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When treating cancer, some of the treatments may cause lasting damage to your heart, especially if you are already at risk for cardiovascular disease. Dr. Steve Nissen is joined by Dr. Patrick Collier and Dr. Rohit Mougdil from Cleveland Clinic’s Cardio-Oncology Center to discuss what is the field of cardio-oncology and how we best care for patients.

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Cardio-Oncology – Caring for Cancer and Heart Patients

Podcast Transcript

Announcer:
Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute. These podcasts will help you learn more about your heart, thoracic and vascular systems, ways to stay healthy and information about diseases and treatment options. Enjoy.

Steven Nissen, MD:
So I'm Steve Nissen and I'm here with two colleagues to talk about the field of cardio-oncology. So they're going to introduce themselves. Dr. Moudgil.

Rohit Moudgil, MD:
So my name is Rohit Moudgil and I'm an Assistant Professor here for the last three years and my interest has been in cardio-oncology. I got trained in MD Anderson and I'm very happy to be here.

Patrick Collier, MD, PhD:
My name is Dr. Patrick Collier, Co-Director of the Cardio-Oncology Center. I’m here for over 10 years and looking forward to our conversation.

Steven Nissen, MD:
What is the field of cardio-oncology?

Patrick Collier, MD, PhD:
The field of cardio-oncology really is a merge between heart ... where heart doctors and cancer doctors come together really to try and provide optimal outcomes for patients. There's an increasing recognition that patients with cancer have risk factors for heart disease, or indeed may have preexisting heart disease and that these can be affected by their therapies and that if we work together as a multidisciplinary team, that we can provide the best outcomes.

Steven Nissen, MD:
So treatment of cancer can have consequences for the heart. What are some of those consequences?

Rohit Moudgil, MD:
In terms of consequences, they can range from anywhere from things that can happen right away with the treatment to things that can last for even 20 to 30 years post-treatment. So it can include heart failure where the heart is not functioning very well.

Steven Nissen, MD:
Yeah.

Rohit Moudgil, MD:
It can cause heart disease, heart attacks also. And not only that, more and more new therapies that are coming out, it can affect every aspect of the heart. So it is becoming more and more vital to understand this field.

Steven Nissen, MD:
So as we've gotten better and better at treating cancer, the drugs have gotten to be more effective in many ways, more powerful, and they're very good at eradicating the cancer, but they may have consequences for the heart. So you guys have formed a kind of a partnership with our cancer doctors, so that everybody gets access to both the best cancer treatments and the best heart related treatments. So how common are heart problems in patients that have cancer?

Patrick Collier, MD, PhD:
I think it's important to say that most patients get through their cancer therapy without trouble.

Steven Nissen, MD:
Right.

Patrick Collier, MD, PhD:
I think though it is a significant and important minority of patients that can develop significant problems. I mean, the problems that they can develop aren't minor, and that's why it's very important for us to try and identify those at increased risk and make sure they get access to heart care.

Steven Nissen, MD:
This field is now developing rapidly. What are some of the things that patients might need to know about heart complications and cancer? So, Dr. Moudgil.

Rohit Moudgil, MD:
So in terms of heart complications, you have to be cognizant about some of the symptoms that you are developing after the cancer therapy. So for example, if you are tired, fatigued, or you're developing swelling off your ankles, are they due to the chemotherapy or is it due to a new cardiac problem? So you have to be cognizant about it. So that is why it's a multidisciplinary approach to treat every cancer patient, and cardiology is a major aspect of it.

Steven Nissen, MD:
Are there things you can do to predict who's at greater risk for heart complications? Blood tests, are there risk factors? Dr. Collier, maybe you could tell us a little more about that.

Patrick Collier, MD, PhD:
For sure. Well, we've certainly identified those that have already preexisting cardiovascular disease that face now a new journey with cancer, that those patients need particular attention because sometimes the treatments can worsen or exacerbate their preexisting disease. Also those with risk factors, and we now recognize that many of the risk factors for heart disease, these traditional risk factors are also risk factors for cancer

Steven Nissen, MD:
Can you give us some examples?

Patrick Collier, MD, PhD:
Diabetes, obesity, sedentary lifestyle, et cetera, hypertension. All these can influence your cancer risk. Smoking, of course.

Steven Nissen, MD:
And so though are the same risk factors for heart disease: diabetes and smoking and so on. So now do you routinely see these patients? Does everybody with a cancer that gets chemotherapy see you, or how do people decide that they need to see a cardiologist? How do their cancer physicians or the patients decide that they need to see a cardiologist?

Rohit Moudgil, MD:
So this is a up and coming field, and right now we are not screening every patient that needs to be screened for cardiology, cardiac diseases. Unfortunately, a lot of our patient that comes in are after the fact where they had developed cardiac disease and then they are seen. But definitely one of the major aspect of providing a comprehensive care to our cancer patient is to preemptively go in and try to see what we can do for the cardiac disease.

Steven Nissen, MD:
So you want to see the disease? You want to detect the disease before patients are in a lot of trouble.

Rohit Moudgil, MD:
Absolutely.

Steven Nissen, MD:
How do you do that?

Rohit Moudgil, MD:
So the thing is, so what we have to do is recognize those cardiac risk factors as Dr. Collier mentioned early on. So for example, the breast cancer patients tend to have obesity. They tend to have diabetes quite often.

