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.
Pregnancy and Breastfeeding Dental Considerations.pptx
Cancer and Heart Disease - Where the two intersect
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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. 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
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CANCER STATISTICS
IN CANADA 2015
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““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
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
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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
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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
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What have we learned?
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Shared risk factors for cancer and cardiac disease
Modified from Farmakis D et al. Int J Cardiol 2016
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Johnson CB et al. Can J Cardiol 2016;32:900-907
Virani SA et al. Can J Cardiol 2016; 32:831-41
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Frequent coexistence of cardiac problems
in cancer patients
Oncologic
disease
Cardiac
disease
Courtesy, Dr. Cardinale
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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. 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
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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. 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
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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
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England
Italy
Israel
Poland
Japan
Brazil
Argentina
Mexico
Australia
China
Spain
India
Cardio-Oncology
Clinics
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.
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0rganization of Cardio-Oncology Program
Okwuosa and Barac, JACC 2015
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
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Does access to cardio-oncology clinics
impact patient care?
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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
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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.
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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
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The Evolution of Cardio-Oncology
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Canadian Cardiac Oncology
Network (CCON)
www.cardiaconcology.ca
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Global Cardio-Oncology Summit (GCOS)
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Journal of Clinical Oncology, on line
December 2016
NCCN Clinical Practice Guidelines in Oncology: Survivorship-
Anthracycline-induced cardiotoxicity (2015)
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Circulation, October 2014
37. Click to edit Master title stylePublications in Cardio-0ncology
Barac A et al. JACC 2015: 65(25): 2739
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Cardiooncologyjournal.biomedcentral.com
JACC: CardioOncology coming in 2019JACC: CardioOncology coming in 2019
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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
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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
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“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
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ICOSICOS
ChinaChina
ArgentinaArgentina
PolandPoland
IndiaIndia
International
Collaboration
ItalyItaly
IsraelIsrael
SwitzerlandSwitzerland l
UNDER CONSTRUCTION
BrazilBrazil
SpainSpain
MexicoMexico
JapanJapan
AustraliaAustralia
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RESEARCHRESEARCH
198 registered
CT on diagnosis
and treatment
of cancer
related cardiac
dysfunction
clinical
trials.gov
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• 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
Cardiovascular side effects of modern cancer therapy include arrhythmias, ischemia, myocardial infarction, contractile dysfunction, thromboembolism, and hypertension. Thromboembolism and hypertension are more common with newer biological agents.
Arrhythmia and induction ischemia is generally not problematic because it is an acute effect that can be solved by slowing down an infusion or stopping the drug. This is not the case with contractile dysfunction and especially late contractile dysfunction, which can potentially lead to heart failure.
Presented at Canadian Cardiovascular Society Meeting, Montreal Oct 2013