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Cancer and Heart Disease - Where the two intersect

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We have made great strides in the treatment of cancer. More individuals are surviving a cancer diagnosis, but cancer treatments can have a detrimental impact on cardiovascular health.

Dr. Susan Dent, a medical oncologist who co-founded the first multidisciplinary cardio-oncology clinic in Canada, discussed the importance of optimizing cardiovascular health for patients during and following completion of their cancer treatment.

Published in: Healthcare
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Cancer and Heart Disease - Where the two intersect

  1. 1. Click to edit Master title style Cancer and Heart Disease: Where the two intersect ! Susan Dent, MD, FRCPC Medical Oncologist, Duke Cancer Institute Associate Director, Clinical Breast Cancer Research Co-Director Duke Cardio-Oncology Program Founder and past-president, Canadian Cardiac Oncology Network (CCON) March 28th , 2019
  2. 2. Click to edit Master title styleObjectivesObjectives •To discuss the impact of cancer treatments on the heart •To discuss how we can optimize cardiac health in cancer patients •To discuss the benefit of a multidisciplinary approach in optimizing cardiac health in cancer patients
  3. 3. Click to edit Master title style
  4. 4. Click to edit Master title styleCancer Drug Development
  5. 5. Click to edit Master title styleCancer Survivorship
  6. 6. Click to edit Master title style CANCER STATISTICS IN CANADA 2015
  7. 7. Click to edit Master title style ““The cured cancer patient of todayThe cured cancer patient of today does not want to become the heartdoes not want to become the heart failure patient of tomorrow.”failure patient of tomorrow.” Eschenhagen T et al. Eur J of Heart Fail 2011; 3:1-10Eschenhagen T et al. Eur J of Heart Fail 2011; 3:1-10
  8. 8. Click to edit Master title style © Corbis Anthracyclines
  9. 9. Click to edit Master title styleCardiovascular Side Effects ofCardiovascular Side Effects of Modern Cancer TherapyModern Cancer Therapy Arrhythmia HypertensionAP / MI Cardiac Dysfunction Heart Failure Thromboembolism
  10. 10. Click to edit Master title style Incidence of cardiac events in pediatric cancer survivors Cardiovascular events in cancer survivors Patnaik et al. Breast Ca Res, 2011 Helena J. van der Pal et al. JCO 2012
  11. 11. Click to edit Master title style Cardiovascular Disease: Important cause of mortality in early breast cancer Years from diagnosis PercentMortality Other causes Patnaik et al. Breast Ca Res, 2011 CVD Breast cancer
  12. 12. Click to edit Master title style What have we learned?
  13. 13. Click to edit Master title style Shared risk factors for cancer and cardiac disease Modified from Farmakis D et al. Int J Cardiol 2016
  14. 14. Click to edit Master title style Johnson CB et al. Can J Cardiol 2016;32:900-907 Virani SA et al. Can J Cardiol 2016; 32:831-41
  15. 15. Click to edit Master title style Frequent coexistence of cardiac problems in cancer patients Oncologic disease Cardiac disease Courtesy, Dr. Cardinale
  16. 16. Click to edit Master title style Cardiac Disease & Risk Factors In Older Cancer Patients Cancer Site Patients (n) CAD (%) CHF (%) HTN (%) DM (%) Prostate1 185106 4.0% 20% 35% 14% Breast2 48353 5.0% 34% 77% 29% Lymphoma3 6388 2.1% 28% 73% 32% Colorectal4 1966 11% 0.2% 41% 13% CAD = coronary disease; CHF = congestive heart failure; HTN = hypertension; DM = diabetes mellitus 1. Keating et al. European Urology 2013;64:159-166 2. Doyle et al. Int J Radiation Oncology Biol Phys 2007;68:82-93 3. Hershman et al. J Clin Oncol 2008;26:3159-65 4. Hawkes et al. Eur J of Cancer 2011;47:267-76
