Getting To The Heart of Cancer Survivorship

[00:00:03] This is The Good News About Cancer. I'm Dr. Chuck Ryan. And I'm Dr. Alicia Morgans. We're oncologists, and we've spent our careers working to understand cancer. We believe that there's more progress now in research and treatment than ever before, and we're here to share that with you. In each episode of this show, we talk with one of our colleagues about a promising development in oncology. We'll break down what's new, why it matters, and how it points the way forward.

[00:00:27] And so it's really important for physicians to recognize these new issues that didn't arise before, and us as a community to both recognize what the toxicities are, what the unwanted side effects are, but also how we go about quickly diagnosing these and potentially treating them. Alicia, you hold the title of Director of the Adult Survivorship Program at the Dana-Dana-Farber Cancer Institute Cancer Institute,

[00:00:57] so I can really think of nobody else in the world who might be better at describing for our listeners what exactly survivorship is, and why is it important. Well, thank you for that. And importantly, cancer survivorship actually starts from the moment of diagnosis with cancer and extends through the duration of someone's life. It is really the study and the care of people after that diagnosis, whether they are living after being cured from their cancer,

[00:01:23] or they're living during treatment, or they're living with their cancer in an incurable state for the rest of their lives. And cancer survivors live both with the complications of the cancer itself, as well as the complications and after effects of all of the treatments that they may have received. Those effects, of course, can be on their heart or on their lungs or on any part of them.

[00:01:48] And it's important for us to understand all of those effects so that we can best care for people as they live as cancer survivors. That's a great definition and really, I think, underscores the importance of this growing medical specialty. Let's call it that. You know, the American Cancer Society estimates that there's about 19 million cancer survivors in the United States right now. And the issues that many cancer survivors have are unique because of the treatments they've received,

[00:02:16] whether it's chemotherapy, hormonal therapy, radiation therapy, immunotherapy, etc. So the topic that we're going to focus on today is a very important one. It's the heart. And we're going to talk to a cardiologist who specializes in the hearts of individuals who are being treated for and have been treated for cancer. That's right. We talked to my former colleague and a friend of both of ours, Dr. Javed Moslehi. He's a cardiologist at the University of California, San Francisco,

[00:02:42] who specializes in the cardiovascular health of cancer patients and cancer survivors. He is also the chief of UCSF's cardio-oncology and immunology section. Hi, Javed. Thank you so much for being here. Welcome to the Good News About Cancer podcast. Hey, Alicia and Chuck. It's really good to see you guys and great to be here.

[00:03:12] Great to have you. Well, you know, Javed, I would love if you could share with us a little bit about the history of cardio-oncology. First, start out by telling us what is cardio-oncology? Why should we care about it when we think about progress and updates in cancer care? And then if you could just briefly give us a bit of an understanding of where it's been and where we are now in terms of cardio-oncology. I think it's important for us to think of cardiovascular issues and put that in context.

[00:03:42] It turns out the number one and number two cause of death in any society is heart disease or cancer. It's really the two of them that really define many deaths that we see in America and other places. And a lot of other things come almost secondary. And so the cardiovascular issues is important because it is one of the two, the other one being cancer-leading cause of death.

[00:04:08] And in some ways, us appreciating cardiovascular sequela in cancer patients is important to put that in context in that now that you're offsetting cancer, now that you're treating cancer successfully, we just have to think about cardiovascular issues that come into play. When you think of therapies, really there is a long laundry list of therapies that have effects on the heart. Some of the drugs affect the vasculature. Some affect the heart.

[00:04:37] Some affect the pericardium, which is the fluid sac around the heart. And it's just really important now as physicians for us to be cognizant of these potential issues as we start patients on the therapies. So in many ways, it's a very positive thing. It's the very success you as oncologists have had in treating cancer that really underlies cardiovascular issues that we now think about.

[00:05:06] Because we didn't care about that before because cancer was number one thing. And it's still the number one thing. But there's so much better success in treating patients that we think of other areas and cardiovascular is right at the top in terms of potential other things that patients may be affected by.

[00:05:26] You know, let's dial back and go back many decades now with various cancer treatments that have been subsequently proven to have toxicities or challenges to the heart later in life. And what comes to mind for me is, of course, adriamycin chemotherapy for breast cancer and many other cancers, lymphomas, etc., as well as the sort of pediatric oncology group, which I think, you know, we've made so much success in so much progress in curing kids with cancer that now they're adults.

[00:05:56] Was that one of the areas where the cardiology community began to see that there was an issue or there was an opportunity to improve the lives of cancer survivors? Yes. So really, I think the people who have led this cardio-oncology field, all the pediatricians, specifically at the Farber, there was Steve Salen and Steve Lipchulz, tried to work together on the pediatric patients.

