Detecting heart issues in cancer survivors

The number of cancer survivors in the United States continues to increase each year. Encouraging as this news is, it’s not the whole story. Many survivors must cope with the physical effects of cancer and its treatment, potentially leading to functional and cognitive impairments. One area of particular concern is an elevated risk of heart disease. Penn Medicine Chester County Hospital is expanding a program to improve the detection of heart health issues that may arise from cancer treatment.

A need identified

Almost two decades ago, Joseph Carver, MD, chief of staff at Penn Medicine's Abramson Cancer Center, anticipated what was coming and began developing what is known today as Penn Medicine’s cardio-oncology program. Essentially, Abramson oncologists started collaborating with cardiologists to identify patients who were at elevated risk for heart disease related to their cancer treatment.

Shortly thereafter, Carver met with several providers at Chester County Hospital’s Abramson Cancer Center, including Sandra Moffat Camarota, MSN, CRNP, AOCNP, survivorship program coordinator, and William Clay Warnick, MD, FACC, medical director of the hospital's cardiovascular service line.

“We’re really trying to innovate and find different ways to minimize toxicity and other health-related issues because we want to focus our survivors on their recovery and wellness as they move forward with their lives,” said Camarota.

“This is not intended to be an urgent consult,” she added. “Rather, it’s meant to be an evaluation by the cardiologist to determine risk and plan interventions to help mitigate that risk.”

Camarota and Warnick have largely steered the effort, with guidance from a larger network. Each month, Carver leads a virtual meeting of representatives from every Penn Medicine hospital to discuss strategies and insights into detecting heart disease in cancer survivors sooner and treating it more effectively.

The group also includes Bonnie Ky, MD, MSCE, director of the Penn Cardio-Oncology Translational Center for Excellence and, according to Warnick, one of the field's foremost experts.

Many of the most sophisticated cancer treatments being performed today are done at Penn Medicine's Abramson Cancer Center. Thanks to these monthly conferences, Warnick said he is able to learn how the newest drugs can potentially affect the heart well before they are more widely used.

“Cancer therapies have truly exploded over the last several years,” he said. “Without this group, I’d have a more difficult time deciphering them and anticipating the potential impacts.”

Streamlining risk assessment

Because the most prevalent types of cancer treated at Chester County Hospital are breast, prostate, and lung, Warnick and Camarota focus on drugs like doxorubicin and trastuzumab. Used to treat some types of breast cancer, these drugs can potentially elevate a person’s risk for heart-related issues.

“We look at the medical history for other risk factors like obesity, diabetes, hyperlipidemia, hypertension, and atrial fibrillation," Camarota said. "Even family history of heart disease can elevate risk.”

Occasionally, Warnick and his team are asked to offer guidance on patients who develop changes in heart function during their cancer treatment. Still, most patients referred by Camarota have completed their treatment and are in remission.

“They may be completely asymptomatic at the time of our visit, but I always tell the patient I’m not worried about their heart right now, but rather 10 years down the road. I try to encourage them to seek consultation,” Camarota said.

“Ideally, we like for them to follow up with a cardiologist within a year after treatment is completed because, according to the National Comprehensive Cancer Network, the risk elevates for many patients when they reach the five-year mark,” she continued. “The goal is to do the cardiovascular risk assessment and see if there's anything that can be done now to avoid or minimize the progression of issues in the future.”

Other risk factors

Warnick said he’s learned from Carver and Ky that age is a key variable in determining someone’s risk for developing heart trouble after their treatment. Also on that list is the strength of their heart.

“We want to know what their heart looks like because there are medications that can put them at risk of fluid retention or congestive heart failure,” he said.

He also asks about other conditions – hypertension, high cholesterol and diabetes are all significant risk factors – and lifestyle. Research has shown that the more active you are, the better you should be able to tolerate therapy.

“I can also easily access all of their imaging, including the CT scan of the chest or abdomen that’s typically done during a staging workup or in a diagnosis,” Warnick said. “That allows me to quickly see if there’s evidence of any type of atherosclerotic disease present in their coronary arteries and/or aorta or vasculature, which then gives me further insight into their risk.”

Improving with demand

Since moving toward a more formalized referral process, Warnick said they’ve made the greatest inroads with detecting potential heart issues related to breast cancer therapies.

“We’ve really sharpened our skills as far as imaging of the heart muscle during an echocardiogram with strain.” This newer ultrasound test enables providers to identify subtle changes in heart function to better predict complications of therapy, specifically with trastuzumab and doxorubicin. “We can now predict much earlier, who is at risk of having a complication of breast cancer therapy.”

Two cardiologists in Warnick’s practice, Sharayne Mark Coffin, MD, and Adrian Richard Pearson, DO, also conduct cardio-oncology consultations.

“Because of our aging population, the advancements in cancer treatment, and all the phenomenal work that Sandy and her group are doing, the need for cardiology-oncology is only going to continue to grow,” he said. “Originally, it was just kind of a niche. But from our own experience and those shared with us throughout our network, it's clear now that it’s here to stay.”