The Cardio-Oncologist Will See You Now
At 86, United States Supreme Court Justice Ruth Bader Ginsberg has been diagnosed and cured of early stage pancreatic cancer. Jeopardy! host Alex Trebek is in treatment for Stage IV pancreatic cancer and sharing his health updates publicly.
Their stories are more common now as individuals are living longer after a diagnosis of cancer. But with an aging population of cancer survivors also comes more chronic medical conditions, both related and unrelated to the original cancer diagnosis.
There are more than 15 million cancer survivors in the United States, expected to exceed 20 million by 2026. Of those survivors, heart disease is the second leading cause of death. The first leading cause of death is second malignancy.
As the numbers of survivors grow, so too does the number of patients living with late effects of cancer-related cardiotoxicity. For example, among Hodgkin lymphoma patients who have received radiation, cardiovascular disease is a major cause of death.
Over the last two decades, awareness that cancer care can directly result in cardiac complications is growing, as is the understanding that patients who have survived cancer have an increased risk of dying from heart failure, coronary heart disease and stroke. This has led to an increase in interest in the field of cardio-oncology.
Cardio-oncology specialists treat those with cancer who also have cardiovascular disease either before or as a result of cancer treatment. They also focus on preventing potential heart problems that may occur as a result of cancer diagnosis or as a side effect of therapies, or treat these cardiac problems as they arise.
Although cardio-oncology’s roots stretch back as far as the 1960s, and despite the fact that it is recognized medical specialty, only a handful of training programs in this field exist in the United States. The Accreditation Council for Graduate Medical Education does not endorse any structured training format.
Cardiac care is not likely the first thing on a patient’s mind when facing a diagnosis of cancer. However, increasing evidence of the link between cancer and cardiovascular disease led to the development of the first paper on cardio-oncology in the 1990s; and eventually, the first onco-cardiology program at MD Anderson in 2000.
The purpose of this subspecialty is to diagnose, prevent and treat cancer therapy–induced cardiac toxicity. Since the field’s formal origin in 2000, many centers, such as the Rush University Medical Center, the Moffitt Cancer Center and Vanderbilt University, have employed cardio-oncologists.
Cardio-oncology has been a topic of discussion and research at national scientific forums such as the 2019 American Heart Association conference. The American College of Cardiology convened the first cardio-oncology intensive conference at the ACC national meeting in 2015, and has since held a national cardio-oncology course every February.
Nonetheless, many institutions do not have a cardio-oncologist on staff. Centers that offer cardio-oncology services roughly doubled from 2014 to 2018. However, these findings were based on responses from only 39 percent of programs surveyed; and according to the Journal of the American College of Cardiology, fewer than 50 percent of the cardiovascular training programs include cardio-oncology topics in their curriculum.
Recognizing the importance of this unique specialty, governing cardiology organizations such as the ACC developed a cardio-oncology council in 2014. The American Heart Association followed suit and instituted a cardio-oncology committee in 2019.
Despite its importance and history, this field is still expanding slowly. In 2015, a survey sent by the ACC cardio-oncology council to cardiology program directors and chairs reported that 27 percent of centers have dedicated cardio-oncology programs.
Over 70 percent of those who responded agreed that cardiovascular complications are a major issue that faces cancer patients. Over 50 percent reported that cardio-oncology programs improve patient care. But only 12 percent were planning on adding the services into their programs within the year.
Unfortunately, within cancer centers, allotment of resources towards cardiovascular evaluation and testing may not be seen as a priority. With the evidence mounting on the link between cancer survival and cardiovascular disease, it is essential that a priority be placed on incorporating cardio-oncology specialists into the cancer care treatment model.
As two physicians—one of us an onco-cardiologist, the other an oncologist—with cumulative experience of 12 years in our fields, we have seen the benefit of this multidisciplinary and coordinated approach to screening, prevention and treatment for cancer patients at risk for cardiac disease.
For example, a 48-year-old female patient with history of lymphoma had received a cardiotoxic drug—doxorubicin, also known as Adriamycin—about 20 years earlier for breast cancer. They needed to use this medication a second time in order to cure her lymphoma.
Her heart function was already abnormal, likely due to her prior doxorubicin. The oncologist consulted us in cardio-oncology at Rush because there was concern her heart function would worsen with further doxorubicin treatment.
We made recommendations for cardio-protective medications and cardiovascular management during cancer therapy. She was followed closely and was able to safely make it through her lymphoma treatment. Now five years later, she remains alive and well, with heart function that is mildly abnormal but very stable.
In response to the dearth of cardio-oncology programs through much of the Midwest region, Rush University in Chicago launched the biennial cardio-oncology regional symposium aimed at educating other non–cardio-oncology health care professionals on the issues. The first symposium in 2018 exceeded its capacity due to overwhelming interest among health care professionals.
Rush and seven other hospitals within Chicago formed the Chicago Cardio-Oncology Consortium to organize a quarterly Chicago cardio-oncology rounds where we discuss cardio-oncology cases, learn and collaborate with each other. This forum is also well attended by health care providers.
For patients, Rush held its first biannual cardio-oncology patient education series in October 2019; the next will be held in May 2020.
The success and interest among health care professionals and patients in these educational series speaks to the need for cardio-oncology and collaborations between this specialty, oncology, primary care, patients, families, nurses, support staff and other health care providers; in order to achieve the best comprehensive care for the cancer patient with present—or future risk for—heart disease.
Given oncology’s fast pace of cancer care and changes in treatment paradigm, it is imperative for oncologists to work closely with subspecialists and keep abreast of the most current information, data, potential side effects and updated screening protocols that may impact patients.
Because of improved cancer screenings, early detection and screening, people are living longer after a cancer diagnosis; and increasing numbers of patients are cured of their cancer. With further improvement in cancer therapy, this number will continue to increase in years to come.
As the aging patient population of cancer survivors grows, the National Cancer Institute, the American Society for Clinical Oncology and others have developed survivorship models and guidelines to ensure screening and monitoring for potential late side effects. The American College of Cardiology offers resources on side effects that occur during or immediately after cancer treatment.
Yet many patients’ cardiac side effects of cancer therapy go undetected for years or even decades after cancer treatment has ended. In our cardio-oncology clinic at Rush, several patients present with heart failure, heart rhythm issues, heart valve disorders, coronary blockage and heart attacks, mostly as a result of earlier cancer therapies.
Medical staffs and patients need to be aware of these possible complications following cancer treatments, or from the disease itself.
Hospital administrators and medical schools need to encourage more cardiologists to further specialize and pursue a career in this evolving field as an increasing number of cancer survivors will benefit from this specialized approach to their cardiac care.
One of the greatest gifts to an oncologist and to patients is a multidisciplinary team of physicians including oncologists, surgeons, pathologists and radiologists, nurses and support staff who all have some understanding and knowledge of the specific cancers for each patient.
Cardio-oncology needs to be a universal subspecialized group of physicians in all health care organizations and medical institutions. The need is growing. The availability of solutions needs to grow at the same pace.