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CardioNerds (Amit Goyal and Dan Ambinder), Series Co-Chair Dr. Dinu Balanescu (Academy House Faculty and Chief Resident at Beaumont Hospital), and Episode Lead Dr. Manu Mysore (Former CardioNerds Ambassador and Cardiologist at the University of Maryland) discuss The Need for Cardio-Oncology with Expert Faculty Dr. Bonnie Ky, Director of Penn Cardio-Oncology Translation Center of Excellence and Editor-in-Chief of JACC CardioOncology. Audio editing by CardioNerds Academy Intern, student doctor Yousif Arif. This episode is supported by a grant from Pfizer Inc.

Cardio-Oncology is a burgeoning field. There is a need for cardiologists and oncologists to work together in a multidisciplinary fashion using multi-modality imaging and personalized medicine. Cardiologists in particular need to understand basic oncology, anti-cancer therapies, and address risk factors which play an important role in oncologic progression and/or adverse cardiovascular events. The field can only be furthered by research with a focus on specificity of endpoints and multidisciplinary collaboration. The future of the field is in the hands of investigators and clinicians alike.

This CardioNerds Cardio-Oncology series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Giselle Suero Abreu, Dr. Dinu Balanescu, and Dr. Teodora Donisan. 

Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.

Pearls • Notes • References • Production Team

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Pearls and Quotes – The Need for Cardio-Oncology with Dr. Bonnie Ky

1. Over 20 million new cancer cases are expected to be added annually to the global burden as novel therapies have improved cancer survivorship. These therapies may be directly associated with cardiotoxicity or may prolong life to allow time for cardiovascular disease to develop in cancer survivors.
2. Hypertension, hyperlipidemia, and obesity are modifiable risk factors that portend a poor prognosis from both an oncologic and cardiovascular perspective.
3. Multi-modality imaging is useful in risk assessment within oncology, with echocardiography (including strain imaging) having a class I indication prior to treatment with many chemotherapeutics.
4. Diverse trial enrollment is essential for furthering the science within Cardio-Oncology to translate clinically into personalized management.
5. There is a need to strengthen a pipeline of young physicians and scientists to further the field of Cardio-Oncology.

Show notes – The Need for Cardio-Oncology with Dr. Bonnie Ky

• Why should cardiologists have familiarity with cancer therapies?
  1. By 2030, 23.6 million new cancer cases are expected to be added annually to the global burden.¹
  2. Novel therapies and/or combination therapies have improved cancer survivorship but are associated with cardiovascular complications, especially in the elderly and those with pre-existing cardiovascular comorbidities.²
  3. Cardiologists currently lack an understanding of oncologic treatments, with poor knowledge of dosing protocols and cardiotoxicities. This can lead to less aggressive protocols administered, as well as early discontinuation of important treatments for both oncologic and cardiovascular conditions.³
  4. A multidisciplinary collaboration between pharmacists, cardiologists, oncologists, and nurse navigators is needed to improve treatment decision-making for the benefit of cancer patients.
  5. Cardiologists should have basic knowledge and understanding of some of the commonly used chemotherapeutic drugs and any adverse events during treatment courses based on clinical trials, FDA reporting, and epidemiological data.
  6. JACC Cardio-Oncology seeks to disseminate knowledge through live courses such as Advancing the Care of the Oncology Patient and journal-associated podcasts, with plans to develop a “how-to” series to educate both cardiologists and oncologists.

• What is the impact of cardiovascular risk factors and morbidity in oncology?
  • In the age of personalized cancer therapies, patients with metastatic disease are living longer and are instead dying from cardiovascular events.
  • Hypertension, obesity, and dyslipidemia are a growing epidemic within the oncologic population.
  • Retrospective analysis by Dr. Sun from the University of Pennsylvania VA suggests that only 68% of men receiving treatment for prostate cancer had a comprehensive cardiovascular risk factor assessment and of those, 54.1% had uncontrolled risk factors!⁴ Of these, 29.6% were not receiving corresponding cardiac risk-reducing medications.⁴
  • Treat the modifiable risk factors aggressively!

• What type of conditions do cardio-oncologists manage?
  • Cardio-oncologists manage a variety of treatment-associated cardiovascular conditions and adverse events.
  • Common oncologic therapeutics with known cardiotoxicity include anthracyclines, HER-2 receptor antibodies, radiation, tyrosine kinase inhibitors, VEGF-associated tyrosine kinase inhibitors (TKIs), aromatase inhibitors, and even modern treatments including stem cell transplantation and CAR-T therapies.
  • Patients follow-up with the cardio-oncologist before, during, and after treatment sessions.
  • Common cardiovascular events addressed include hypertension, dyslipidemia, arrhythmias, heart failure, coronary artery disease, and obesity. More on these in future episodes!
  • After cancer therapy completion, focus is on addressing cardiovascular and cancer-related risk factors and lifestyle modification.

