COMMENTARY

Cardio-Oncology: An Integrative Approach

Joerg Herrmann, MD; Naveen Pereira, MD

Disclosures

March 16, 2016

Editorial Collaboration

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Naveen L Pereira, MD: Hello, everybody. My name is Naveen Pereira. I'm a consultant in cardiovascular diseases at Mayo Clinic in Rochester, MN. I'm very excited to have with me Dr Joerg Herrmann, who is the director of the cardio-oncology clinic at Mayo. Today, at Mayo Clinic Trending Topics, we will be discussing the new cardio-oncology clinic here. It's an integrative approach to the treatment of cancer patients with cardiovascular risks or injuries.

Joerg, welcome. It's a pleasure to have you here and talk about this exciting topic.

Joerg Herrmann, MD: Thank you, Naveen. Thank you for the invitation.

Why Cardio-Oncology?

Dr Naveen Pereira: Cardiology and cancer—two separate fields. Why are we getting them together?

Dr Joerg Herrmann: In some places, they've always been together. When you think about the primary cancer centers—like MD Anderson, Sloan-Kettering, New York—by nature, the cardiologists employed there had to take care of these patients who happened to have cancer.

Apart from these particular places, what has now occurred is that we have more cancer patients getting treated and more comorbidities. When you look at the map of the United States and you overlay the cancer prevalence and the ischemic heart disease prevalence, there is a certain match.

You have these two together, but then you also have new therapies with new potential for injury or previously unrecognized injury potential. You're really in a situation now where things are getting more complex and where it's getting a little bit more difficult to just focus on cardiology, or oncology, or hematology, where you really have to see the patient as a whole.

What Kind of Patients Will Be Seen at Clinic?

Dr Pereira: What kind of patients do you envision coming to this clinic? Are they patients who have preexisting heart disease being considered for advanced cancer therapy, like stem-cell transplantation, etc? Are they patients who have complications from chemotherapy? Can you give us a broad gestalt? You've started this clinic already, I presume, so what kind of patients are you seeing, and do you hope to see in this type of clinic?

Dr Herrmann: Cardio-oncology, the word in itself, at least for some, brings to mind this thought—"Is this the malignancy of the heart?" Are they to see patients who have a malignant tumor or metastases? The answer to that is yes. Those patients are to be seen, but that's not the great majority because they are relatively rare, fortunately.

Dr Pereira: You definitely would like to see that patient with an intracardiac tumor, for example?

Dr Herrmann: Right, that definitely should be seen and we should have a joined collaborative effort, as you alluded to in the very beginning. The majority of patients whom we'll see here, or elsewhere in other cardio-oncology clinics, is with the main goal to uncouple, if you will, these two processes. We're coming together—cardiologists, oncologists, hematologists—in a multidisciplinary fashion, but we're trying to uncouple the cancer therapy from the cardiovascular side effects or the cardiovascular limitation potential, if you will.

That being said, our goal is to enable the patient to get the best possible cancer therapy with the least amount of risk of any cardiovascular toxicity or worsening cardiovascular condition. We would ask that we see them before they're considered or committed to a certain type of therapy and then also during and after the therapy. So it's really following these patients who are at high risk based on their cardiovascular morbidities or based on the therapies planned—we evaluate them together. That would be the approach we have.

Dr Pereira: So patients with preexisting heart disease and being considered for advanced cancer therapy, you'd like to see them to appropriately plan for them—for example, someone with preexisting cardiomyopathy who has developed lung cancer or something like that? Is that right?

HER2 and Ejection Fraction

Dr Herrmann: Exactly. And others—the great majority we're seeing these days are the ones to undergo HER2-directed therapy for breast cancer, which is about 20% of the breast cancer population. It used to be the worst of all types of breast cancers, but nowadays, because we have these HER2-directed therapies, it's actually become the breast cancer with the best prognosis, if it is responding.

But there is this concern, and legitimately so, that if they're started on this therapy, the ejection fraction could drop. And there are certain risk factors for that. It gets even more complicated if you have someone with metastatic HER2-positive breast cancer and an EF that's about 40% to 45%, in that range—what do you do? These are the perfect patients to see and to follow while we try to enable that therapy without them slipping into heart failure.

Dr Pereira: Right. Certainly, cardiomyopathy is a big part of this, whether it's caused by chemotherapy or whether it's preexisting before you get chemotherapy that can potentially exacerbate cardiomyopathy.

Are there any other examples, Joerg, that you can cite of coronary artery disease due to chemotherapy? Can you give us some other illustrative examples?

Vascular Toxicities

Dr Herrmann: It's not only those, cardiomyopathy is wide spectrum. Ischemic heart disease—just sticking with the example of the HER2-directed therapy, we know that myocardial ischemia upregulates that pathway. So if that's previously unrecognized, that could also be a problem.

Other examples in the line of vascular toxicities—it used to be that 5FU [fluorouracil] was the classic example, often it's colon cancer and patients get FOLFOX therapy, and they present to the point of an acute coronary syndrome. But they would be seen in the hospital, not in the outpatient practice necessarily.

What we see nowadays is that with some of these so-called targeted therapies, the ones directed to the Philadelphia chromosome product, the BCR-ABL, some of these—not all of them, it's really a puzzle at present—we've seen some accelerate atherosclerosis to the point that patients will develop critical limb ischemia, myocardial infarctions, strokes, all sorts of these vascular complications. It was never anticipated this would happen. It's not completely understood how it happens and, even less so, how we monitor and treat.

