The Emerging Field of Cardio-Oncology: A Look at the Multidisciplinary Team

Dr. Butler:
You’re listening to Heart Matters on ReachMD. I’m Dr. Javed Butler. And joining me today to explore updates in cardio-oncology is Dr. Ana Barac, who is the D’Aniello Chair and Director of the Inova cardio-oncology program at Inova Heart and Vascular Institute.

Dr. Barac, thank you so much for joining me today.

Dr. Barac:
It’s a true pleasure, Dr. Butler.

Dr. Butler:
So let’s begin with some background about cardio-oncology. You know, if you can just tell us to, for our listeners, what exactly is cardio-oncology? What is it about this emerging field that we should think about, or whether it’s even an emerging field anymore, or is it an adolescent or an adult field.

Dr. Barac:
I love that question, Dr. Butler. I think it’s definitely reaching adolescence. And if we think in the decades, it’s a field that we define as overlap, as really cardiovascular care of patients either with history of cancer or living with cancer and that has grown from patients who were exposed to our paradigm, such as anthracyclines paradigm, cardiotoxic drug, but what has happened over the last two decades, a number of paradigms have changed in oncology, meaning that patients are living much longer. The number of drugs that are being used, many of them targeted have interactions with the cardiovascular system, so I think that the field has grown. The field of cardiovascular care in oncology patients has grown into many directions from heart failure into prevention, into cardiac imaging, into vascular and cardiometabolic, so it’s still a growing field, but I think it’s not in its infancy any longer.

Dr. Butler:
So that’s great. But just to clarify for myself and for our listeners, when we talk about cardio-oncology, are we talking about people with preexisting cardiovascular diseases that happen to develop cancer and how to manage their cardiovascular disease, or are we talking about, about cardiovascular complications of chemotherapy, or both?

Dr. Barac:
That’s an excellent question, and I think that we really try hard to address all cardiovascular needs, and I think that labeling cardio-oncology purely surrounding the complications of cancer therapy would be a disservice to our patients. And we have learned one of the big lessons from cardio-oncology early studies, and we are learning that more and more that there is a strong synergism between the host and the host, or the patient’s cardiovascular risk factors with the drugs, and sometimes, it’s very hard to draw that line. There is also an increasing number of patients who come in to treatment, just like you said, with preexisting cardiovascular conditions, and those patients are also excluded from oncology clinical trials. Therefore, we really need to put an emphasis and focus on those patients who, yes, they are probably at a higher risk for cardiovascular complications, but even if their journey is more complicated just because of those preexisting conditions, that makes them the patients of cardio-oncology.

Dr. Butler:
So, medicine for the most part is team sports, and here we have cardio-oncology, so we already have two specialties involved: cardiologists and oncologists. So, what does the rest of the multidisciplinary team look like in this field to better take care of our patients?

Dr. Barac:
That’s a great point. It does cover the cardiovascular team and multidisciplinary oncology team. So, I think depending on with what the patient is presenting, we think the bare minimum of the team is a representative of cardiovascular team and representative of oncology team, which could be medical oncologists, radiation oncologists, a surgeon or other team member. On cardiovascular side it could be cardiologists specializing in prevention, heart failure cardiologists, but someone who is focused on that cardiovascular care of oncology patient. Very important members of the team that we always try to have present is a nurse. That navigation and coordination of care is of the essence. It has to be seamless for the patient. And then pharmacist. Pharmacist is crucial for drug-drug interaction, which are of particular relevance in this space as well as monitoring of adverse events which are involving, as we just stated.

Dr. Butler:
Now, you characterized the field in the first answer that it’s not a baby anymore and it’s in adolescence. So, looking ahead into the future as the field matures to become an adult, what sort of changes do you foresee happening in the field?

Dr. Barac:
That’s an excellent question. I foresee a lot of changes where we are going to start understanding better the interaction between new classes of drugs and cardiovascular system, and this field will grow with the growth of oncology field and with the growth of cardiology. So, from the oncology side, from that therapeutic evolution, I foresee us seeing many more patients who are receiving immunotherapy. That was also discussed at the ACC, very important for all cardiologists, not only cardiologists who are seeing cardio-oncology patients. As we all know, majority of the oncology patients live in the community. And immune therapy presents with a very unique set of adverse events that we are starting to understand, so I foresee us understanding better. We will all have to become a little bit of immunologists and understand what immunology means for cardiovascular system. So, one risk very rare but with high mortality still is myocarditis, also very interesting data shown at the recent meetings and in recent publications suggesting that the longer-term use of immune therapy may be promoting atherosclerosis. So, understanding these mechanisms will also, I think, help us potentially with new druggable targets for cardiovascular disease.

Another similar to that area of growth I see in other targeted therapies, so small molecule inhibitors such as tyrosine kinase inhibitors, which are now used for chronic diseases, which, for example, CLL, CML, so chronic myelogenous leukemia or chronic lymphocytic leukemia are diseases which today in general are treated lifelong. We are learning more and more about the subtle effects of these treatments. They are no longer like we used to have these marks, ‘Oh, if toxicity is discovered, stop the drug.’ It’s much more about understanding, preventing cardiovascular risk factors. So I envision many more targeted strategy trials that will help us comanage these patients along the way.

Dr. Butler:
Well, good. So it looks like you and your colleagues will be busy for a long time and real excitement in the field going forward as well. Well, thank you very much. This is about all the time that we have. I certainly learned a lot, and I’m sure that our audience members will too as well. It was really a pleasure speaking with you, and thank you so much for your time.

Dr. Barac:
A huge pleasure in talking to you, and I hope to recruit many more cardiologists to our field. Thank you.

Dr. Butler:
For ReachMD, I’m Dr. Javed Butler. To access this and other episodes in our series, visit ReachMD.com/HeartMatters where you can be Part of the Knowledge. Thank you for listening.