• What are strategies for risk assessment of cancer patients in terms of cardiovascular toxicity?
  • Advanced imaging plays a vital role within the field of Cardio-Oncology.
  • The European Society of Medical Oncology gives echocardiography a 1A recommendation that all patients who receive anti-cancer therapy associated with left ventricular dysfunction should have a baseline ejection fraction (EF) assessment. Those who have a reduced EF at baseline are at a higher risk of cardiotoxicity. This can be limited however by body habitus or recent mediastinal surgery.⁵
  • Cardiac MRI is a gold standard for measuring left and right ventricular volume and function and is used when there is suboptimal image acquisition. It is particularly useful in the assessment of cardiac masses and inflammatory conditions such as myocarditis.⁵
  • Stress echocardiography plays a vital role in the risk stratification of patients undergoing cancer therapies associated with myocardial ischemia, including VEGF inhibitors and TKIs. There is a potential role for assessing diastolic dysfunction as well.
  • Calcium scoring can be determined on non-gated non-contrast CT scans performed for staging of malignancy.
  • Hundley et al. have done remarkable work in understanding if exercise programs will help prevent heart disease with strict cardio-metabolic testing in patients undergoing cancer treatment.⁶
  • Large efforts are underway to identify risk calculators to predict cardiotoxicity in a personalized approach.

• What are monitoring strategies for cardiotoxicity?
  • Consensus statements and expert opinions continue to grow and more of this will be addressed in future episodes.
  • In particular, guidelines are in place for anthracycline use and HER-2 targeted therapy.
  • In August 2022, the European Society of Cardiology released Cardio-Oncology Guidelines, addressing the cardiotoxicity of numerous other classes of anti-cancer therapies and further highlighting the importance of echocardiography and multi-modality imaging for the monitoring of cardiotoxicity in cancer patients.⁷

• What are challenges in designing clinical trials in cardio-oncology?
  • Patients feel vulnerable during the early treatment course with chances of lower trial enrollment.
  • Multi-disciplinary collaboration with a patient-centric focus is needed.
  • Partnership with key stakeholders, including NIH/AHA, is needed.
  • Defining the optimal timing for the initiation of cardio-protective therapy and the duration of such therapy is another challenge.

• Where do we go from here in Cardio-Oncology?
  • Scientifically, we need to advance personalized medicine to improve patient outcomes.
  • We need to understand the mechanistic overlap between cardiovascular and oncologic disease.
  • We need to leverage technology to assist in the treatment of cancer therapy-related adverse cardiovascular events and oncologic progression.
  • We need to work together to overcome healthcare disparities which play a vital role in Cardio-Oncology.
  • We need to strengthen the pipeline of young investigators and clinicians.

References – The Need for Cardio-Oncology with Dr. Bonnie Ky

Cancer Statistics (National Institute of Cancer website). https://www.cancer.gov/about-cancer/understanding/statistics. Published 2018. Accessed August 4, 2022.

Cardinale D, Biasillo G, Cipolla CM. Curing Cancer, Saving the Heart: A Challenge That Cardioncology Should Not Miss. Curr Cardiol Rep. 2016;18(6):51.

Okwuosa TM, Prabhu N, Patel H, et al. The Cardiologist and the Cancer Patient: Challenges to Cardio-Oncology (or Onco-Cardiology) and Call to Action. J Am Coll Cardiol. 2018;72(2):228-232.

Sun L, Parikh RB, Hubbard RA, et al. Assessment and Management of Cardiovascular Risk Factors Among US Veterans With Prostate Cancer. JAMA Netw Open. 2021;4(2):e210070.

Yu C, Pathan F, Tan TC, Negishi K. The Utility of Advanced Cardiovascular Imaging in Cancer Patients-When, Why, How, and the Latest Developments. Front Cardiovasc Med. 2021;8:728215.

Bellissimo MP, Canada JM, Jordan JH, et al. Changes in Physical Activity, Functional Capacity, and Cardiac Function during Breast Cancer Therapy. Cancer Epidemiol Biomarkers Prev. 2022;31(7):1509.

Lyon AR, López-Fernández T, Couch LS, et al. 2022 ESC Guidelines on cardio-oncology developed in collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO) and the International Cardio-Oncology Society (IC-OS). Eur Heart J. 2022.