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Melanie Cole: Cancer is the second leading cause of death in the United States right behind heart disease. While new therapies are helping more people survive cancer, they can also cause other issues such as heart problems. My guest today is Dr. Jay Rubenstone. He's a cardiologist with Lourdes Cardiology. Explain a little bit about the field of cardio-oncology. What's the evolution of it? How long has it been around?

Dr. Jay Rubenstone, DO: First of all, thank you for having me speak. Cardio-oncology in a sense has been around for decades but has now taken on a more formal effect. I would characterize it as a collaboration between cardiology and oncology. What really has happened is the crossover of survival of cancer patients long enough due to the success of current trends in oncology that during their lifetime they may experience the cardiac effects of their therapy. Let me say that in 2022, we will have 18 million cancer patients in the United States and I characterize as others do it, cancer survivors, somebody existing from day one of the diagnosis. This includes not only adults but adult survivors of childhood cancer. More people now as they age after surviving their cancer may crossover and now actually suffer the effects of cardiotoxicity. Cardiotoxicity really is the effects on the heart from chemotherapy and radiation. Our job and collaborative effect with oncology is to diagnose this as early as possible, prevent it if possible, monitor for the onset during treatment as well as manage the treatment in the acute setting, short-term and long-term the effects on the heart. Long-term can be decades later. The primary purpose is to successfully help patients get through their treatments. That’s the short-term primary purpose. With increasing age and survival, more patients will begin to suffer their cardiac effects due to the cardiotoxicity of chemotherapy and radiation than their actual cancer. I want to emphasize that the onset of cardiotoxicity is relatively low. Having said that, it exists and it must be monitored at all times with regards to the possible effect on any given patient.

Melanie: What are some of those effects as far as chemotherapy or radiation? How do they affect the heart?

Dr. Rubenstone: When you talk about cardiotoxicity, first the prototypes of cardiotoxicity are the standard treatments for lung cancer, the anthro recycling types as well as breast cancer. There’re two types of cardiotoxicity. One can be permanent, one is characterized as possibly not permanent, but basically, we’re talking about the effects on the heart and the heart muscle itself is affected by the toxic effects of the chemotherapy can in a sense poison the heart muscles so that it no longer contracts normally. The common term is cardiomyopathy. In this case, it really translates to congestive heart failure with regards to any individual patient. The same chemotherapy can affect the lining of the heart called the pericardium, caused pericarditis, it can cause an inflammatory reaction of the heart muscle called myocarditis, arrhythmias or irregular hearts as well as affect the coronary arteries and accelerating the onset of coronary artery disease, the type that can lead to heart attacks. With regards to radiation, the onset is much later, but the effects of radiation can affect the heart valves, the lining of the heart, the heart muscle itself and the coronary arteries. The toxicity itself is relatively rare, but again, what we now know is that the effects can be acute and some of the agents used by oncology can be short-term onset and long-term. We have to monitor certain patients, particularly those that have received radiation for decades, even in adulthood when they're survivors of childhood cancer.

Melanie: In cardio-oncology, does the patient assessment begin before the start of chemotherapy or radiation by estimating that risk of cardiotoxicity? How do you begin this delicate balance of treatments starting with preventing some of this cardiotoxicity as it happens?

Dr. Rubenstone: That’s very interesting. If you said who is at risk, I would say everybody receiving chemotherapy or radiation. Those that are increased risk it’s interesting that we have found the risk factors that make people more prone to this susceptibility of toxicity are very much the same that we treat every day as cardiologists to prevent coronary artery disease or congestive heart failure, such as tobacco use, hypertension, high cholesterol, diabetes, obesity, sedentary lifestyle. When a patient begins chemotherapy, oncologists now are using certain studies which I can on in a minute to look at the heart to see if there's any preexisting issue or if the heart is normal. Depending on some of the agents used, there are protocols in place now for monitoring. Depending on the chemotherapeutic agents, they can be every single month, every several treatments, every treatment or it can be based on the cumulative dose that the patient receives. That's how we begin to monitor. One of the exciting areas is the evolution of strain echo, which now allows us to attempt to look at the earliest onset of cardiotoxicity before it has been obviously seen in prior studies. That's one of the most exciting things and maybe a tipping point that in cardio-oncology the start of this huge collaborative effect, which you can say has been there for decades, but has now evolved in quite an academic field.

Melanie: That leads me into my next question beautifully. What types of care are involved in cardio-oncology? Does it require management of several aspects of care and improve coordination between providers?

