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Ann H. Partridge, MD, MPH: Hello. I'm Dr Ann Partridge. Welcome to Medscape's InDiscussion series on Cancer Survivorship. Today, we'll discuss surviving cancer and cancer treatments. And one of the most important things about surviving cancer is keeping your other organs intact, including your heart. So let me introduce my guest, Dr Joshua Mitchell. Dr Mitchell is the director of the Cardio-Oncology Center of Excellence at Washington University in St Louis and chairs the Patient Advocacy Committee for the International Cardio-Oncology Society. Welcome, Dr Mitchell, to InDiscussion.
Joshua D. Mitchell, MD, MSCI: Thanks, Dr Partridge. It's always great to be able to sit and chat with you.
Partridge: I think that everybody always wonders when they are talking to someone who has chosen something that's a little bit off the beaten path … what really drew you in to not just cardiology, but the subspecialty of cardio-oncology or some call it oncocardiology. What brought you into that?
Mitchell: Absolutely. It's a slightly confusing name. Patients sometimes think I'm an oncologist and I have to explain that I'm a cardiologist. But what makes me enjoy the specialty so much, what really drew me in, is how much of a difference we can make in our patients' lives. Patients are going through a really tough time, as you know, having been diagnosed with cancer and dealing with the effects of cancer treatment. And then on top of that, if they're seeing me, they've also been told that their heart is at risk or that they've already had a cardiac complication, which just adds to the stress. And for a lot of patients, that can be really reassuring, which is nice, and I can walk them through what the effects are, but also how we can take care of that. For other patients, we can start treatment and it's just such an important niche. Too often, a clinician without the experience is not as able to navigate that. They may overreact to potential toxic effects and stop a necessary cancer treatment, or they may overly stress the patient out with concerns. So being there as a steady hand to help navigate the situation with the patient is a really rewarding experience.
Partridge: That's great, Josh, and we're so glad that people like you are there for our patients. So let's get to some nitty-gritty facts here for our audience. How important is this? We know that we want people to be cured of their cancer and live long term. Tell me what the heart brings to bear in this regard and why are a whole group of people like you focusing on this?
Mitchell: We know that cancer survivors are at significantly increased risk for cardiac mortality. In one recent study, it was a two- to sixfold risk, depending on the cancer type. And they also have a lot of potential risk for cardiac morbidity, heart failure, etc., after their cancer diagnosis. Importantly, we always want to balance that with how good the cancer treatment is. As you know, cancer treatment is phenomenally better than it was in the past, and people are constantly living and doing so much better than they used to. And so at no point in time when I bring up the cardiac risks do I ever want to imply that we should stop necessary cancer treatment.
Partridge: Let me interrupt you here. Unless it's a person who has preexisting cardiac issues, most of the conversation happens around this issue between a patient and their oncologist, right? And so you get brought in either because they're worried about a patient or because they've had a complication, correct?
Mitchell: Yes. I will be brought in at different stages along the way. If a clinician says, "You have some known heart problem, I'm not sure I can give you cancer therapy; let's have you see Josh Mitchell." Or they say, "We're giving you this toxic medication that might affect your heart. Maybe we're seeing a mild signal early on that you might have a problem. Let's have you see Josh." Or later on when something significant has already happened or the patient is really interested in this topic during survivorship, which I know this podcast is really focusing on, how do I, as a patient, best make sure that my heart health stays there for the long term?
Partridge: At any point along the way, you're going to add value. Thank you for pointing out the survivorship aspects of this. So a person has been treated for cancer and they're hopefully either in long-term control of their cancer and they are undergoing maybe chronic therapy or they've already been treated. What is a common scenario that you might face and how might you handle that with the patient, and how do you incorporate the oncologist? I realize that's two questions. So, let's start with how do you think about things with the patients?
