COMMENTARY

Cardiologists, Oncologists Desperately Need Your Help

Donald W. Northfelt, MD; Joerg Herrmann, MD

Disclosures

June 29, 2020

Editorial Collaboration

Medscape &

This transcript has been edited for clarity.

Joerg Herrmann, MD: Hello, and welcome back to the Mayo Clinic Medscape video series. I am Joerg Herrmann, professor of medicine at Mayo Clinic, and consultant in the Department of Cardiovascular Diseases at Mayo Clinic Rochester. Today we will be discussing the topic of cardio-oncology. I am joined by my colleague, Donald Northfelt, professor of medicine and consultant in oncology at Mayo Clinic Arizona, and an expert in this area. Welcome, Donald. Hearing about cardio-oncology, I think one of the first questions that comes to mind is why is this relevant today, and why do providers across disciplines need to know about it?

Why Do Cardiologists Need to Know About Cancer Treatments?

Donald Northfelt, MD: From my perspective, medical oncologists and hematologists desperately need the help of cardiologists in our current environment. We are increasingly using treatment strategies and medications that cause cardiovascular toxicities. In addition, because our patients are living longer, they are accumulating the harms of our treatments as well as the harms of aging that lead to cardiovascular complications. For these reasons, it is critical that, in the 21st century, medical oncologists and hematologists are closely aligned with cardiologists in the management of these patients.

Herrmann: You alluded to the fact that you need the help of the cardiologists maybe more than ever, which also implies that cardiologists need to be familiar with this topic more than ever. Would this be correct?

Northfelt: Yes. As these patients are living longer and are exposed to many different cardiotoxic agents, it is critical that cardiologists have an awareness of these treatment strategies and of the consequences and harms that are being caused by effective cancer treatments so that they can assist us in caring effectively for survivors of cancer.

Herrmann: But it is not as simple as some may think. It is not just another cardiology patient who just happens to have cancer. It is unique, so general cardiologists may not have that extra knowledge or expertise. There has been such growth in knowledge and the number of publications in the literature that you really need to devote time and training to become familiar with the advances. Would you agree that it is not as simple as one might think?

Northfelt: I absolutely agree with everything you have just said. We have many new drugs for the treatment of various cancers and many new treatment strategies that have become available just in the past 10-15 years. All of these are capable of causing unique cardiotoxicities. It is incumbent on our cardiology colleagues to have some understanding of this background. What are the drugs that can cause these problems, and what are the specific strategies that can be used to address them? There is a depth of understanding that cardiologists will need to develop in order to be effective in this arena.

And What Do They Need to Know?

Herrmann: You just alluded to the second key question. The first was why we need to know; the second is, what do providers need to know in this area? What are the main issues to be aware of? How would you summarize that broad topic?

Northfelt: There has been an exponential increase in our repertoire of anticancer therapies in medical oncology and hematology practice. Whole new classes of drugs have been developed in the past decade that have had a profound benefit for patients with various malignancies. At the same time, these treatments are presenting us with unique cardiotoxic effects that cardiologists need to understand in order to best address the needs of these patients.

Some drugs cause unique arrhythmias, some cause unique cardiomyopathies, and some cause unique inflammatory conditions of the heart and vascular system, all of which would not have been seen even a decade ago in a general cardiology practice. When a patient presents with these sorts of problems, especially if they present without adequate background being provided by their oncologist, it can result in some very confusing circumstances.

Herrmann: Would you say that this often relates to the aspect of safety and toxicity, and not just through the cancer therapy but even before? In essence, when we think about these patients and the involvement of cardiologists, is it for the initiation and continuation of cancer therapies and to have their input about the best, most feasible manner to accomplish this?

Northfelt: I will refer patients to our cardio-oncology colleagues here at Mayo if I am planning a treatment for which I anticipate a toxicity and I need the cardiologist's input in advance, to optimize the patient so that they can have the best outcome. That is one scenario. Another scenario would be when, in the midst of treatment, I recognize that a toxic effect of the treatment is affecting the patient's cardiovascular system.

A third scenario is into survivorship. A patient may have a cancer that has been effectively treated, and now, 10 or 15 years later, the patient develops effects on the cardiovascular system that have only become apparent over the course of time. The specific example I think of in that regard are the cardiotoxic effects of radiotherapy delivered to the chest. Patients with lung cancer or Hodgkin's disease will receive intensive radiotherapy to their disease in the chest, and it may be 10 or 20 years before the cardiotoxic effects of that radiation treatment become apparent.

