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Oct 15

Cardio-Oncology: Care model changes to prevent cardio-toxicities?

An Interview with Dr. Carrie Lenneman – PART 2 of 4

In June 2021, The Kinetix Group, interviewed Dr. Carrie Lenneman, a cardiologist who specializes in working with cancer patients who have a higher-than-normal risk that their cancer treatment may affect their heart. She also works with patients who have had previous cancer treatment and are experiencing symptoms that may be related to their prior treatment. Dr. Lenneman is Medical Director of the Cardio-Oncology Clinic at the University of Alabama at Birmingham (UAB) O’Neal Comprehensive Cancer Center at UAB, in Birmingham, Alabama.

Cardio-oncology is a subspecialty area of cancer care that has become increasingly important as the number of long-term cancer survivors continues to go up. Advancements in cancer therapies have tremendously improved the long-term survival of patients. However, some of the treatments can be hard on the heart, especially for those individuals who may have other medical conditions, or who have sensitivities to their therapies.

What follows is Part 2 of a transcript of our interview with Dr. Lenneman, edited for this format.

Warren Smedley: Here at UAB, you have the advantage of working with oncologists to care for patients in advance of their therapy that’s known to cause some cardiotoxicity, as well as for patients who present with some latent symptoms. But what are you seeing in patients who are coming to you from the community?
Dr. Lenneman: We’ve actually made a huge push to have a focus on prevention. We have been focusing a lot on encouraging oncologists think about which patients are at high risk for cardiotoxicities. So we’ve begun to see collaborative referrals coming sooner rather than waiting until they’re symptomatic. The highest priority are patients that have uncontrolled risk factors who are getting cardiotoxic treatments. We’re seeing those patients to risk stratify and optimize them before starting treatment, but also at the same time minimizing any delays to their treatment. Of course, when patients present with symptomatic issues, we’re working to control the symptoms, whether it’s heart failure or coronary disease or valvular disease, and then to get them back on track to make sure that we’re not interrupting or creating major delays in their treatment plans. That’s one of the biggest focuses in our cardio-oncology program. Cancer patients can’t wait. We can’t let them see a cardiologist two to four weeks later. They have to be seen quickly so that they can continue their plan of care.
Warren Smedley: Are you seeing gaps in the knowledge of other physicians out in the community, like among the primary care providers? A lot of patients who are long-term survivors are being followed by their primary care providers, or even cardiologists may be out there and may not recognize some of these toxicities. What are you seeing from patients that are coming to you?
Dr. Lenneman: Yes, absolutely. There are probably two big areas where, golly, if we could even increase the awareness of two things, I think that would be highly important. One is that, in general, we’re very good at getting echoes pre anyone being exposed to an anthracycline. We actually do not do a very good job of getting a post anthracycline baseline echo. And we actually know that one of the biggest predictors of how a patient’s going to do, as far as their development or probability of developing heart failure, is getting that post anthracycline ejection fraction assessment. And so, making sure that our oncology colleagues, as well as our primary care physicians, are like, “Oh, wait a minute. You’ve just finished breast cancer treatment in the last several months. Let’s get another echo, see where your ejection fraction is.” I think that would probably be one of the most pivotal things for our community providers to help us catch people early when they may have subclinical cardiac dysfunction related to anthracyclines.

The second thing is realizing that cancer patients, even if they’re metastatic, they can live 5, 10, 15, or more, years. I think many of us would be like, “Oh, okay, well, they have metastatic breast cancer. Yeah. Their blood pressure is 160/90 that’s okay.” That’s not really okay. We really need to treat cancer as a chronic disease. We need to be more aggressive in our risk factor prevention for these patients so that they don’t have metastatic breast cancer and are fighting it for 5 or 10 years, but, in the meantime, develop an acute heart attack or an acute stroke because we haven’t been managing their cholesterol and their lipids and their diabetes well because we thought, “Well, it doesn’t matter, it’s metastatic and we don’t have to be so tightly controlling, there are other risk factors.” Those are probably the two things that I think are most important for us to close those gaps on.

Warren Smedley: You wrote a great article in 2016 with Dr. Sawyer. And in that article I believe you mentioned that cardiovascular issues are the second leading cause of mortality in cancer patients.
Dr. Lenneman: Absolutely. Yes, it is. That statistic still remains true, that cardiovascular disease is the second most common reason people will pass away, after cancer. So it’s very important that we really understand their cardiovascular risk factor, so we can minimize that.
Warren Smedley: Now, in your article you also mentioned that there were not really any structured guidelines for surveillance, for care of patients that have these exposures. Has that changed recently, or what are you seeing in the guidelines?
Dr. Lenneman: There is an emerging body of guidelines that has come out, but that’s actually still very recent. In 2020, the European Society of Cardiology put out a guideline in the last six months providing recommendations on how often we should do surveillance for different cardiovascular testing, depending on the treatment that a patient was exposed to. The European Society of Medical Oncology has also put out some guidelines. I will still say, there’s still not a robust amount of long-term data for the American College of Cardiology or the American Heart Association. We don’t have major guidelines through those two major societies. They are coming, but those societies’ guidelines are highly driven on data and we just do not have a substantial amount of long-term data that has collated enough clinical trials on cancer survivors to really have hard and fast guidelines.
Warren Smedley: Oh, interesting. What research needs to be done in that area, do you think?
Dr. Lenneman: One of the big things is just bigger initiatives to have larger registries and larger prospective studies on cancer patients. In general, we think about clinical trials for cardiovascular-related drugs and therapies. They exclude cancer patients. And then alternatively, on the flip side, a lot of the newer oncology drugs that are coming out, they exclude patients with preexisting heart failure, preexisting coronary disease, and so forth. So if you think about it, these two populations are generally excluded from the different trials, because they’re too high risk, but they don’t represent what we really take care of in a normal setting of everyday practice. We need to have people who are doing clinical trials and drug companies who are sponsoring clinical trials to say, “Okay, well, maybe we need to take different arms and have arms that might represent a true normal population of patients that might live in Alabama or might live all over the U.S. So I think that’s one part. And then, again, long-term registries with follow-up that are well-characterized for cardiovascular outcomes are really needed. And there are growing registries at this point, which is great.

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