Cured of Cancer but now Let s Heal the Heart An exploration into the effects of cancer on the heart

Transcription

1 Cured of Cancer but now Let s Heal the Heart An exploration into the effects of cancer on the heart Suma H. Konety, MD, MS Associate Professor, Cardiovascular Division University of Minnesota

2 What is Cardio-Oncology? Emerging field that represents the intersection of cancer and cardiovascular disease. Specialty is aimed at preventing and managing cardiovascular disease in cancer patients and survivors.

3 Current State 15+ million cancer survivors in the US. Cancer treatment can have unintended CV effects. Clinical presentations of CVD in cancer patients may not be straightforward. There is a wide variation in cardiac care offered to cancer patients. Care coordination can be challenging with multiple specialists involved. Estimated and projected number of cancer survivors in the United States from 1977 to 2022 by years since diagnosis. Janet S. de Moor et al. Cancer Epidemiol Biomarkers Prev 2013

4 Cardiovascular Surveillance for Cancer Survivors Key components Raise awareness of possible CV disease among survivors Provide appropriate follow-up of such patients Inform patients of increased CVD risk at the outset of their chemotherapy and latent effects of radiation therapy Advice to promptly report early signs and symptoms of CVD and make appropriate lifestyle modifications

5 Cardiovascular Surveillance for Cancer Survivors CV concerns can be summarized into three categories Myocardial dysfunction Vascular disease Valvular heart disease

6 CHF in Breast Cancer Survivors Using the Surveillance, Epidemiology and End Results (SEER) Medicare database women aged 66 to 70 treated with anthracycline compared with other chemotherapy had a 26% higher risk of CHF. Pinder MC, et al. JCO 2007;25(25):

7 Survival in Symptomatic and Asymptomatic LV Dysfunction Thomas J. Wang et al. Circulation. 2003;108: Copyright American Heart Association, Inc. All rights reserved.

8 ~2600 consecutive pts receiving anthracycline therapy, median f/u 5 yr Overall incidence of cardiotoxicity 9% 3 distinct types: - Acute, occurring after a single dose/course, clinical manifestation <2 weeks from treatment - Early-onset chronic, developing within 1 year - Late-onset chronic, developing years after treatment 98% occurred within the first year Patients generally do well if detected early and treated with HF medications Circulation. 2015;131

9 ACC/AHA Guidelines for Evaluation and Management of HF

10 Cardiac MR for Accurate Assessment of Ventricular Performance and Viability

11 Factors Associated With Anthracycline Cardiomyopathy ESC CPG Position Paper. Eur Heart J 2016:37.

12 Challenges in Survivorship Stage Once started, how long do we continue HF medications? Clinical trial data is lacking Continue HF therapy indefinitely unless normal systolic LV function remains stable after cessation of HF therapy and no further cancer therapy is planned. Since trastuzumab-induced cardiac dysfunction is frequently reversible, cessation of HF treatment after normalization of LVEF may be considered

13 Radiation Therapy and Cardiovascular Disease

14 Radiation Induced Valvular Disease

15 Porcelain Aorta Extensive ascending aortic calcification Limited options for treatment

16 Transcatheter Valve Replacements TAVR and TMVR

17 Cardiovascular Injury Following Radiation Therapy Groarke JD et al European Heart Journal (2014); 35

18 JAMA Intern Med. 2015;175

19 Increasing risk of death and coronary events in women treated with higher doses of RT and increased cardiac risk factors. Darby SC et al. NEJM: 368; 2013.

20 The World of Cardio-oncology Where Cancer and Cardiovascular Disease Meet. Moslehi JJ. N Engl J Med 2016;375

21 Strategies to Mitigate Cardiotoxicity Strategies to mitigate CV toxicity Oncologic Cardiovascular Dexrazoxane Altered delivery system Radiation techniques Risk factor management Life style modification diet, exercise Beta blocker, RAS blockade, Statin therapy

22 AHA Scientific Statement 2018 Cardiac Imaging during and after treatment with anthracycline or HER2 directed therapy

23 EACVI/ASE Consensus Guidelines for CVD Screening Post radiation Symptomatic patient yearly history and physical examination with echocardiography Asymptomatic patients screening transthoracic echocardiogram at 10 years post-radiation and serial exams every 5 years thereafter.

24 Screening for Cardiomyopathy After Chemotherapy COG LTFU Guidelines: 2008

25 Summary It is clear that both the disease (cancer) and the treatment itself carry life threatening risk. Active cardiac surveillance is essential during and after cancer therapy. Comprehensive care is essential in the management of cancer patients to maximize gains in cancer treatments while minimizing the potential deleterious impact on CV health.

26 Questions Suma H. Konety, MD, MS