Ramping Up Cardiac Care for Cancer Survivors

By Katy Mena-Berkley
Sunday, September 1, 2019

Increasing cancer survivorship means healthcare providers are encountering new challenges in cardiac health, underscoring the need for additional subspecialists in cardio-oncology.

According to the American Cancer Society, by 2026, an estimated 20 million people in the United States will be cancer survivors. Roughly half of cancer survivors as of 2016 were ages 70 or older.

Experts in cardio-oncology recently authored a paper, published in the Journal of the American College of Cardiology, highlighting efforts to respond to the growing need for cardio-oncology care as the negative cardiovascular effects of some life-extending cancer treatments become more apparent.

Cardio-oncology training equips providers to balance patients’ oncologic and cardiovascular needs before, during and after treatment, co-senior author Ana Barac, MD, PhD, states in a news release about the paper.

“Examples of clinical strategies include pre-therapy risk stratification and cardiovascular health optimization, personalizing cancer therapy based on the cardiovascular risk profile, and the diagnosis and treatment of a widening array of therapy-related cardiovascular complications,” says Dr. Barac, Director of the Cardio-Oncology Program at MedStar Heart & Vascular Institute in Washington.

Critical Training

Cardio-oncology care is on the rise, according to the paper. A survey by the authors found that in 2014, 27% of accredited general cardiology fellowship programs were part of institutions that provided cardio-oncology services. Today, 51% of those programs are affiliated with institutions that have dedicated cardio-oncology services. The survey also found that 33% of respondents plan to add cardio-oncology care to their programs.

Yet only nine of the institutions providing cardio-oncology services also offer dedicated cardio-oncology training.

“Some leaders do not notice the need, and some do. There are varying levels of interest,” Tochi M. Okwuosa, DO, FACC, FAHA, Associate Professor of Medicine and Cardiology and Director of the Cardio-Oncology Program at Rush University Medical Center in Chicago, tells MD News. “But there is a need for it. Now, as cancer patients are living longer, there is a an even greater need.”

In 2015, Dr. Okwuosa co-authored a paper with Dr. Barac and Edward T.H. Yeh, MD, exploring the development of cardio-oncology. The paper, also published in the Journal of the American College of Cardiology, details the importance of collaboration among a multidisciplinary team of clinicians, including those specializing in cardiovascular disease, heart failure, oncology and psychosocial support, as well as primary care providers. It calls for institutional support for cardio-oncology training as well.

Four years after the publication of that paper, Dr. Okwuosa is encouraged by progress toward achieving that goal. However, she notes, much work remains.

“Ideally, I would like to see training become Accreditation Council for Graduate Medical Education-accredited,” Dr. Okwuosa says. “I really would like to see some specialized training for the field of cardio-oncology and for the American College of Cardiology, in conjunction with the ACGME, to generate a set of parameters for training ... and standardize those parameters across institutions.”

Overcoming Barriers

Establishing the right training and attracting clinicians to the field is critically important to the health and longevity of patients living with comorbid cancer and cardiovascular disease as well as to cancer survivors, Dr. Okwuosa says. But there are hurdles to overcome in terms of the existing perceptions of specialists.

“The cancers that used to kill within six months or a year,” Dr. Okwuosa says, “people are now getting four, five, six years with those cancers because of immunotherapies and advanced therapy.”

However, the field of cardiology has not always responded promptly to advances in survival, meaning patients in some cases do not receive the care they need “to live at maximum capacity from a cardiovascular standpoint,” she adds.

Updating cardiology training is crucial, says Bonnie Ky, MD, MSCE, Associate Professor of Medicine and Epidemiology at the Perelman School of Medicine at the University of Pennsylvania and co-senior author of the more recent Journal of the American College of Cardiology paper.

“Inclusion of cardio-oncology as a component of general cardiology training programs is the first step in establishing a workforce capable of recognizing and managing the complex cardiovascular burdens associated with cancer in every community,” Dr. Ky states in the news release.

“We are realizing more and more cardiotoxic profiles of a lot of these [cancer] treatments. ... Involving a physician who is well-versed in cardio-oncology — even if it is a general cardiologist who is knowledgeable about cardio-oncology — is important.”
— Tochi M. Okwuosa, DO, FACC, FAHA, Associate Professor of Medicine and Cardiology and Director of the Cardio-Oncology Program at Rush University Medical Center

The Value of Specialized Care

When patients do receive collaborative cardio-oncology care, the results can be transformative.

One patient Dr. Okwuosa treated was living with non-Hodgkin’s lymphoma. However, because the active 82-year-old also had severe aortic valve stenosis, the cardiotoxic chemotherapy that could cure his non-Hodgkin’s lymphoma was deemed high-risk.

“They consulted us in cardio-oncology because they were really concerned,” Dr. Okwuosa says. “We arranged for the patient to have transcatheter aortic valve replacement to get that aortic valve fixed in a very expeditious manner.”

That, in combination with the use of an agent, dexrazoxane, that helps prevent cardiotoxicity, enabled him to receive the treatment he needed.

“He went back to exercising after treatment was completed and did well,” Dr. Okwuosa says. “This is a good outcome because the oncologist consulted us, and we worked together to get [the patient] where he needed to be with minimal toxicity. He is now five years out from his cancer therapy.”