Mitchell: Yes. I think that question obviously runs a huge gamut and so I'll try to parse it out briefly. One is the patient that's already had a problem but they've survived their cancer, or their cancer treatment has worked well but they didn't escape unscathed. And so we maybe have heart dysfunction and we have to guide them through cancer survivorship. And then in another category is the patient who's done with their cancer treatment but they've been told that their heart is still at risk. And so they want to see me to understand how can they most improve that — how can they avoid heart problems down the line? And it's always important in any of these categories, especially the latter one, where we're really just screening what we know and what we don't know. But the most important thing we want to focus on is normal heart health-type stuff. Let's make sure your blood pressure and your cholesterol are controlled. Let's recommend exercise and nutrition. All of the things that have been shown to help patients without cancer but have a significant impact on patients with cancer in their long-term health.
Partridge: So you basically are saying we want to optimize their regular risk factors for heart disease, especially given that they may be at higher risk because of their cancer exposures.
Mitchell: That's absolutely right. I think it's really important for those two things. One, optimize the cardiovascular risk factors that we should already be doing. But it's really important to recognize those, especially if the patient is seeing an oncologist, maybe it's not a thing the oncologist treats all the time, but to say, hey, you know what? I need to pay attention to this blood pressure. Let me have them see their primary care physician or a cardiologist — just focusing on those long-term health things. But then also recognize, like you point out Ann, that these patients are potentially at significantly increased risk, especially patients who, for instance, went under radiation or got anthracyclines. And so their risk factors or their risk for cardiac disease may be ten times higher than that of a patient who's the same age who did not get those cancer treatments.
Partridge: Thank you for that. So, we're talking about the exposure to cytotoxic therapies that might hurt the heart. Anthracyclines, platinum — right? Platinum is bad for the heart, too, isn't it?
Mitchell: I don't know if any of it's good for the heart, but the biggest ones that give us the long-term heart problems are anthracyclines. Number two probably are the HER2 antagonists, but most of that, honestly, is during therapy. So if patients complete their therapy and have normal heart function and did not get anthracyclines, they're good. But things like stem cell transplants will put someone at risk for diastolic [heart disease], especially stiffening of the heart to heart failure over time. Radiation is very bad for the vasculature, including the heart, but also the blood vessels. And that can cause long-term issues, especially years or decades down the line.
Partridge: Clinicians need to know those risks and then obviously modify the risk factors as best one can around them. Let's just get back to some basic medicine. We can't change if the patient is a man or a woman or they're getting older or not. Getting older is actually what we're trying to achieve in cancer survivorship, just slowly and healthily. But what can we modify there when it comes to the heart risk factors?
Mitchell: That's a great point. We can modify blood pressure. We can modify cholesterol. We can encourage a patient to stop smoking if they're already smoking. We can encourage good nutrition like the Mediterranean diet or some related diets that have good long-term health outcomes. And we can encourage regular exercise, which not only has been good for cardiovascular health but is shown to improve cancer-specific outcomes as well. And those are the most important things that we can intervene on and encourage for good long-term health and survival.
Partridge: Great. And is this something that a patient should ask their oncologist or their primary care physician or do they need to find someone like you? And I think I always struggle with the idea … I'm not going to start people except maybe on a tiny bit of antihypertensive medication if they're in the middle of active therapy. Otherwise, typically with a cancer survivor, I'll defer to the primary care physician. But where is the line between someone feeling comfortable with their primary care physician managing something vs needing to see a cardiologist vs needing to see a cardio-oncologist? How does that shake down, recognizing that we have a lot of survivors?
Mitchell: That's a great question. To be truthful, there aren't enough oncocardiologists or cardio-oncologists. And so it certainly should not be limited to specialists like myself. Really, a good primary care physician can handle almost all of this and certainly handle the important things as far as good cardiovascular health. I think the most important thing is for awareness. That primary care provider, physician, or oncologist or someone needs to be aware that these patients are at risk and so that these things can be addressed. And then for some of my patients, they may only see me once. There's a lot of people who come to Washington University who drive hours out of their way to come see us for their cancer treatment. And so I just want to weigh in with them at least once to say, "Hey, you're at increased risk. It's really important to address these risk factors. Your primary care doctor can address them. If you ever have any concerns and don't feel like they're adequately addressed, you can always reach out to cardiology or myself." But most of these things can certainly be handled by our general practitioners or primary care providers.
