Transcription:
Cardiologist’s Role in Cancer Care

Bill Klaproth (Host): Many people are living longer after a cancer diagnosis which means doctors are careful in treating the cancer without harming the heart. here to talk with us about the cardiologist's role in cancer care is Dr. Edward Spangenthal, Clinical Chief of Cardiology at Roswell Park Comprehensive Cancer Center. Dr. Spangenthal, thanks for your time today. So, what is the role of heart health in the field of cancer?

Dr. Edward Spangenthal (Guest): Well, thank you so much for having me. My role, primarily, at Roswell Park is to help the cancer patients who have heart disease get through their cancer treatments and alternatively, also, to help patients who have had a heart problem and have survived their heart problem and essentially have lived long enough to, unfortunately, have developed cancer. We do have a screening clinic at Roswell Park and we do some prevention, but my role is primarily in taking care of patients who have already established both medical problems.

Bill: And, how do you do that? What is your main form of treating that patient, then?

Dr. Spangenthal: It's interesting. I first started out doing this several years ago when I was asked for my cardiology practice to provide cardiology services at Roswell and it was rather primitive then. Since that time, there's been a great deal of interest and some research done in the area and now there's actually a separate field that's recognized by the American College of Cardiology called Cardio Oncology and my role is multiple, or many things that I do. One of the most important things is I help people get through their chemotherapy treatments. Sometimes patients will start out with a heart problem and we will have to help tailor their chemotherapy treatments based on that and other times, their treatments, which could be chemotherapy or radiation therapy or immunotherapy, can cause problems with their heart, in which case we then have to screen them very carefully and properly and then sometimes tailor their treatments. Sometimes stopping treatments, sometimes adjusting it, sometimes switching to something else.

Bill: So, for the person with heart disease, then, how do you help them get through the chemotherapy treatment?

Dr. Spangenthal: If a patient has established heart disease, that can be very important for us, especially if we're trying to get them through cancer surgical therapy; in which case, we may need to do some cardiac testing on them or sometimes even perform procedures such as angiography, coronary stenting, or, in rare cases, even surgery to optimize their cardiac condition in order to get them through their therapies. If they start out by having a problem such as a reduced ejection fraction, or the pump action of the left ventricle, that would then limit what types of therapies they can receive. There are certain chemotherapies that can cause that problem as a side effect of therapy and we would need to be very careful with that person to not give them the wrong chemotherapy or too much of a toxic chemotherapy because then they could run into trouble. We always try to optimize them first so that we can get them the best possible therapy.

Bill: So, the optimization of chemotherapy, then. That's very interesting. So, then, on the other side, how do you minimize or mange or reduce the side effects of chemotherapy for the person that doesn't have heart disease? Is the same kind of testing?

Dr. Spangenthal: Well, in that circumstance, the approach is almost the opposite. So, we're now starting with someone who has a healthy heart and we need to make sure that we don't cause significant damage to their heart or something that might cause them to have a side effect that could be life-altering. So, in that circumstance, we have protocols in place where we monitor them with things such as echocardiography, looking at the pump action of the heart. That's the most established way of following patients but there are some new areas that are targets of research including diastolic function of the heart, something that we call strain imaging of the heart, and we can also follow markers in the bloodstream from blood tests. Things such as troponin, BN peptide, beta naturetic peptide, and if we find changes in these parameters, particularly if we find that somebody's LV ejection fraction is falling because of their chemotherapy, we will then adjust their therapy by either holding doses, changing the timing of administration, choosing a different agent. In some circumstances, there are agents where the loss of pump action is thought to be temporary and we hold for a period of time, then we reassess and when their pump action returns to normal, we are then able to re-challenge them with that agent.

Bill: So, the good news is people are living longer with their cancer but these important steps need to be taken to ensure the safety of the heart?

Dr. Spangenthal: Yes. That is correct. I would totally agree with that.

Bill: So, as your role as Clinical Chief of Cardiology at Roswell Park Cancer Institute, what are your other duties there?

Dr. Spangenthal: Well, there are many. We're involved in some research trials and I've recently increased my time at Roswell Park to three quarters time, and when I did that and achieved the role of Chief of Cardiology Services, I've been asked to also participate in clinical research trials where we look at different chemotherapy treatments on different types of cancer. Many of the newer agents, especially immunotherapies and something called “checkpoint inhibitors” have been shown in some cases to cause damage to the heart, particularly a condition called “myocarditis”. The feeling is that this is rare, but the clinical experience, as is often the case after chemotherapy and other drugs come to market, is that the frequency of these side effects is actually probably more common than we know. So, I'm involved as co-investigator in several trials looking at chemotherapy agents. In addition to this, I am currently the Chairman of the Anticoagulation Management Committee at Roswell Park. As a cardiologist, I frequently have to help people manage their anti-coagulation therapies either because they've had a complication from their cancer such as a blood clot in their leg or in their lungs or, more commonly, because they present already having an indication for the blood thinner, or the anticoagulant, such as atrial fibrillation, which is an irregular heart rhythm, or the presence of a mechanical heart valve. I read all of the EKG's. I read all of the echocardiograms. We're starting a survivorship clinic--that's something else that I've been involved in--which is essentially seeing patients who have survived their cancer treatments, particularly pediatric survivors of cancer who are now adults; survivors of bone marrow transplantation, survivors of radiation therapy, because, especially radiation therapy, can have an impact on the heart many months or even years after the treatments. People who were treated with large doses of radiation to the chest, such as for lymphoma, can have problems in their heart decades later, including problems with pump function, problems with conduction system and arrhythmias, and especially problems with valvular heart disease. We have several patients who have had to have their valves replaced surgically because they became dysfunctional many years after the radiation treatments.

Bill: So, again, the steps that you take to ensure heart health throughout the chemotherapy treatment is vital and very important because the side effects of chemotherapy can emerge decades after the treatment is completed. It's great that you're trying to address these issues right away, right up front. Dr. Spangenthal, since February is heart month, can you share some tips for heart health with us?

Dr. Spangenthal: Certainly. One of the conversations that I commonly have with my cancer patients is that it is never too late to quit smoking. There have been several research studies that show that patients with cancer have better health and survive longer if they quit smoking. So, it's very important not to say "Well, I've developed cancer, so what's the difference? Why bother?" I strongly encourage all of my patients in both my clinical practice and at Roswell Park that they should quit smoking as soon as possible and completely. Also, of course, when you're undergoing cancer treatments, it's extremely important to follow a heart healthy diet, rich in fruits and vegetables and whole grains. It's very important to have proper sleeping habits, to avoid excessive caffeine and alcohol, and to try to stay as physically active as possible. So, if I have a young patient who's in good physical condition, and is receiving some form of cancer therapy and they're still able to run and exercise, I strongly encourage them to do that but even in patients who have received radiation and chemotherapy and have had their physical conditioning knocked down, I just ask them "Do whatever you can. If you can get up and walk; if you can go out of the house and do something, go grocery shopping; try to stay active. Try to keep your strength up," just like I would ask anybody who's in a cardiology practice.

Bill: Dr. Spangenthal, thank you again for your time. For more information, visit www.roswellpark.org. That's www.roswellpark.org. You're listening to Roswell Cancer Talk. I'm Bill Klaproth. Thanks for listening.