Dr. Rubenstone: Absolutely. Before I answer that, I would like to touch upon how we monitor and look for the onset of this. First, I mentioned those people that are at an increased risk and it’s those people with the common risk factors for other forms of heart disease I mentioned. Also, if a patient is receiving multiple agents, if a patient is receiving a chemotherapeutic agent in combination with radiation tends to make them more susceptible to the onset of cardiotoxicity. In the past, echocardiography was the mainstay of looking and monitoring for cardiotoxicity. For example, a patient may have a baseline echocardiogram at the beginning of their therapy. Let's say the grossly ventricular function, this is the term we use for how well the heart contracts, was normal. Periodically they may be assessed by echocardiography to see if there's any onset of cardiotoxicity. Unfortunately, at that time, if there was cardiotoxicity, you might say that the horse is out of the barn, meaning we would see the myocardium already would start to show the effects if not gross over congestive heart failure. The patients were treated, but you might say already that they were on their way to significant cardiotoxicity and possibly a poor outcome. Other studies were dated studies, meaning marker scans, also CAT scans, the problem there is CAT scans of monitoring exposes patients to additional radiation. The conventional MRI and dated studies also can be expensive. With the onset of strain echo, it's in addition to the echocardiogram. If a patient underwent an echocardiogram in the past and had the addition of strain, they would not know the difference. It's just something else we acquire. What's very exciting is it enables us to look at the earliest form of cardiotoxicity before the heart starts to grossly suffer.

What do we do at that point? There's a number of things. First of all, we become very aggressive in monitoring the lifestyle issues such as tobacco use, hypertension, high cholesterol, diabetes, etc. This should be done routinely in any patient that is going to receive radiation or chemotherapy, but at the onset, if we find early onset, right now depending on the drug we’re using, there are standard medications that we can begin. It’s interesting because the medications that we can begin to use are the very same medications that we have used in congestive heart failure patients for decades of any cause. Anybody that has impaired contractibility of the chambers of the heart, we have been using a pretty standard cocktail of medications such as beta blocker, ACE inhibitors, angiotensin receptor blockers, spironolactone and drugs like that for decades. Where we are right now is very interesting because literature comes out every day from studies showing how do we apply these medications. It may not be as we have conventionally done in the past because some of the chemotherapeutics may respond better to the beta blockers being started first versus the ACE inhibitors, but the treatment is interesting in that it is the same medications that cardiologists have been comfortably using for decades, along with we continue to monitor the patient.

In collaboration with oncology, and this is the most important collaborative part of cardio-oncology, knowing that the patient may have early toxicity, the oncologist has options to either change to other therapeutic agents, possibly modify the dose, possibly hold the dose and so the cardiotoxicity is less and then restarting the dose so it gives him a number of options to apply to this patient along with early medical therapy from our standpoint and very early on in my talk today. The primary consideration is to get patients through successful their chemotherapy because as you can imagine, the bottom line is these are patients with underlying cancer and they need their chemotherapy, they need their radiation, to successfully combat their problem.

Melanie: Beautifully put. You make it so understandable, so wrap it up and summarize it for us. What would you like cancer patients to do to be a healthy survivor? What questions about cardiotoxicity and cardio oncology would you like them to know? What steps do you advise them to take to protect their heart?

Dr. Rubenstone: I would say the first thing is something I would tell a 16-year-old teenager if he said what should I do at my age to prevent me from having heart disease. I would tell him not to smoke. As he gets older, if he has high blood pressure, to be sure that it's treated and controlled. If he becomes a diabetic, then he has to have his diabetes extremely well controlled, and if he's obese and it's type 2 diabetes to lose weight and exercise. Those patients who acquire who have not done that throughout their years, it is imperative that they do it at that point in time. No different than patients who I discover with the run of the mill coronary artery disease who may have been smoking and so forth than I tell them at that point in time it’s time to stop smoking, lose weight, have your diabetes and hypertension controlled. That is absolutely imperative. The second thing, maybe the most important thing I want to emphasize to cancer patients, no cancer patient hearing this talk should ever refuse to have chemotherapy because of the fear of cardiotoxicity and that’s something I want to emphasize because it’s always existed. Their susceptibility may literally be more now than before because of the success of their cancer treatment and the ability for them to live longer. Now more than even we are able to detect it early and possibly prevent it. I want to reemphasize and I want to reiterate one of the most important things that I want to say to people who are listening to this, those who develop or may have cancer, by no stretch of the imagination should this ever deter them from having radiation or chemotherapy.

Melanie: Thank you so much for sharing your expertise. What a wonderful segment and what an interesting field that you're in. Thank you so much for explaining it so very well for us. This is Lourdes Health Talk. For more information, please visit lourdesnet.org. That’s lourdesnet.org. This is Melanie Cole. Thanks so much for listening.