[00:06:22] A lot of the kids with cancer received adriamycin, which had led to fairly good success with treating cancers. That's a chemotherapy drug. That's a chemotherapy drug. As well, they got radiation, which again led to survival in patients. And these kids with cancer, many of them survived. And that was the great news. The bad news were with these fairly traditional therapies,

[00:06:50] patients would grow up to be 25 and 30 long after they had their cancer 20 years later and have heart disease. And almost everybody could tell you that 25-year-olds are not supposed to have heart disease. And that was really the beginning of us appreciating the field as a whole. It was our pediatric colleagues putting in place strategies to help offset these cardiovascular issues.

[00:07:19] And for example, with lymphoma patients, you cut the radiation. And it turns out with adriamycin, you did quite well. And so that, I would argue, was the beginning of the field very much in the pediatric realm. Although what changed then was the explosion of therapies in the adult oncology space, many of which were targeted, but which had cardiovascular sequelae. So, Javed, we've talked about other successes in cancer, including things like Gleevec.

[00:07:48] We've talked about immunotherapy, immune checkpoint inhibitors. And I know as I started to learn how to use these agents, I became acutely aware of the rare but real potential cardiovascular effects associated with these, which are essentially transformative drugs in our field. I wonder if you can share, just as an example of success, your experience with this as just an example of our understanding as a field that, hey, there are cardiovascular issues here,

[00:08:19] then understanding not only just how to respond to that effect, but how to be early responders or even to think proactively about how do we monitor patients so that they don't find themselves in a catastrophic situation and how this cancer success has actually led to what I view as a cardio-oncology success, where we all work together as a team to prevent where we can and to detect really early complications that may be meaningful if we need to.

[00:08:48] Yeah, so I think the discussion about immunotherapy is very timely. First of all, I can't fathom the incredible success that's come about from immuno-oncology drugs, namely immune checkpoint inhibitors. Cancers that were considered hopeful are now treatable. For example, malignant melanoma or metastatic melanoma, which is an aggressive form of skin cancer. We now have 10-year survival.

[00:09:17] 10 years later, 43% of the patients being alive and cancer-free. That's unfathomable with this skin cancer melanoma. And we have success stories like former President Jimmy Carter, who at the age of 90 had metastatic melanoma, skin cancer that went to his brain and subsequently was cancer-free. So I think it's really important to put that in context.

[00:09:43] But we, as well as others, noted that especially when we combine immunotherapies, a small but significant number of patients, very small, can have inflammation, friendly fire of the immune system that can go to the heart. And we had observed this in other tissues. For example, you can have skin inflammation, dermatitis,

[00:10:07] or colon inflammation in the form of colitis, which are fairly treatable. But for this rare but real signal for myocarditis, inflammation of the heart, it can be deadly. And so it's really important for physicians to recognize these new issues that didn't arise before. And us as a community to both recognize what the toxicities are,

[00:10:35] what the unwanted side effects are, but also how we go about quickly diagnosing these and potentially treating them. Right. It's a good example. When these drugs first came out, we didn't really understand that they could affect the heart. And I think I was involved in a few cases where it was sort of a tragic outcome. But now we know we want to get a cardiac workup in before we even start them in many cases. And that's the arc of progress in our field.

[00:11:02] Perhaps I should also underscore another new dimension to cardio-oncology that's come about. A lot of times we think of drug toxicities. But one thing we and others are appreciating is that once you treat the cancer, a lot of patients have heart disease. And one possibility is that it's the drugs. But another real possibility is our growing appreciation that common risk factors predispose to both.

[00:11:32] And for example, age is a risk factor for both cancer and heart disease. I mentioned that. But now we realize things like obesity, like high cholesterol, may not only be important risk factors for cardiac disease, but also cancer. And it really affords us the opportunity to really help all patients. It's a real public health issue that if the number one and number two cause of death,

[00:12:00] cancer and cardiovascular disease have common roots, that we sort of snip those risk factors right at the butt from early on. For example, how great it would be for us to treat obesity, where we not only help with cardiac issues, but also cancer issues that we know come about from obesity. And now we're appreciating this in various cancers with diabetes and also high cholesterol. And so it's really important.