Partridge: I would say that if someone's already had some kind of cardiac event or has a serious cardiac kind of predisposing condition, I'd want them in with, at a minimum, a cardiologist and ideally a Josh Mitchell. Am I right?
Mitchell: We certainly want to make sure that we're addressing cardiac issues, and that becomes a real need for cardio-oncologists. And I'm always happy to see the survivor who's interested in seeing me. When patients drive from a few hours away, I want to have that discussion with what I bring to the table since they're driving so far to see me. There's a lot of patients who still like to see me once a year just to check in, make sure everything's tuned up, and then they follow up with their primary care physician more closely.
Partridge: So, you'll share care with people often?
Partridge: That makes sense. And so let's say you have a patient who's either going through treatment or is in survivorship. You've determined they're at risk and you tell them, "Okay, you need to quit smoking and you need to exercise more." Are there other resources and things you do to help them actually accomplish those goals? And do you have a sense of how successful we are as a community at that? And are we getting better?
Mitchell: That's a great question. I think the first step or the first obstacle is recognition. And so I will at least back us up slightly because I think these things are very important in survivorship, but I want to at least make sure and emphasize that they start even at the diagnosis, if not before. Too often in the past, at the time of the cancer diagnosis, we're really focused on the cancer, which we should be. But other things — like, their cholesterol was super high or their blood pressure is uncontrolled — get missed. And then we've unfortunately seen those patients have heart attacks during treatment. And you say, Oh, I wish I had started those cholesterol medicines beforehand … so we want to attack it at the start. And part of that is just recognition. But it is tough, as you mentioned, especially to a patient undergoing cancer treatment to say, "Hey, you should be working out all the time while you're in the middle of your cycle of R-CHOP." I mean, that's not necessarily an easy thing to do. And so I think making sure to have some empathy for the patient and what they're going through, and work with them on a plan and what's actually feasible with where they're at in their life is really important. And to your point, as far as how do we be the most successful, I think the more specific we can be. And then often using physician extenders like nutritionists or other nursing support to be able to talk with them about dietary plans or other things can be helpful, but just making sure they have some concrete stuff to act on as opposed to just saying, "Hey, you should exercise more."
Partridge: I like meeting the patient where they are and try to get them to improve, not necessarily become a bodybuilder or marathoner or the perfect vegetarian.
Mitchell: Absolutely. And I always try to help strike that balance with the patient so that they understand. Sometimes patients will ask me what's recommended. And so I'll give them the American Heart Association recommendation, which is in general about 150 minutes of exercise. And sometimes that's broken down as the "4 for 40" — 4 days a week for 40 minutes a day. But if they're someone who's been mainly limited on the couch up until that day, they can become very discouraged if you tell them that. And so you just want to make sure and reinforce that there's several studies on cancer patients that simply going for a few minutes' walk instead of sitting on the couch all day drives extensive benefit. And so it's one step at a time; it's achievable, attainable goals.
Partridge: That's great. I like the 4 for 40, too. I hadn't heard that one. Getting people moving. I always say to people, you don't need to run a marathon, you just need to get off the couch and walk around the block a little more or park the car a little further away from the store and then build on that.
Mitchell: Absolutely. Those are great points.
Partridge: You don't want people getting discouraged. Another topic that comes up a lot in survivorship and even in active-treatment patients, and I'm curious about your thoughts on this for cancer survivors and people living with cancer, is alcohol. It's not a conventional coronary risk factor, but it is a toxin to the heart. How do we think about alcohol and a person who's a survivor, aside from some of the diseases where we know it actually might impact on their risk of getting those diseases or getting a second primary disease, and that's a real issue too. How do you think about alcohol and the heart? And what's the lore these days, even for people who haven't had cancer yet? Is it good for our hearts or is that just an excuse we use so we can have a few?
