Expert: Understanding Cardio-Oncology Is Critically Important to Address the High Rate of Heart Disease in Patients With Cancer

Pharmacy Times interviewed Christopher Fine, MD, FACC, a cardiologist at National Jewish Health, to discuss the relationship between heart disease and cancer.

Alana Hippensteele: Hi, I’m Alana Hippensteele with Pharmacy Times. Joining me is Christopher Fine, a cardiologist at National Jewish Health, to discuss the relationship between heart disease and cancer.

Dr. Fine, how exactly are heart disease and cancer linked, and why is recognizing their association important?

Chris Fine: So that’s a great question, especially to start out with. I kind of think of heart disease and cancer—at least to simplify things—operating in tandem. If you think about our growing appreciation for just how organic cardiovascular disease can increase your underlying cancer risks, there’s actually a lot of data suggesting, especially over the last few years, that people with a common diagnosis called heart failure, which is fairly heterogenous in nature, their risk of developing cancer after the fact is more than 2-fold the normal population or if they had never been diagnosed with heart failure to begin with. And that’s just 1 small aspect of organic cardiovascular disease to begin with.

On the other side of the coin, cancer, independent of the cancer type, also increases your risk of a variety of cardiovascular syndromes, whether it be systemic hypertension, thromboembolic disease like a DVT or pulmonary embolism, even arterial clots, electrical abnormalities with the heart, etcetera. Then, if you add into the equation cancer treatment, like chemotherapy, radiation, even more new targeted therapies or immunotherapies, all of cardiovascular risk kind of across the board also increases. This is just starting to be a more significantly appreciated field or concept within cancer treatment care over the last 10 to 20 years or so.

Alana Hippensteele: What is the field of cardio-oncology? How long has it been established within the framework of cancer care?

Chris Fine: So cardio-oncology, at its core, is the clinical evaluation before, during, and after cancer treatment in cancer patients. It actually can be traced all the way back to the late 50s and early 60s when anthracyclines were first being utilized for cancer treatment, mostly in children with sarcoma or lymphoma. They were receiving high doses of anthracycline, and then we were noticing that they were having what ultimately was a clinical diagnosis of heart failure. If you fast forward over the course of the next decades, our appreciation for that correlation of treatment and clinical heart failure, it just became stronger. We just didn’t really know how we could meaningfully change outcomes, whether it be cancer-related outcomes or cardiovascular-related outcomes.

It really wasn’t until there was a huge push for cancer screening, surveillance, early detection, where we were starting to find cancers at earlier stages where we could intervene and start curing cancers to meaningfully impact morbidity and mortality in the patients. That’s when cardio-oncology as a discipline started to blossom. Legitimate cardiovascular data started being cranked out kind of in the late 80s, when you talk about outcomes and breast cancer patients with anthracycline treatment or HER2 targeted therapies, and cardiac biomarkers like troponin and NT-proBNP, how could these things be utilized before, during, and after treatment in this patient population to ultimately improve clinical outcomes. That’s when we first got a taste of surveillance strategies. Risk identification started to be more prevalent, but it wasn’t until we started getting more sophisticated cancer treatment, more sophisticated cardiovascular imaging modalities and surveillance strategies to guide our intervention.

[inaudible] which now at the heart of cardio-oncology, is by far the major goal because anytime we interrupt cancer treatment, pause cancer treatment, or have to completely switch cancer treatments to something that may be less efficacious, the patient does universally more poorly. Where cardio oncology shines today is a risk stratification model of baseline cardiovascular risks or cardiotoxicity risk based on the patient’s comorbidities at baseline, what kind of cancer they have, and what kind of cancer treatment they’ve received in the past and is anticipated to be given in the future, to where we can identify subclinical evidence of cardio toxicity with the goal being to intervene mostly in the form of pharmacotherapy, but as well as lifestyle modifications throughout treatment to minimize the likelihood these cancer treatment interruptions actually happen.

Alana Hippensteele: How does the work of a cardio-oncologist differ from that of an oncologist when treating a patient with cancer, and does a cardio-oncologist work alongside an oncologist or is only one or the other needed on a single patient’s cancer care team?

Chris Fine: A cardio-oncologist is a medical provider for a patient who has had dedicated cardiovascular-centered training around cancer patients and cancer-related treatments. It can be someone classically with a general cardiology training background. It could also be someone with an oncology trained background as well. The difference between the two is an oncologist, I actually want their primary focus, all their mental energy, to be geared towards selecting the most highly efficacious cancer related treatment for the patient with the goal being event-free survival, cancer progression, and overall improved mortality. A cardio-oncologist can be incredibly complementary to the oncologist in that we assess baseline risk, we intervene when appropriate with the goal being I want them to be on the best possible cancer treatment that is available to the patient, and I want to significantly minimize the likelihood of an adverse cardiovascular effect getting in the way of that best cancer treatment.

To answer your second question, in a perfect world, the oncologist and the cardio-oncologist, they'll work in tandem—kind of side by side, a Batman and Robin type of model—ideally in a multidisciplinary clinic so they’re physically shoulder to shoulder, they're bouncing ideas off of each other in real time. That model is already being employed in bigger academic centers, centers of excellence—the Washington Universities of the world and St. Louis, the UPenns, and Philly, etc. There's a number of great academic large-volume cancer centers with associated cardio-oncology presence, but most of cardiovascular disease and most of oncology and cancer patients is actually treated out in the community. That's where there's a big driving force for people with a cardio-oncology background to increase awareness, not just in the medical community but also at the patient level as well, to start trying to disperse some of this expertise in more community-based or community-affiliated oncology practices.