  17. 17. Click to edit Master title styleEvolution of Cancer Therapy Anthracyclines 1970s Trastuzumab 1990’s Anti-VEGF Therapy 2000’s Proteasome inhibitors 2005 Checkpoint inhibitors 2010
  18. 18. Click to edit Master title style VSP Inhibitors Hypertension Heart Failure Thrombosis Her2 Targeted Therapies Cardiomyopathy Anthracyclines Radiation Heart Failure CAD Anti-metabolites (5FU) Ischemia Vasospasm Adapted from Moslehi, Cheng. Science Translational Medicine, 2013. Moslehi, NEJM. 2016. PI3K Inhibitors Hyperglycemia Metabolic ?Myocardial/ Arrhythmia BTK Inhibitors Ibrututinib: Arrhythmia/ Atrial Fibrillation MEK/RAF TKI Cardiomyopathy Drugs Affecting UPS Immunomodulators (IMiDs): thrombosis Proteasome inhibitors (e.g. bortezomib, carfilzomib): vascular HDAC inhibitors Arrhythmia Cancer Immunotherapies Myocarditis Cancer Survivorship CML TKIs Imatinib Dasatinib/Nilotinib/ Ponatinib: PAH/Vascular/ Atherosclerosis
  19. 19. Click to edit Master title style Oncologist Cardiologist The cardiologist! The patient developed cardiac disease ! The oncologist! The patient has a cancer! Who is responsible for patient care? Courtesy, Dr.Cardinale
  20. 20. Click to edit Master title styleThe birth of Cardio-Oncology A clinically based discipline focused on the cardiovascular health of cancer patients and cancer survivors A clinically based discipline focused on the cardiovascular health of cancer patients and cancer survivors
  21. 21. Click to edit Master title style Cardiotoxicity 360° management The cardio-oncologist Courtesy, Dr. Cardinale Health care providers focused on the prevention, early detection, management and recovery of cardiovascular function potentially resulting from cancer therapies Health care providers focused on the prevention, early detection, management and recovery of cardiovascular function potentially resulting from cancer therapies
  22. 22. Click to edit Master title style
  23. 23. Click to edit Master title style England Italy Israel Poland Japan Brazil Argentina Mexico Australia China Spain India Cardio-Oncology Clinics
  24. 24. Click to edit Master title styleWhat does a clinic offer ? Education of patients and health care providers Resident/fellowship training Preceptorship Multidisciplinary rounds Development of a collaborative research environment: basic/translational research and clinical/health outcomes research.
  25. 25. Click to edit Master title style 0rganization of Cardio-Oncology Program Okwuosa and Barac, JACC 2015
  26. 26. Click to edit Master title styleOttawa Cardiac Oncology Program Dr. Susan Dent Medical Oncologist Nadine Graham Research Assistant Jason Wentzell Pharmacist Dr. Jeffrey Sulpher Medical Oncologist Dr. Ellamae Stadnick Cardiologist Dr. Michele Turek Cardiologist Dr. Christopher Johnson Cardiologist Dr. Angeline Law Cardiologist Dr. Olexiy Aseyev Cardiac Oncology Fellow
  27. 27. Click to edit Master title style Does access to cardio-oncology clinics impact patient care?
  28. 28. Click to edit Master title style Seven (2008-2015) Years Experience Of The Ottawa Hospital Cardio-Oncology Clinic: Patient Characteristics & Clinical Outcomes (n=779) Kappel C, Johnson C, Rushton M, Aseyev O, Small G, Law A, and Dent S. Presented at GCOS, 2017; accepted for publication Current Oncology
  29. 29. Click to edit Master title style Presented at GCOS 2017; accepted for publication Current Oncology Seven (2008-2015) Years Experience Of The Ottawa Hospital Cardio-Oncology Clinic: Patient Characteristics & Clinical Outcomes (n=779) Kappel C, Johnson C, Rushton M, Aseyev O, Small G, Law A, and Dent S.
  30. 30. Click to edit Master title style Impact of a cardio-oncology clinic on oncology patient access to cardiology Patients referred to cardiology: •70% β blocker •87% ACEI •9% loop diuretic •2% MRA Yau et al., CCC 2017 abstract