[00:12:29] And so when I think of cardio-oncology, it's not just the cardiotoxicities, but also these common risk factors and the opportunity for us to identify these risk factors and really treat them aggressively. It's a really interesting observation. And in my world of treating prostate cancer, we have epidemiological data, I think we've talked about before on the podcast, around diet and exercise and how healthy lifestyle practices in terms of diet and exercise

[00:12:58] after a diagnosis of prostate cancer is associated with a reduction in the risk of dying of prostate cancer. And when I talk to patients about this, I'll say, you know about the Mediterranean diet, you probably know what a heart-smart diet is. And if you don't, we'll talk about it. But that's pretty much the prostate-cancer-smart diet as well. And we don't say that because we're trying to keep their hearts healthy so that they can give more treatment. It's actually potentially an intrinsic or associated way

[00:13:27] to mitigate or reduce the risk of that particular cancer in accelerating that person's death. So it's just the flip side, I think, Javid, of what you just said, which is if the risk factors are very similar, and I want to hear more about that, sort of the treatments can sometimes overlap as well. When you talk about the risk factors being similar, are you talking mostly about inflammation, obesity, and those types of things, cholesterol,

[00:13:53] is high cholesterol a risk for developing various types of cancers, that kind of thing? Yeah. So Alicia and I overlapped at the Farber 12 years ago, but then we also overlapped at Vanderbilt 10 years ago, at least 10 years ago. And under Alicia's leadership, realizing that people work in their own silos, right? Urologists, radiation oncologists, and cardiologists are all taking care of prostate cancer patients.

[00:14:21] How can we bring everybody together to better our patients and what we can do for our patients? And this especially is important for prostate cancer survivors. So in the U.S. alone, we have 20 million Americans who are cancer survivors. That's 6% of the U.S. population. About 4 million of those are prostate cancer survivors. And another 4 million are breast cancer survivors.

[00:14:46] And what many people realize is, again, study after study, for the cancer survivors, yes, the cancer coming back is absolutely paramount and critical to identify. But for many of these patients, the number one cause of death is actually heart disease. And how can we think of ways to identify and prevent heart disease? But also, if there are common risk factors, how can we identify those risk factors?

[00:15:16] And we came up with a very simple acronym, ABCDE's of cardiovascular wellness in cancer survivorship. Let's hear it. ABCDE. Yeah. So A is awareness of cardiovascular disease. How does cardiovascular disease present? It's different in men and women. Assessment of cardiovascular disease and risk factors is another A. A also presents aspirin, which in some patients,

[00:15:45] it's an important tool to prevent heart disease. B stands for blood pressure, knowing what your blood pressure is and treating it. C stands for cholesterol and also cigarettes. Two important risk factors for both heart disease, but also probably cancer. D stands for diabetes, what your sugars are, what your diet is. And in this particular case with survivors, what the dose of therapy is. And finally, E stands for exercise,

[00:16:14] knowing that exercise is not only improves your heart, but also probably good for your cancer. And some strategies that we have in cardiology, for example, echocardiography or EKG in select individuals to detect cardiac disease. I'm happy to report this is now part of the NCCN as a guidelines, which is these are the guidelines that we have for all patients, including all cancer survivors. And these are risk factors that you can identify

[00:16:43] or areas you can pay attention to that prevent heart disease down the road. So for those who aren't aware, the NCCN guidelines are the predominant set of guidelines in the United States, at least, that clinicians follow. And many therapies have to be in the guidelines to be administered for insurance coverage, et cetera. And so if you're a cancer patient out there and you're listening, you can, next time you see your oncologist, you can ask about the ABCDEs. And if they look confused,

[00:17:13] you should say, well, it's in the NCCN guidelines. So they then can be able to look it up. So I just want to pull on one thread that you mentioned, Javed, which is the number of people living after a diagnosis with cancer or of cancer in the United States is over 20 million people. And many of those people are going to live beyond a diagnosis being cured. Others will live with that diagnosis for the rest of their lives. And some, because of the treatments that we have,

[00:17:42] will live very long time, even with cancer. And although it is terrible to get a cancer diagnosis, one of the pieces of good news that we have is that as people come into care and become cancer survivors, they can learn more about the rest of themselves and have an opportunity to improve the rest of their health, particularly their cardiovascular health, with this knowledge and with the support that teams in survivorship clinics and in their general oncology clinics

[00:18:11] can actually provide. And cardio-oncology plays a huge role in bringing that to the fore of people's minds. And then intervening in ways that can be safe, even as patients potentially continue to get cancer-directed treatments. And I couldn't agree with you more. Again, one of the things I want to emphasize is people generally hear cardio-oncology and think of cardiovascular toxicities of drugs. But it's really about cardiovascular wellness. It's really about identifying risk factors

[00:18:41] that may lead to cardiac disease down the road and preventing them. This is something we've learned in cardiology many years ago. It's unfortunate that we wait until people have heart attacks and then start among four different drugs. But in many cases, we can prevent a lot of cardiac diseases if we identify the risk factors early and treat those risk factors early. And this is particularly important to our cancer survivors. many, many, many people

[00:19:10] for whom cancer is an afterthought and have successfully either lived with their cancer with treatment and completely doing well or are true survivors in that there's not a bit of cancer in their body left. So, Javid, we're talking about the importance of cardiology in cancer care and oncology. How big of a footprint does cardio-oncology have in the world training to become cardiologists now?

