By JULIE MINDA
Research has shown that survivors of certain cancers, including breast cancer, are more likely to develop cardiovascular disease than they would have been if they'd never been treated for cancer.
New Jersey artist Cindy Muglia designed the artwork in this cardio-oncology unit waiting area at Saint Peter's University Hospital in New Brunswick, N.J. Here, Muglia is joined by Dr. David Jacob, chief of cardiology at Saint Peter's.
The emerging field of cardio-oncology is attempting to better understand the interplay between cancer treatment and heart health. A small but growing number of health care facilities are putting in place specialty cardio-oncology programs to identify cancer patients at risk of cardiovascular problems, monitor their heart health during cancer treatment, provide interventions when concerns arise and help the patients stay healthy during and after cancer treatment.
Dignity Health St. Joseph's Hospital & Medical Center in Phoenix and Saint Peter's University Hospital in New Brunswick, N.J., are among the early entrants into this field. Both have established specialty services that unite cardiologists and oncologists in tailoring patients' cancer treatments to prevent or reduce damage to the heart. St. Joseph's established its cardio-oncology program in 2015, and Saint Peter's did so last February.
"Our goal is the treatment of the whole patient, not just the cancer," said Dr. Nidhi Kumar, a cardiologist and medical director of Women's Health at Saint Peter's. "With more information given to the patient and their health care providers, we can keep hearts healthy and prevent disease."
An emerging field
Cardiologist Dr. Anantharam Kalya is the medical director of the center for heart failure at St. Joseph's and heads the hospital's cardio-oncology program. He said it has only been within the past six or seven years that the specialty has become an area of focus.
He said in large part because more people now are surviving cancer — and living longer posttreatment — researchers have been able to identify a link between some cancer treatments and heart disease. Kalya said with the field in its infancy, some major academic medical centers with strong cardiology programs offer cardio-oncology programs, but few community hospitals do.
He added that clinicians' lack of awareness of the cardio-oncology connection often means that cancer survivors are not alert to their potential risk for developing cardiovascular disease.
Reducing heart risk
Kalya said that chemotherapy and radiation can cause both short- and long-term cardiovascular complications, including high blood pressure, abnormal heart rhythms and damage to the heart muscle that can lead to heart failure. Kalya and Kumar said breast, lung and stomach cancer patients are at particular risk for heart damage because of the toxic risk to the heart of the commonly used treatments for these cancers. Breast and lung cancer patients who undergo radiation are at additional risk of treatment-related heart muscle damage.
Cancer and heart disease may be linked metabolically too. In an Oct. 1 article in The New York Times Magazine, oncologist Dr. Siddhartha Mukherjee wrote that cancer and heart disease both are linked to inflammation and so they could have a common pathological root. Mukherjee cited recently published research by a team led by cardiologist Dr. Paul Ridker as well as prior work by Ridker and cardiologist Dr. Peter Libby.
Kalya and Kumar said regardless of the type of cancer, the stage of cancer progression or treatment regimen, the key first steps to reducing heart risk are to identify patients most at risk of heart damage and to screen them. Patients at greatest risk include cancer patients with pre-existing heart conditions, high blood pressure or a prior cancer episode that involved treatments that could have been cardiotoxic. Additionally, certain types of cancer treatment put cancer patients at increased risk of cardiovascular concerns, said Kalya and Kumar. For instance, Anthracycline chemotherapy drugs can damage the heart.
Both St. Joseph's and Saint Peter's programs use echocardiograms and blood tests to establish the exact condition of the heart and its level of functioning, assess risk level and monitor changes in the heart.
Kalya and Kumar said patients can enter the screening program at any point in their cancer treatment, even if they are cancer survivors who received treatment in the distant past.
Both facilities use an echocardiogram with advanced software called strain imaging. Dr. David Jacob, chief of cardiology at Saint Peter's, said strain imaging "enables cardiologists to detect signs of cardiac dysfunction at its earliest stages. (The) software can pick up changes months earlier than a conventional echocardiogram would show."
In both St. Joseph's and Saint Peter's programs, cancer patients with concerning echocardiogram results will continue under the cardio-oncology program, with the cardio-oncology physicians securing regular echocardiograms and consulting with the patients' oncology team about ways to alter cancer treatment to reduce harm, or the risk of harm to the heart.
Kalya said, "Cardiotoxicity is treated one of two ways — by optimally treating cardiovascular risk factors and by modifying cancer treatments to reduce cardiac risks." Kumar said, "Oncologists may switch a patient to another treatment agent or another dose of chemotherapy, or addcardio-protective medications to the regimen to allow protection of the heart." She said two commonly used protective drugs are ACE inhibitors and beta-blockers.
Kumar emphasized that in providing consultation to cancer patients' oncology teams, "Our goal is not to stop cancer treatment, but to help identify issues early and protect the heart."
Both Kalya and Kumar underscored that the success of efforts to get ahead of potential cardiac issues hinges on the ability to closely connect the patient's cardiologist with his or her oncology team members. With this specialty program, they are in frequent contact.
Kalya and Kumar also said education is essential. Since cardio risk factors are not high on the radar of many cancer physicians nor most cancer patients, continual awareness building is important.
Both St. Joseph's and Saint Peter's programs are too new to gauge success, but both are maintaining databases, in part to track patients' short- and long-term outcomes.
Kumar emphasized the centrality of overall wellness to Saint Peter's program. In addition to the clinical interventions, the cardio-oncology program optimizes the general health of patients, including by assisting them with weight loss, cholesterol management, blood pressure management and smoking cessation — if any of these cardio risk factors are present to a worrisome degree with patients.
Saint Peter's offers calming waiting room, to reduce stress
Saint Peter's University Hospital in New Brunswick, N.J., is intentional about trying to reduce the anxiety and stress inherent to being a cancer patient with a risk of heart disease.
For instance, the hospital created a waiting room within its breast center that is specifically for cardio-oncology patients. The room has comfortable sofas, pleasant decor and even art supplies so people can create art while waiting. Some patients leave inspirational and encouraging messages and drawings in waiting room sketch pads for those who take up pencil and paper after them.
"We know that these patients spend a lot of time away from their homes and families, sitting in waiting rooms, so we wanted this room to be warm and intimate" and relaxing for patients, said Dr. Nidhi Kumar, a cardiologist and medical director of Women's Health at Saint Peter's.
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