When Cancer Meets Cardio
April 04, 2016
A national model for onco-cardiology care
Cancer and cardiovascular disease are closely linked, both by their shared risk factors and the cardiotoxic effects of certain cancer therapies. Nevertheless, there are only a handful of hospitals that recognize this reality. A 2015 survey of U.S. adult and pediatric cardiology division chiefs, reported in the Journal of the American College of Cardiology, found that only 27 percent of medical centers offered an integrated onco-cardiology program featuring the services of more than one clinician. At 16 percent of centers, there was just one cardiologist with onco-cardiology expertise. The vast majority of cancer patients had no attention paid to their hearts.
This unrecognized need has potentially devastating consequences for patients.
“Most cancer patients with heart disease fail to receive appropriate cardiovascular care,” says Guilherme Oliveira, MD, Director, Advanced Heart Failure, & Transplant Center, UH Harrington Heart & Vascular Institute, Director, Onco-Cardiology Program, UH Harrington Heart & Vascular Institute; Clinical Associate Professor of Medicine, Case Western Reserve University School of Medicine. In fact, his study of nearly 7 million patients, recently published in the Mayo Clinic Proceedings, found significantly high rates of co-existing cardiovascular disease among cancer patients. More alarmingly, however, was the fact that less than half of these patients were followed by a cardiologist or treated with appropriate cardiovascular medications.
“Heart disease is incredibly common and often neglected in patients with cancer,” Dr. Oliveira says. “Patients with lung cancer, for example, have an almost 50 percent chance of having underlying severe cardiovascular disease at the time of cancer diagnosis. Identifying and treating underlying cardiac disease may not only attenuate cardiotoxicity but also prevent unexpected cardiac complications during treatment, such as myocardial infarction or heart failure, thereby improving overall survival.”
In a collaborative effort between UH Seidman Cancer Center and UH Harrington Heart & Vascular Institute, Dr. Oliveira has built a program that bucks the national trend, reaching out to oncology patients and bringing them under the onco-cardiology umbrella before cancer treatment even begins.
“Our program is one of the largest, best organized and most comprehensive in the country,” he says. “In 2015 alone, we treated more than 1,200 patients, providing comprehensive cardiology longitudinal care. We evaluate patients before they receive the first dose of chemo, monitor them through their treatment and follow them as survivors. Because of its scope, the UH Onco-Cardiology Program has been nationally recognized as a model of onco-cardiology care. Physician groups from Europe, South America, Africa and over a dozen centers in the U.S. have traveled to Cleveland to learn from our experience.”
Part of the success of the program at UH comes from partnering with providers within the UH system to offer onco-cardiology services locally. Although initially only available at the main campus of UH Seidman Cancer Center, onco-cardiology services are now available at four UH community hospitals and two ambulatory health centers, with expansion planned soon to another community hospital.
“We strive for close integration of practice patterns and protocols at every location, so that there is high reliability of care across all the health system,” Dr. Oliveira says. Another key to success is standardization of echocardiography machines, software, image acquisition and interpretation. All echocardiography imaging is performed on state-of-the-art GE Vivid 9 equipment with three-dimensional and strain software.
“We have strict adherence to our imaging and interpretation protocols,” Dr. Oliveira says. “We train echo techs in our main lab and only allow level 3 certified echo techs to perform these studies. We also conduct frequent quality reviews and continued education.”
Evidence is emerging that onco-cardiology services translate into improved outcomes for patients. Dr. Oliveira and colleagues from UH recently reported lower cardiovascular mortality among survivors of Hodgkin lymphoma, publishing their findings in the journal Clinical Lymphoma, Myeloma & Leukemia.
“We found that cardiovascular mortality in these patients has decreased about 7 percent per year over the past two decades,” Dr. Oliveira says. “We also have data soon to be published showing that cardiovascular death among breast and lung cancer survivors has decreased in recent years. We speculate that this reflects the impact of improved cardiovascular care and onco-cardiology.”
To spur even better outcomes for patients, Dr. Oliveira and his team at UH have secured more than $1.5 million in intramural and extramural funding for onco-cardiology research.
“We currently participate in multicenter clinical trials in the field of onco-cardiology,” he says. “We also have several investigator-initiated clinical and translational studies trying to understand different aspects of cardiotoxicity.”
One area of investigation is the idea of an “individual cardiotoxic threshold” or ICT. Dr. Oliveira’s research, published in both the Journal of the American College of Cardiology and the Journal of Heart and Lung Transplantation, has shown that women are more likely than are men to develop cardiotoxicity in response to cancer treatment.
However, other factors affecting ICT are still to be identified.
“We have observed that there are patients that can withstand large doses of chemotherapy without developing cardiotoxicity, while others develop cardiotoxicity with only one dose,” he says. “This clinical observation, in combination with work showing that genetic factors can modulate cardiac susceptibility to the toxic effects of chemotherapy, gave rise to the concept of ICT. Patients with cancer often have characteristics such as age, gender, genetic predisposition and pre-existing cardiovascular disease that partly determine cardiotoxicity. Specialty cardiovascular assessment, more sensitive monitoring technology and timely interventions in selected patients can decrease cardiotoxicity and improve patient outcomes.This and other concepts require confirmation through research and clinical experience.”
For this to occur, however, Dr. Oliveira and his team need to evaluate as many newly diagnosed cancer patients as possible. Having access to patients before they start cancer therapies is essential, and requires strong partnership with oncologists.
“As we’ve shown, less than half of all cancer patients with cardiovascular disease are treated with guideline-directed medical therapy or are referred to a cardiologist,” Dr. Oliveira says. “That is something that needs to change to optimally care for these patients.”