Jaime E. Murillo, MD, was inspired to establish the Sentara Cardio-Oncology Clinic after learning that his friend's 35-year-old daughter was diagnosed with breast cancer. He recommended cardiology tests for her as she started chemotherapy.
As he discussed the need for monitoring her heart health during treatment with his friend and daughter, he realized that most cardiologists aren't knowledgeable of the effects of chemotherapy on the heart, and that a lot of women are vulnerable to developing heart disease in conjunction with cancer.
"The cardio-oncology clinic at Sentara provides care to a special group of people who have underlying heart disease and cancer, or who are at risk of developing heart disease while they receive chemotherapy, and cancer survivors who need monitoring for heart problems," said Murillo, Medical Director of Noninvasive Cardiology at Sentara Healthcare and Director of the Sentara Cardio-Oncology clinic. Another objective of the program is to bring cardiologists and oncologists together to more closely collaborate on patient care.
Many cancer patients may not have access to the technology to test and monitor heart function. "This population has not been well-served," said Murillo.
To further enhance care, the 2-year-old cardio-oncology clinic for chemotherapy patients at Sentara Princess Anne Hospital in Virginia Beach, Va., is expanding to additional locations in to meet patient demand. Physicians will start seeing cardio-oncology patients at Sentara Port Warwick in Newport News, Va., and on the campus of Sentara Leigh Hospital, in Norfolk, Va. The latter will be located at Sentara Cancer Center, expected to open in 2020. The cardio-oncology clinic will be in the same building where the oncology patients are seen, reflecting a joint health care process between oncology and cardiology, Murillo explained.
Clinic Goals
Caring for patients who have underlying heart disease and ensuring they receive the best possible cancer care is one of the clinic's goals.
"There are breast cancer patients, for instance, who happen to have cardiomyopathy, where the heart muscle doesn't work properly," Murillo noted. The most effective treatments for breast cancer, for example doxorubicin and trastuzumab, can be cardiotoxic and worsen underlying cardiac disease.
A risk assessment of these patients is invaluable before starting a cancer treatment plan. "We still want them to receive the best chemotherapy for their cancer, but at the same time, maybe we add some medication to help address congestive heart failure and provide heart monitoring," he said.
In rare instances, oncologists may need to change the chemotherapy regimen or the dose of drugs prescribed to protect the heart, added Murillo.
Another group of women to consider are those who don't have heart disease but are at risk because of their age (65 and older); comorbidities such as high blood pressure, obesity and diabetes; or behaviors such as smoking.
Cardiologists try to identify those at risk of developing heart disease and offer testing of the heart to ensure patients can receive cardiotoxic therapies, if they are recommended by oncologists, said Murillo.
The clinic also takes a proactive approach to prevention and treating heart disease. "For example, medications and lifestyle changes can help prevent congestive heart failure. Some treatments such as ACE inhibitors or beta blockers can help to manage or reverse the condition," he said.
Cardiac Imaging Integral to Clinic
Cardiologists typically use imaging tests as part of their risk assessment. Most notably, an echocardiogram with strain analysis has the ability to assess multiple points within the heart muscle and track these points as the heart contracts, Murillo explained. This allows cardiologists to detect subtle changes in heart function and determine whether a patient can withstand certain cardiotoxic treatments.
As a screening tool, strain is simple to do, does not involve radiation, and is widely available. Moreover, he noted this imaging approach detects problems with heart function earlier than with a multigated acquisition scan (MUGA scan).
Cardiac MRI may also be necessary. It is reserved for instances where cardiologists need to know more about the actual heart muscle, for example, whether scar tissue or infiltrations exist, Murillo said. Strain quantifies the function of the muscle, while cardiac MRI gives anatomic details about the muscle when needed.
Cardiologists conduct an echocardiogram with strain analysis at baseline, then at 3 months and 6 months during treatment, then 6 months and 12 months after treatment is complete. Some patients need to be followed for a longer period because of their risk for developing heart disease, whether from the cancer treatment or from comorbidities. "For patients who receive radiation therapy, we'll do this even 5-10 or more years down the road."
All cardiac sonographers at Sentara have ben trained in how to conduct an echocardiogram with strain analysis. While insurance often doesn't cover the procedure, "it's the right thing to do to offer this testing to patients," Murillo said. "We hope that CMS reimburses for it one day."
Ongoing studies should help increase awareness about strain imaging in the early detection of problems with heart function and whether this approach has some impact on long-term outcomes. "We have some small studies that indicate strain is beneficial and detects changes in the heart earlier, so it would make sense that it would also impact long-term outcomes," noted Murillo.
A Collaborative Relationship
Creating a cardio-oncology clinic naturally takes the collaboration of oncologists and cardiologists. These two specialties typically have not worked together in the past with the goal of taking care of patients.
"Most cardiologists are not trained during fellowship to handle cancer patients," said Murillo. "There's a void in real knowledge. If you talk to 20 cardiologists, 18 won't have real knowledge about chemotherapy medications and their potential effects, especially with specific doses."
In turn, while oncologists may understand the side effects of drugs like doxorubicin and trastuzumab, they may not always know which patients are at high risk of developing heart disease. "In general, they don't feel comfortable identifying high-risk groups."
While major medical centers are moving toward developing collaborative working relationships between cardiologists and oncologists, community hospitals "may still have room for improvement," noted Murillo.
Implementing New Guidelines
Implementing guidelines on managing heart health in cancer patients is another important step in developing cardio-oncology programs.
Guidelines for the prevention and monitoring of cardiovascular morbidities are available from ASCO (J Clin Oncol 2017;35(8):893-911). A report on imaging evaluation of adult patients during and after cancer therapy is available from the American Society of Echocardiography and the European Association of Cardiovascular Imaging (Eur Heart J Cardiovasc Imaging 2014;15:1063-1093).
Cancer-specific heart health guidelines are also being created, noted Murillo. For example, new guidelines published by the American Heart Association in Circulation address heart disease and breast cancer (2018; https://doi.org/10.1161/CIR.0000000000000556). The document addresses prevalence of both conditions, overlapping risk factors, cardiotoxic therapies, and the prevention and management of cardiovascular disease in women with breast cancer.
"Scientific statements like these represent a huge effort from the medical community to spread the word about cardio-oncology," Murillo stated. The next step is to take these guidelines and ensure they are being implemented at the medical institution level.
"Cancer societies can do the same and start providing guidelines on heart disease and different forms of cancer and their treatments."
Patient groups can also help to increase awareness and "encourage patients to talk to their oncologist about seeing a cardiologist."
Heather Lindsey is a contributing writer.