We really have now something beyond just the cardiomyopathy spectrum that you're alluding to. There is the vascular toxicity spectrum as well.

Advantages of Coordinated Care

Dr Pereira: Clearly there's an advantage for cardiologists to be very familiar with what the oncologists see and what the oncologists do, to be able to talk the language—that's clearly an advantage. For example, in the Transplant Clinic, if I do a heart transplant, it's easy to see a liver-transplant patient with a cardiac problem because I know what the liver-transplant surgeons and hepatologists do. So this is one of the advantages, talking the same language, being able to understand each other in a better way.

What are the other advantages, do you think, of having such coordinated care? Are there oncologists who are going to be working with the cardiologists in the cardio-oncology clinic? What constitutes, physically, a cardio-oncology clinic, and what are the types of cardiologists that you've staffed the clinic with?

Dr Herrmann: Here and elsewhere, I have yet to see the oncologist who works in the cardio-oncology clinic [laughter]. In some centers, what they've started to do is, just like we're here at the table [together], they would see the patient together, an oncologist and a cardiologist. But in most places, it's not like that, it's the cardiologist seeing these patients because the oncologists and hematologists are too busy.

But it's in close interaction with them, so you have to talk the same language, you have to be on the page, and you have to really pursue the same goal.

Within our clinic, what we're fortunate to have is such a spectrum of experts. You with the transplant experience, the heart-failure experience—we have that. We have those who are really interested in vascular disease. That adds to it, and I think it's very useful. Even our discipline has gotten so multidisciplinary that it's really—and cardio-oncology, in the cancer patient, really spans all that entire spectrum of cardiology.

The goal should be, ideally, that you have a representation of everyone, not just echo, not just heart failure, even though, I think, this is what you often see elsewhere, where these are the individuals, primarily, because they happen to see these patients. They are doing the echo and they have new LV dysfunction, as you alluded to in the beginning—cardiomyopathy was kind of the stepping-stone for this, but now it's much more.

That's for the future, too, to define this more—cardio-oncology beyond the malignancies of the heart, beyond the cardiomyopathy. What else is there to do?

A particularly challenging scenario too is that it's not just the communication with the oncologist and hematologist, it's also with the radiation therapists. Because radiation-induced heart disease, is an extreme challenge.

Dr Pereira: Yes.

Dr Herrmann: For the future of this field, it's something that we really need to invest in. We're doing it with different types of radiation therapy, but beyond that.

Dr Pereira: This is very exciting. These are a bunch of committed cardiologists who understand the oncology field from an oncology perspective but know the different aspects of cardiology because these patients have a broad spectrum of cardiovascular disorders: ischemic heart disease, vascular disease.

[We have] an expert in heart-failure transplant, imaging experts—we have a multidisciplinary integrated cardiovascular team that forms the cardio-oncology clinic to serve these patients in a holistic way. Is that an accurate description?

Dr Herrmann: That's right.

A Look at the Future

Dr Pereira: What about the future—what's the hope in terms of getting this clinic together? We can actively treat known cardiovascular disorders, but is there a vision, ultimately, for going beyond that? Are there other benefits to organizing these patients coming in under one platform and seeing these patients together, like for research purposes or to advance the therapy? Can you elaborate a little bit on that?

Dr Herrmann: Obviously, rather than having these patients being seen everywhere scattered around, if you do this in a more organized fashion, like everything, you improve the quality of care. First of all, I mean the medical care, but then it also provides some unique opportunities while doing so, to have new resolute research ideas and registries that are being created. We have one big one in Europe that's being created where multiple centers feed in because some of these diseases or processes are not that common still. You need to have a larger cohort to really study different aspects and also for prospective studies that you want to do.

We saw the PRADA trial[1] being presented at the AHA—smaller numbers, 30s in each group. To come to more conclusive terms, that's what you need, to organize, so you start on an institutional level and then the collaboration level. There are opportunities, obviously, for biobanks, to look into some of these genomics and how they influence things. That's an important aspect.

And while doing so, as we've recognized now with HER2—coming back to one of our favorite stories—this effort, in itself, especially if you have a multidisciplinary group with everyone bringing in a certain element, you recognize, potentially, some previously unrecognized players in cardiovascular disease.

The HER2 story was—this pathway, all of a sudden, we realize it's important for the cardiomyocytes, for the stress response. In the same way, with some of the vascular toxicities we see, there might be opportunities to discover new molecular mechanisms of biology and pathobiology. We really need the mind-set, I don't see this happening if one by himself or herself does this. And then people are not seen in a consistent way, and things are not getting followed in a consistent way.

Dr Pereira: Joerg, this is exciting. Thank you so much for spending time with us today. I think this is the future—seeing such complex patients in a multidisciplinary fashion in an organized way, especially if there are certain rare occurrences of disease processes that can affect these unfortunate patients, to pool in all different types of resources, in the form of a registry or biobank, and understand these patients a little better, to ultimately provide the best care possible.

Dr Herrmann: Exactly.

Dr Pereira: Thank you for your leadership in this clinic, and we look forward to hearing more from you. And we thank our viewers for joining us at theheart.org on Medscape.

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