CLINICAL
NEWS
American College of Cardiology Extended Learning
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Cardio-Oncology Intensive: The Birth of a New Sub-specialty
N
ot that long ago, a cancer diagnosis often
meant a fight for life to the end. Quality of life after the fight was not a big
issue because survival seemed more an exception
than a rule. That has changed, dramatically, in
the last couple decades and the sheer number of
cancer survivors has brought greater attention
to ensuring that cancer treatment does not cause
other harms. In short: the cured cancer patient of
today does not want to become the HF patient of
tomorrow.
Cancer patients are not just living but living
longer, often much longer. As of Jan. 2014, the
National Cancer Institute reports that there are
14.5 million cancer survivors in the United States,
representing more than 4% of the population.1 An
estimated 41% of cancer survivors live 10 years
or more and 15% live 20 years or more; currently,
60% of survivors are 65 years of age or older.1
At its 2015 Annual Scientific Sessions, the
American College of Cardiology (ACC) took a
decidedly different approach to the problem with
a half-day Cardio-Oncology Intensive. Traditionally, such sessions at national meetings have been
cardiotoxicity-related and embedded in focused
clinical pathways, like heart failure and CV imaging. These sessions succeeded in highlighting
novel developments within specific areas, but
struggled with introducing a broader interdisciplinary dialogue and bringing multiple stakeholders to the stage.
This time around, it was a very different approach, with a focus on highly relevant clinical
questions in the CV care of patients with cancer
and cancer survivors. All debates and panel discussions included members of both cardiology health
teams and oncology health teams, thereby allowing the audience to glean perspectives on patient
care from both sides of the aisle.
Bonnie Ky, MD, the Intensive co-chair said,
“We have carefully designed this experience to
involve many of the world’s leading experts in
cardio-oncology and have specifically incorporated
key clinical questions facing us today as we care
for this growing population.”
“I believe that some of the biggest challenges
lay in our traditional approach to patients as ‘oncology’ or ‘cardiology’ patients,” noted Ana Barac,
MD, PhD, the session co-chair. “The cardiology
community has a wealth of clinical documents
and guidelines to diagnose, follow, treat, and prevent hypertension, hyperlipidemia, coronary disease, and cardiomyopathies, and oncologists have
detailed guidelines in managing diverse forms
of cancer, but when it comes to a patient who has
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CardioSource WorldNews
cardiovascular disease, or develops one,
while being treated for cancer, or as a consequence of cancer treatment, our resources are
extremely limited.”
WHY IS IT IMPORTANT NOW?
Pamela S. Douglas, MD, tried to answer this question. She is the Ursula Geller Professor of Research
in Cardiovascular Diseases at Duke University
(and a Past-President of the ACC).
She cited four reasons why the time is now.
Because We Share Patients and Disease Risk Factors
Cancer and cardiovascular disease (CVD) happen
in the same people, namely an aging population,
and both have become chronic diseases. Multisystem disease is increasingly common. And we
know there are overlapping risk factors for cancer
and CVD: smoking, air pollution, inflammation,
obesity, a sedentary lifestyle, poor nutrition/diet,
and aging.
Because CV Health Is Essential to Good
Cancer Outcomes
At presentation, the clinical approach includes
risk factor/comorbidity optimization and treatment selection/modifications. During treatment
for cancer, cardiotoxicity must be recognized as
an issue and optimal care should ensure access
to lifesaving therapies, minimize or eliminate offtarget effects, and manage on-target effects. Also,
treatment should include prevention, surveillance,
and management. After treatment is the time to
turn attention to late effects, survivorship, and any
concomitant CVD.
Because CVD and Cancer Are Inextricably Linked
Heart failure patients with cancer have a 56%
increased death risk. Cancer and cancer treatment
provides a multiple hit to an already compromised
CV system and, we know, ‘CV reserve’ affects
treatment and survivorship.
Because We All Need Experts to Help Us
Dr. Douglas said one key issue is that “we are
silo’d in our world views and training.” A survey
conducted jointly by the ACC and the American
Society of Clinical Oncology showed substantial
need for expertise. While survey respondents
acknowledged that CV considerations are thought
to be ‘Very Important’ in cancer for planning treatment (40%), during treatment (45%), and after
successful treatment (37%), the respondents felt a
substantial current patient load already, with 85%
reporting more than 100 CV consultations per
year and 69% reporting more than 100 imaging
requests. Yet, they admitted limited understanding
of “cardio-oncology” due, at least in part, to few
training/educational opportunities.
Session co-chair Dr. Barac added that the challenge lies in creating high-level data and evidence
to guide how to approach and treat this complex
group of patients, suffering from two of the most
common diseases today. “We talk about a comprehensive approach to the patient, not the disease,
all the time, but we are at a very early stage of an
ideal setting where interdisciplinary teams would
work seamlessly in creating evidence and guidance
for this approach.”
Dr. Barac also noted, “Professional societies
have critical roles in achieving this comprehensive
care goal by providing a framework for collaborative activities within and across different disciplines that will lead to advancement of clinical
care, guideline development, and dissemination
of knowledge through education and training.
With this Cardio-Oncology Intensive, the ACC and
its cardio-oncolo gy working group can bring key
health care providers and partners together for
important discussions of current practices, challenges, and future goals.” ■
REFERENCES:
1. DeSantis C, Chunchieh L, Mariotto AB, et al.
CA Cancer J Clin. 2014;64:252-71.
Take-aways
• With a large and growing population of cancer
survivors (often long-term survivors), the cured
cancer patient of today does not want to become
the heart failure patient of tomorrow.
• There are a number of key reasons why it is
necessary to develop a new sub-specialty: cardiooncology.
• A lot of work needs to be done to achieve
comprehensive care goals for patients who
have been treated or are being treated for
cancer and who are consequently at high risk of
cardiovascular disease.
March 2016