Mitchell: That's a great question. We don't have all the answers that you may want for the podcast. Historically, we've seen low-quality evidence that maybe a glass of red wine could be good for you, but it was never high-quality evidence and it never became a guideline. And certainly on the other side of that there's evidence where the alcohol can be a toxin. And our best evidence is when you drink lots of alcohol. We know for sure that six drinks of alcohol a day are going to cause an alcoholic cardiomyopathy or heart failure. And then in general, I believe that the US Preventive Services Task Force still recommends less than one drink of alcohol a day for women and less than two for men. So I generally try to coach people in that. If someone asks me if alcohol is good for the heart, I say that there's no evidence that it is. I can't say it's not because the one glass of red wine might help your cholesterol, but I really just try to focus on moderation and meet the patient where they're at. I certainly counsel against alcohol excess. I don't tell them if they feel alcohol is important in their lives, that they have to abstain. But I certainly try to counsel them on avoiding anything other than moderation.
Partridge: It sounds very prudent. You don't want to be the buzzkill on New Year's, but at the same time, we do have to watch for some of the lifestyle patterns that maybe contributed to their getting the cancer in the first place in many settings.
Mitchell: I think that's really important to recognize and sometimes it gets overlooked. And so it's really important to make sure that we include that in the discussions and look for those risk factors.
Partridge: And smoking is another one that's such an addictive substance for so many people. Yet, we know it's a clear pathogen for the heart. How do you manage that with your patients? Another hard one.
Mitchell: For that one, there is very clear evidence that people should not smoke. No part of a cigarette is good for you. The hardest part, as you know, is that it is hard to quit. So part of it is trying to get the patient to the point that they're willing to consider quitting. If you come in every single time you see them and just harp on them, then they may not ever come for follow-up. So I do something in the middle where I don't let it go. I don't care how many times a patient said that they don't want to quit smoking yet, it's still going to get brought up, at least briefly, every visit, although I'll acknowledge how hard it is to quit. And I understand what they're going through. But then I reach out to them about how important it is and that we're always there to support them with tobacco-cessation products or any other type of support we can provide.
Partridge: That's great. I've been pleasantly surprised. We just launched a smoking-cessation program here at our institution at Dana-Farber. Believe it or not, we didn't initially have one, at least consistently. There is more progress being made there. And you know, it's that stages-of-change model of when people eventually get all the facts and feel ready, you want to be there and be able to plug them in with resources, either the public health resources or cancer center resources, so they can be supported to make those changes.
Mitchell: Absolutely. We want to stay engaged. Before I was a doctor, my grandmother told me a story of when she went to go see her doctor, and she was someone who followed the doctor's recommendations to the T. If the doctor told her not to have salt, she would have no salt. And she asked her cardiologist at the time about some recommendations for diet. He basically said he never gave them anymore because no one ever listened to him. So he had given up. And I never want to be that. I never want to be the person who doesn't even try anymore, because you can be pleasantly surprised, like you said. On a quick aside, there is a patient who I saw when I was moonlighting in the emergency room earlier on in my career. He came in and it was obvious that he was an alcoholic by all his lab work and everything else. And when you talked to him, he said, "I don't drink." But his family was in the room. And I said, "It's pretty clear that you do drink. And if you want to be around for your family, you need to do something to stop." But I left the room not expecting anything to happen. That was another fruitless conversation that I would have. And the patient's wife reached out to the nurse to let us know that he had quit drinking and that he had improved his life. It was so helpful that I had that conversation with him. So you never know when you'll have that impact with a patient. I'll always remember that.
Partridge: I think that's a wonderful story. I'm so glad that you shared that with us, because I completely agree. And the other thing is, you can't assume that just because the last patient didn't listen, that the next one won't be at a place to. It's not that people don't listen. They're just not at a place where they're ready to make that change because it's just so hard. And I think your approach with continued fresh eyes and empathy is so key for how we manage these behavioral changes and a lot of the things we do for our patients and try to support them.