[00:19:40] Are they rotating through and learning about cardio-oncology? Is it part of the big meetings that you all go to? Like, how much of an impact are we seeing given all the numbers you talk about with the 20 million cancer survivors in the country right now? How big of an impact is it happening on cardiology which is arguably a medical specialty that really affects all of us? It's become the new clinical frontier in cardiology and that is because there's no other scenario in which we are seeing an explosion

[00:20:10] of new patients, right? If you look at the data over the last 10 years and how successful you oncologists have been in treating cancer patients, there's no other place in cardiology where we have a higher increase or explosion of new patients and it's become an issue for us to think about like how do we best take care of patients? There's no way we as cardiologists can see all those patients.

[00:20:39] It really underscores the importance of teamwork, primary care physicians, oncologists, nurse practitioners within oncology to have things and some of the things like the ABCD checklist I brought up is really important because you can't expect to see a cardio-oncologist but if everybody has the checklist, if every patient has the checklist, they feel empowered to say, hey, what was my blood pressure? What was my cholesterol?

[00:21:08] When they see various physicians. But I also want to sort of caution that it is important to take each case by case. Every patient is very different although it's perfectly fine to think about more global care for patients. Because of the success you have had as oncologists, we now bring in other doctors to care for the cancer patient and cardiovascular issues is one aspect of it but it also

[00:21:38] has made us as physicians better doctors because for me I don't live in my own silo and only see cardiac issues. I learn from you guys about what are the new treatments, how should we think about new treatments and how can we help patients. I always tell my patients two things. These are cancer patients who come through the door I see. My number one goal is to empower your oncologist to give you the best treatment

[00:22:07] there is. And the number two thing is it's really critical that your doctors talk to each other. It's when I have the oncologist's cell phone and I call them I feel okay to ask a question about a new treatment that we may not know about. But it's really the education that we can do and it's the interaction between the physicians that I think ultimately leads to better care for our patients.

[00:22:37] Well, Javed, I so appreciate the time that you've taken today to go through all of this. It's no small task to think through where we've been and where we're going and you did a great job. So I just want to say thank you and keep up the great work. It's a pleasure to see it all come through. Yes, I agree with that. Keep up the good work. Thank you again. Thank you guys so much for having me on this show and it's been a real pleasure to interact and work with you over the last

[00:23:07] several years. You know, it's a growing field of medical specialty that's based on cancer survivorship here, cardio-oncology. And what was striking to me among the many great things he said was how cardio-oncology is now becoming a very popular and sought-after specialty for people taking on careers in cardiology. And that speaks

[00:23:37] to the need. It speaks to the number, the 19 million cancer survivors out there living in the world. It speaks to the fact that there's something to do for those patients and something to offer those patients which I think is really significant. I completely agree. I think especially as the treatments that we have are becoming more complicated and we're still learning about the effects that some of our newer therapies might have, it's so critical for us to develop the workforce of clinicians and

[00:24:06] scientists who can help us understand what those therapies do in the body, how they affect the rest of the body outside of the cancer, and how to take care of those patients, particularly when it comes to cardiovascular disease. And he said something that I really want to follow over the coming years, which I thought was fascinating. He said, when we talk about heart disease, standard heart disease, and we talk about cancer, we might be talking about downstream events of the same causative process. And he said

[00:24:36] that in a little bit of a subtle way, but it got me thinking about root causes of so many of the diseases, in particular about diseases of aging, degenerative diseases, et cetera, and how there might be some inflammatory or other types of events that lead to us being at risk for both cancer and cardiovascular disease. So, again, it's an amazing moment where you see a field of medicine evolving, but you also see a

[00:25:06] field of scientific inquiry evolving as well. So, really look forward to watching that over the coming years. And hopefully podcasting about it too, right? You are absolutely right. And I think it's going to be so important for all of those people who are diagnosed with heart disease and, of course, all of the people who are diagnosed with cancer, because these are two of the most common things that are harming people in the United States and around the world every single day. If we can understand one better and

[00:25:35] at the same time understand the other more completely, I think it's going to put us all in a better position. Thank you for listening to The Good News About Cancer. I'm Dr. Chuck Ryan at Memorial Sloan Kettering Cancer Center in New York. And I'm Dr. Alicia Morgans at Dana-Farber Cancer Institute in Boston. The views we express on this show are our own and do not represent the views or opinions of the institutions where we work. Thanks to Lily for support of the show. Our production partner for this series is Citizen Racecar.

[00:26:04] This episode was produced by Anna Van Dyn with post-production by Alex Brouwer. And there's a whole lot more good news to talk about, so make sure you subscribe to this wherever you listen to your podcasts. And if you like the show, share it with someone you think might find it interesting. And we'll be back again soon with some more good news about cancer.