If that patient has long since left the practice of their oncologist or hematologist and is now presenting to the cardiologist as a new patient with no particular understanding of the background of the oncologic treatment history, that could end up being a very confusing circumstance to the cardiologist. However, if the cardiologist is aware that cardiotoxic effects of radiation can develop in the heart or vascular system decades after the delivery of the radiotherapy, that gives the cardiologist a leg up, so to speak, in understanding what is happening to the patient.

Herrmann: You summarize very nicely the sorts of cutoffs for oncologists who refer to the cardio-oncology clinic. Would you encourage general cardiologists and even general internists, given the implications with the survivorship and the long-term follow-up, to be confident about referring patients to this subspecialty clinic? Do you believe that there is some extra knowledge that has grown over the years?

Northfelt: It would be quite valuable for general internists and general cardiologists to have a connection with a cardiologist who has special knowledge of oncology practice and the effects of cancer treatments on patients. I would not expect a general internist to recognize a long-term effect on the cardiovascular system of a treatment for cancer given years or even decades ago, long before that patient came into that general internist's care. The same argument could be made for a general cardiologist who does not have a particular interest or understanding of the cardiotoxic effects of cancer therapy. Both should be able to reach out to a cardio-oncologist who has that special knowledge or expertise for assistance in the care of a patient.

Herrmann: Let me ask you a provocative question, one that a skeptic might ask: Do you think the cardiology clinic makes a difference? Do you have the evidence or do you think we need the evidence? You have seen these patients over the years in the cardio-oncology clinic. You were in practice even before we had these dedicated cardio-oncology service lines, so I would value your opinion and experience in this area.

Northfelt: From my perspective, there has been a tremendous advantage gained for my patients in my ability to refer them to a cardiologist who has specific knowledge or background in cardio-oncology. When I refer a patient to the cardio-oncology practice here at Mayo, I know that cardiologist is going to view my patient's care and my patient's problems through a lens of understanding the cancer treatment background that the patient brings to the interaction.

I have numerous examples in our practice. A patient may develop a problem related to cancer therapy, and the initial approach to that is one of misunderstanding or confusion, because the implications of the cancer treatment are not well understood by the cardiologist who initially sees the patient. Put that same patient in the hands of a cardio-oncologist who understands the background of the cancer treatment and the problems it can cause, and that patient gets a completely different experience with a completely different kind of valuable assistance from the cardiologist.

Emerging Needs

Herrmann: It is so critical to speak the same language, right? In this area, it is crucial to have a mutual understanding and it is valuable in the model of team practice and multidisciplinary approaches. What are some emerging needs and upcoming developments and trends in this area?

Northfelt: In this century, we've seen an exponential growth in the number of new treatments available for cancer and hematologic disorders. The drug development pipeline in cancer medicine is tremendous, complex, and expanding rapidly. In order to keep up with new developments, and especially to keep up with the understanding of how these new treatment modalities impact the cardiovascular system, I believe it will require a continued expansion of knowledge among cardiologists. We can achieve this through educational efforts to broaden the awareness in the cardiology community generally. Such efforts will also help providers in various communities understand where the best sources of knowledge are for cardio-oncology care and, in any community, whether there is a cardiologist who has a deeper understanding or a greater experience with cardio-oncology, to bring that person into the care of the patient at these critical times.

Herrmann: What is your prediction of where this field will stand 5-10 years from now? Will it still be here? How will it evolve?

Northfelt: From the perspective of a non-cardiologist, I imagine that there will be special training offered in cardio-oncology and potentially a certification of some sort offered in cardio-oncology. I believe that this will emerge as a full-fledged subspecialty in cardiology and that cancer centers everywhere will find it necessary to have a cardio-oncologist on staff to address the concerns of the cancer patients who develop a cardiac toxicity of therapy or who develop cardiac or cardiovascular complications of their disease.

Herrmann: I agree. Some are already looking into developing formal training programs. A few unaccredited fellowship programs have appeared, and it is taking shape in organizations, so it is going in that direction. With the trends of the aging of the population, more cancer patients, more elderly cancer patients with comorbidities including cardiovascular diseases, and more cancer survivors living longer to experience the full scope of complications including cardiovascular toxicities, I fully agree. I believe that this is here to stay and something to be familiar with and proficient in.

Herrmann: Thanks for these very important insights. And thanks to our audience for joining us on theheart.org | Medscape Cardiology.

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