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Melanie Cole (Host):  Our topic today is cardio-oncology and here to tell us about this very specialized field, is Dr. Carrie Lenneman. She’s a cardiologist who specializes in cardio-oncology at UAB Medicine. So, Dr. Lenneman, explain a little bit about cardio-oncology. What’s the evolution of it? How long has it been around?

Carrie Lenneman, MD (Guest):  It has been around since probably 2008 is when the foremost of the cardio-oncology meetings began to develop around the country and it’s a field that has grown because cancer patients are surviving longer, and they are developing cardiac issues as they are becoming cancer survivors. We know that after recurrent malignancy, that cardiovascular disease is the second leading cause of death in cancer survivors.

Melanie:  So, with chemotherapy, radiation therapy, that can put patients at risk for this variety of cardiovascular complications. How do you identify the needs of these cancer patients and what are some of the late and long-term effects on the heart from cancer treatments?

Dr. Lenneman:  So, we will identify high-risk patients; patients that have cardiac risk factors going into their chemotherapy and individuals that have underlying high blood pressure, high cholesterol, diabetes, are at higher risk for developing cardiac issues from their cancer treatment, both chemotherapy and radiation. And we work with their oncologist to identify these high-risk individuals and we do know that some medical therapy including beta blockers, ACE inhibitors and statins can be cardio protective for these patients undergoing chemotherapy and radiation. And so, in certain individuals, we will start them on these medications to help prevent any kind of heart failure or cardiac problems during their chemotherapy treatment. We routinely will do cardiac screening, prior to them starting treatment and then during their treatment course, looking at cardiac echoes which will allow us to see their cardiac function, how their valves work, and we will continue to follow that through their treatment course and even into survivorship.

Melanie:  So, you are estimating their risk for cardiotoxicity before they even start some of their treatments?

Dr. Lenneman:  Yes, we do. And there is a cardiotoxicity sort of risk assessment tool that we use to help sort of identify low, intermediate, and high-risk patients.

Melanie:  What types of care are involved in cardio-oncology? Does it require the management of several aspects of care? You have already mentioned with the oncologists and you are a cardiologist and I would imagine there is radiation oncologists involved. Speak about the improved coordination of care between you providers and how you are all involved together.

Dr. Lenneman:  Yes, we think of cardio-oncology as sort of an integrated care model where we do actually integrate a patient care with different disciplines. So, exactly right. We work with a medical oncologist to better understand the best chemotherapy regimen that will be optimal for this patient. We will talk to the radiation oncologist to figure out is this patient going to need radiation and how do we plan cardiac monitoring incorporating their radiation exposure and then again, we also talk with the pathologist to better understand how aggressive is this tumor and this cancer and therefore do we need to be more aggressive with the chemotherapy and take a little more risk of cardiac issues knowing that we need to be aggressive for this cancer treatment. So, it very much is an integrated discipline where we all will sort of discuss a patient’s underlying cancer and then plan sort of the best optimal treatment for that cancer as well as looking at their cardiac risk factors and how we need to mitigate any kind of potential cardiac damage with the treatment that they are going to receive.

Melanie:  Do you see down the line that there will be improved methods Dr. Lenneman, developed by radiation oncologists to reduce the cardiac side effects of radiation therapy specifically?

Dr. Lenneman:  We have already seen that in the last ten to fifteen years. I mean there are newer technologies that are coming out that are minimizing the cardiotoxicity risk. They currently will use different techniques such as breast holds or using CT-guided therapy to sort of minimize the exposure to the heart during radiation therapy. So, yes, there are ongoing techniques that are used and then we continue to sort of advance that with newer techniques and in some cases, there are actually on-going interventional trials. We are looking at different medications that could be cardioprotective during radiation treatment as well.

Melanie:  And we are backing up for just a second Dr., tell us a little bit about some of the risk factors for cancer therapeutic related cardiac dysfunction. What are you looking for?

Dr. Lenneman:  Well, we know that like I mentioned earlier, we know patients that have underlying risk factors, so high blood pressure, high cholesterol, diabetes, are risk factors for developing cardiac issues during cancer treatment. We also will factor in what kind of chemotherapy treatment a patient is going to receive because certain chemotherapies put patients at different risk. We know some chemotherapy such as a class of anthracyclines put a patient at higher risk for heart failure versus we know different agents like taxane agents may put a patient at higher risk for arrhythmias. So, we can also help a patient understand early on looking at what chemotherapies they may be treated with, what kind of cardiac symptoms to be looking out for during their treatment course.

Melanie:  Would that change or alter their treatment course depending on what you figure out?

Dr. Lenneman:  Sometimes, if a patient already has known cardiac issues such as a low ejection fraction meaning that they have already sustained some heart muscle damage. In some cases, we will have a multi-disciplinary discussion with their oncologist, their radiation oncologist and maybe even their surgical oncologist to say this person probably is already at too high of a risk to potentially expose them to a certain class of chemotherapy, if they already have significant cardiac dysfunction or cardiac issues at the beginning, before they are even treated.

Melanie:  Looking forward to the next ten years in the field, what do you feel will be the most important areas of research. Give us a little blue print for future research into your specialized field.

Dr. Lenneman:  I definitely think we are making headway in learning what kind of medical therapy can be cardioprotective for patients going through chemotherapy. So, we are making headway to better understand which regimens will improve cardiac outcomes and hopefully prevent heart failure, heart arrhythmias and coronary disease going forward for these patients. We are also trying to keep pace with the oncology world as new drug therapies are coming out such as these new immune check point inhibitors. We are learning more about the cardiac effects of these new drugs that are being more widely used in oncology. So, I think we are also going to learn a lot more about check point inhibitors and the cardiac issues that are associated with it and hopefully how to better treat and how to identify which patients are going to have the potential cardiac issues related to check point inhibitors.

Melanie:  You can I discussed a little bit off the air, that you are one of the only known cardio-oncology clinics in the state of Alabama. So, are you doing some treatments or research at UAB that other physicians may not be aware of, especially in your field?

Dr. Lenneman:  Yes, we are developing cardio-oncology protocols here at UAB that help us better understand which patients being treated with immune check point inhibitors as well as anthracyclines that can cause cardiotoxicity and how best can we identify which patients are at high risk. So, we are doing research here at UAB that is going to help our cardio-oncology community in the future.

Melanie:  Wrap it up for us, in summary Dr., tell other physicians what you would like them to know about the field of cardio-oncology and if they are considering adding a clinic; what you would like them to know about this specialized field at UAB Medicine.

Dr. Lenneman:  We would like providers to know that cancer patients are surviving longer and now they are at risk of developing cardiac complications as they go through their chemotherapy and enter into survivorship. And we would like providers to be aware of the possibilities of different consequences of their chemotherapy and radiation and how it’s important to identify those problems early and even potentially prophylactically in a high-risk patient, they probably should be seen by a cardio-oncologist at the beginning so that we can help mitigate any cardiac issues from even occurring.

Melanie:  Thank you so much. What in interesting field that you are in and what an interesting topic. Thank you so much for sharing your expertise with us today. A community physician can refer a patient to UAB Medicine by calling the Mist line at 1-800-UAB-MIST, that’s 1-800-822-6478. You’re listening to UAB MedCast. For more information on resources available at UAB Medicine, you can go to www.uabmedicine.org/physician that’s www.uabmedicine.org/physician. This is Melanie Cole. Thanks so much for listening.