  31. 31. Click to edit Master title style The Evolution of Cardio-Oncology
  32. 32. Click to edit Master title style Canadian Cardiac Oncology Network (CCON) www.cardiaconcology.ca
  33. 33. Click to edit Master title style Global Cardio-Oncology Summit (GCOS)
  34. 34. Click to edit Master title style
  35. 35. Click to edit Master title style Journal of Clinical Oncology, on line December 2016 NCCN Clinical Practice Guidelines in Oncology: Survivorship- Anthracycline-induced cardiotoxicity (2015)
  36. 36. Click to edit Master title style Circulation, October 2014
  37. 37. Click to edit Master title stylePublications in Cardio-0ncology Barac A et al. JACC 2015: 65(25): 2739
  38. 38. Click to edit Master title style1 Cardiooncologyjournal.biomedcentral.com JACC: CardioOncology coming in 2019JACC: CardioOncology coming in 2019
  39. 39. Click to edit Master title style
  40. 40. Click to edit Master title style The Evolution of Cardio-Oncology 1. Yeh ETH, Chang H. JAMA Cardiol. 2016;1(9):1066-1072; 2. Snipelisky D et al. Heart Fail Clin. 2017;13(2):347-359; 3. Barac A. et al. J Am Coll Cardiol. 2015; 65(25):2739-46; 4. Armenian SH, et al. J Clin Oncol. 2017;10;35(8):893-911; 5. Curigliano G, et al. Ann Oncol. 2012;23 Suppl 7:vii155-66. 6. Zamorano JL, et al. Eur Heart J. 2016;37(36):2768-2801. 1966 1977 1998 2007 2012 2014 2016 2017 Reports of anthracycline- induced cardiotoxicity Understanding that anthracycline-induced cardiotoxicity depends on the cumulative dose Reports of trastuzumab- induced cardiotoxicity 90 PubMed citations in “cardio oncology” Reports of hypertension, heart failure, and vascular occlusion with TKIs ESMO Clinical Practice Guideline published 812 PubMed citations in “cardio oncology” 37 cardio- oncology clinics in the US European Society of Cardiology Position Paper published ASCO Clinical Practice Guideline published
  41. 41. Click to edit Master title style Challenges • Better understanding how modern cancer therapies impact cardiovascular health • Early identification of cardiac risk – e.g cardiac imaging, biomarkers • Strategies to prevent cardiac damage – Primary and secondary prevention • Optimal cardiovascular drugs to manage cardiac damage • Surveillance and monitoring – Imaging, frequency and duration • Lifestyle modification
  42. 42. Click to edit Master title style “Active participation in growing cardio- oncology networks may provide critical clues on potential solutions for these challenges and open horizons for growth” Opportunities Okwuosa and Barac, JACC 2015
  43. 43. Click to edit Master title style ICOSICOS ChinaChina ArgentinaArgentina PolandPoland IndiaIndia International Collaboration ItalyItaly IsraelIsrael SwitzerlandSwitzerland l UNDER CONSTRUCTION BrazilBrazil SpainSpain MexicoMexico JapanJapan AustraliaAustralia
  44. 44. Click to edit Master title style RESEARCHRESEARCH 198 registered CT on diagnosis and treatment of cancer related cardiac dysfunction clinical trials.gov
  45. 45. Click to edit Master title style • Improvement in cancer therapies has resulted in long term survivors who may be at risk of cardiotoxicity. • Individuals with heart disease may develop cancer and require potentially cardiotoxic cancer therapy. • Close collaboration among HCP’s is needed in order to provide the best cancer care while optimizing cardiovascular health. • The establishment of cardio-oncology clinics/programs provides the framework for optimizing clinical care delivery, education and research and promotion of survivorship Key Messages
  46. 46. Click to edit Master title style Thank-you!

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