Mitchell: Absolutely. I think it's so important to get patients to know that you do care. Because they don't want to think, oh, it's just one more doctor telling me what to do. They don't know what I'm going through. They don't know what I've been through. And so being able to express that empathy is really important to make that therapeutic alliance.
Partridge: It's great. One of the issues that comes up, and you brought this up in the beginning of our discussion, was around trying to find that balance. You're talking about finding the balance with the individual patient recommendations around health behaviors. I want to take us back for another minute to finding the balance when it comes to cancer treatment and then not doing damage to the patient or their important organs like the heart with the treatment. How do you talk to patients about that and talk to people like me, oncologists who want to treat that cancer? How do you manage that balance in your practice with patients and their doctors?
Mitchell: That's a great topic and it can go wrong on both sides. I've seen a patient with coronary artery disease, blockages in the arteries of the heart that were not obstructive. So it wasn't actually making any physiologic difference. But because coronary artery disease was on the chart, the breast oncologists decided not to give the patient the anthracyclines that they would normally plan to give. Interestingly, the clinician gave them platinum-based agents and the patient ended up having a thromboembolism.
Partridge: Platinums are no good for those vessels either.
Mitchell: The point is that the patient could totally have had anthracyclines. And so clinicians avoid things. And more often it's the cardiologist saying, "No, the clinician is not trained well." So I've mentioned to you before, but I don't think I've brought it up on the podcast that, number one, when talking to the patients, it's making sure that we're up front with what that risk is, right? Sometimes patients get scared, like the doxorubicin is going to kill their heart. But I'll say to the patient, "Most likely you're going to be fine. You're going to do well into survivorship. But you're right, there is a risk." So we do have to screen for it. I don't want to give the patient trauma and stress from being overly harsh on what their risk might be. And then understanding that the cancer treatment itself is super-helpful in prolonging life, that we as clinicians really want to maximize that. It's on rare occasions that we actually have to stop cancer treatment because of cardiovascular effects. We certainly want to recognize if a patient has significant heart failure on anthracyclines, then I can't continue them on, but there are a lot of instances where we're able to treat the patient, use guideline-directed medical therapy for the heart, get them their lifesaving cancer treatment, and then improve their overall survival and health.
Partridge: That's great. So lots of conversations both with the patient and with the oncology team to try and get them through it.
Mitchell: Absolutely. And that's a great point, Ann — a lot of it is a multidisciplinary discussion. There are many patients where maybe it's more of a straight-and-narrow conversation, but there are lots of patients where after seeing them, I immediately reach out to the oncologist and have that good discussion of what's really needed from a cancer perspective, what my concerns are for the heart, and how best to manage it. So, it absolutely needs to be that multidisciplinary discussion.
Partridge: Well, Dr Mitchell, this was really terrific. Today we've talked with Dr Joshua Mitchell about the art and the science of cardio-oncology. He's emphasized for us things like finding the balance between treatment and preserving heart function and the other parts of patients' bodies that are important to their health and well-being; the attention that the whole multidisciplinary team needs to pay to risk factors for cardiovascular disease, including for the doctors that care for them and the other providers; as well as how we can modify risk factors and help patients to capitalize on that teachable moment in survivorship, including smoking cessation, exercise, and diet management — notable things where patients can have control if they so choose to take it, at least to some degree. So, thank you, Dr Mitchell, and thank you, the audience, for tuning in. If you haven't done so already, take a moment to download the Medscape app to listen and subscribe to this podcast series on cancer survivorship. This is Dr Ann Partridge for InDiscussion.
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Cite this: Cardio-oncology: Engaging a Multidisciplinary Team to Address Risk Factors for Cardiovascular Disease in Cancer Survivorship - Medscape - Apr 26, 2023.