it's really such a burgeoning field and such an important field as well. This subspecialty is really attracting a lot of attention. So, I'd like you to speak about blueprint for the horizon and where you see this going and any research that you're conducting at Northwestern Medicine that you would like other providers to know about.
Dr Nausheen Akhter: You're absolutely correct, Melanie. This is a very exciting field and there's a lot of excitement and advances on the horizon for our patients. We at Northwestern have recently completed a randomized prospective clinical trial on HER2-positive breast cancer patients, evaluating the utility of an advanced echo imaging parameter called strain and starting treatment at an earlier phase and waiting for patients to develop changes in their heart function, and that analysis is currently ongoing. We've also studied the use of the pre-treatment echocardiogram in various cancer therapies such as ibrutinib, which is used in patients with CLL and CAR T-cell treatments in risk assessment for cardiovascular complications. So, incorporating the cardiac imaging phenotype in patient risk assessment before starting treatment. We're also hoping to join some multi-center international cardio-oncology registries.
So in terms of the advancements on the horizon, the European Society of Cardiology just came out this summer in August with a guideline statement, a cardio-oncology guideline statement. And this is the first cardiology society to come out with a guideline statement. We see in this guideline statement there are a lot of areas that require more research. There's a need for cardiologists and oncologists to work together in clinical trial design, whether specifically for cardio-oncology or oncology. There's also a need for better mechanistic understanding of the adverse effects of cancer treatments that can lead to improvements in understanding why these adverse effects happen and potentially drugs to prevent the adverse effects. There's also a need for a better understanding for risk stratification by separate cancer types and separate cancer therapies and incorporating our imaging parameters into that risk stratification.
And finally, the registry data will be very useful in understanding this population from a larger perspective, population science and to understand maybe equity initiatives. And so, there's so many exciting areas and we're just very fortunate to be a part of it.
Melanie Cole (Host): Well, thank you so much and please join us again anytime and update us as these programs and initiatives continue to accelerate and really head towards advancements in the field of cardio-oncology. Just fascinating. Thank you so much for joining us.
To refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/cardiovascular to get connected with one of our providers.
That concludes this episode of Better Edge, a Northwestern Medicine Podcast for physicians. I'm Melanie Cole. Thank you so much for joining us today.