Steven Nissen, MD:
Yes.

Rohit Moudgil, MD:
So if they had those risk factors and they're developing breast cancer, they should also see a cardiologist to make sure that therapies that you're getting for breast cancer are not adversely affecting the heart.

Steven Nissen, MD:
So are some of those patients then sent to your Cardio-Oncology Center before they actually start their chemotherapy?

Rohit Moudgil, MD:
So right now it is in development in terms of, we do see a lot of those patients, but I don't think we see all of those patients, and that is the premise of us spreading the word out there that you should come and see a cardiologist.

Steven Nissen, MD:
So are there any blood tests that can help you detect this, that there might be a cardiac problem developing?

Patrick Collier, MD, PhD:
Traditionally we've relied on imaging testing, but more and more there's this push to try and identify useful biomarkers. We have biomarkers already in clinical use. Troponin, for example, and BNP. BNP is a sensitive of marker of stretch in the heart muscle.

Steven Nissen, MD:
Yeah.

Patrick Collier, MD, PhD:
Troponin being a marker of injury. These markers may be helpful, but again, a lot needs to be learned about their applicability because these tests are so sensitive that we don't want to create a false sense of problems when they're not there either.

Steven Nissen, MD:
Well, they will have consequences, obviously, if somebody's developing a heart problem from their chemotherapy, it may lead to an interruption of their chemotherapy. So you have to be very thoughtful about this and help the patient make a decision on whether the risks and benefits of the chemotherapy are well balanced and obviously understanding the risk side as well as the benefit side is very important. And I would guess that there's a lot of dialogue between you and the patients about what do you do now?

Rohit Moudgil, MD:
Absolutely, and that's where the, I think the art of medicine comes in because it is an art in which we conversate with our patients. We talk to our oncological colleagues, we identify what are the benefits in continuing the cancer therapy and how we can mitigate some of these cardiac risk factors and cardiac problems so that we can provide the best treatment for the patients.

Steven Nissen, MD:
So a patient develops a heart problem that's related to the chemotherapy. Are there treatments available?

Rohit Moudgil, MD:
Absolutely. So the thing is there are certain treatments that are available that can be cardio-protective to the heart. So some of the medications that we use in our cardiac patients are the same medication we use in these population. So for example, beta blocker, ACE inhibitor. They are some of the class medications we use, and we find that these medications are also beneficial in these cases.

Steven Nissen, MD:
So there's evidence that they can reduce the heart related effects of the cancer treatment?

Rohit Moudgil, MD:
Absolutely. So the evidence is not as strong as what can expect in cardiac patients, but there is emerging evidence definitely that they are cardio-protective. I mean, I can tell you anecdotally, with all the patients that we have started these therapy, we have seen positive effect in them.

Steven Nissen, MD:
Now, imaging studies like echo cardiography, echo tests of the heart, ultrasound tests of the heart, are commonly used in these patients. Can you explain a little bit about what that's all about and why that test is used?

Patrick Collier, MD, PhD:
For a lot of the traditional chemotherapies that are used, they can affect the heart muscle function directly. And echo cardiography provides a fantastic way for us to look at the heart muscle and see how it's working at baseline. And then we can follow the patients throughout their course, and see, is there any change in that. The case that you presented was a patient develops a heart problem related to their chemotherapy. Sometimes that scenario isn't a given. So sometimes heart problems may be identified. One of our roles is to try and figure out is the chemotherapy actually likely to be implicated in that issue?

Steven Nissen, MD:
Or is it due to another problem?

Patrick Collier, MD, PhD:
Or is it due to another problem? That's very important because as you mentioned, cessation or holding chemotherapy has implications for cancer outcomes. So I think it's a very important role for us is trying to adjudicate what's going on, decide with our oncology colleagues, does this therapy need to be discontinued or potentially alternative therapy instigated?

Steven Nissen, MD:
So echo cardiography, you can look at the how the heart muscle squeezes. And if it doesn't do that as well over time, then you have to ask the question, what's the cause? And what you're saying is there can be, chemotherapy can be the cause, but there are other heart diseases that can be the cause. And maybe chemotherapy's not the problem. So these are kind of tough decisions, aren't they?

Rohit Moudgil, MD:
Absolutely. And we have identified quite frequently, when these problem arise in these cancer patients, we actually do our due diligence to identify those cardiac risk factors and cardiac things that can happen in these patients. So we make sure that all the cardiac things are taken care of in these patients. So that involves testing and identifying cardiac causes because that will be the most prominent. But before naming chemotherapy as a cause of it, we have to do our diligence in every aspect of the cardiac care.

Steven Nissen, MD:
Well, thank you both for this very enlightening discussion. And we hope that for patients that this is helpful in understanding the relationship between our oncologists, our cancer physicians and our cardiologists. And I want to compliment both of you for making this link and forging this relationship so that patients get the benefit of both cardiology and oncology when they develop cancer. Thank you.

Patrick Collier, MD, PhD:
Thank you.

Announcer:
Thank you for listening. We hope you enjoyed the podcast. We welcome your comments and feedback. Please contact us at [email protected]. Like what you heard? Subscribe wherever you get your podcasts or listen at clevelandclinic.org/loveyourheartpodcast.

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