How to create a cardio-oncology program

He said a co-directorship means both sides have "skin in the game" to make the cardio-oncology center successful.

"And when you try to explain what cardio-oncology is all about to the oncologists, you need to tell them it is not about stopping chemotherapy; it is exactly the opposite. The idea we have as cardiologists is to support the patient alongside the oncologist so that the patient can complete the chemotherapy without any obstacles," Plana Gomez said. 

This means helping the patient maintain their cancer treatment, while giving them support to prevent adverse impacts on the heart. 

Another tip he had was for the cardiologist go to the cancer center to see patients; this makes it more convenient for the patient and can improve their overall satisfaction, all while helping reinforce the idea that the cardio-oncology team works together. Cardiologists are already regularly involved in discussions with the cancer care team.

How to image cardio-oncology patients

Plana Gomez was the lead author of the ASE and European Association of Cardiovascular Imaging expert consensus multimodality imaging evaluation of adult patients during and after cancer therapy. 

"What we recommend right now is that patients should have a good baseline assessment. Use of 3D echo and strain are pretty good when you are trying to establish the baseline. We also have recent data telling us that 3D ejection fraction is actually good enough. And there was no evidence of additional benefit from using strain in these patients, but we do see an important role for strain in the survival patients," Plana Gomez said.

Strain can show very subtle abnormalities in the follow-up imaging exams of cancer survivors, which can be early signs of longer-term heart damage from cancer treatments. He said ejection fraction, even with 3D echo, can miss these small changes, but they are much easier to catch on strain. 

Patients are generally given a baseline and then serial cardiac ultrasound scans might be used during their cancer treatment. However, Plana Gomez said there are some patients that might require closer monitoring. He explained there is an app created by the European Society of Cardiology (ESC) based on the cardio-oncology guidelines where a series of questions are answered about a patient and it will tell you if a patient is at a high or low risk. This can help a program know which patients need more attention and additional surveillance.

"One of the questions that comes up is if you need to see everybody, and this is absolutely not feasible. For instance, one out of every seven women will experience breast cancer, and we do not need to see them all. We are just interested in the ones who are old, the ones who have cardiovascular risk factors, or those who start cancer treatment with a not-so-great ejection fraction. These are the ones from research that we have found that do poorly. On the other hand, if a women is in her 30s, does not have any risk factors and has a perfect ejection fraction, and they are not going to receive an anthracycline, they are going to do fine and you do not need to see them," Plana Gomez explained. 

What cancer treatments cause cardiology concerns?

Anthracycline chemo agents can be very cardiotoxic, so their use automatically requires a closer look at the patient and additional serial monitoring. However, other agents, including immune checkpoint inhibitors may also cause cardiotoxcity in some patients. 

"The idea with these checkpoint inhibitors is that it unleashes the immune system to go and fight the cancer, but it can also lead to myocarditis. It is infrequent, but it is something we need to have on our radar," Plana Gomez said. 

Radiation therapy is another therapy that can cause damage to the heart. The heart is considered a critical structure in radiation oncology treatment planning, so the goal is to avoid or minimize radiation beams through or near the heart. The impact of radiation can be long-term, and may not be detected for years after a patient's treatment. 
  
Plana Gomez is seeing some who had Hodgkins lymphoma 10 or 15 years ago and now present with aortic stenosis, mitral stenosis, constructive pericarditis and/or left main disease.

"These patients are very challenging, because it is their entire chest that got irradiated, so the lungs are also effected. When surgeons go into the chest, they find it is fibrotic all over and the access is very difficult," he said.

But, Plana Gomez said today there are new approaches to treating these patients nonsurgically using transcatheter valves and a protected left main stenting procedures. He said these interventional advances have added to the armamentarium to treat these difficult patients, who 10 years ago would have undergone surgery and had very poor outcomes. 

Due to the long-term issues, he said full chest radiation is no longer a front-line option for treating Hodgkins lymphoma, and now the focus is on using chemotherapy. 

Chest radiation is still used for breast cancer and lung cancer, where the heart has the risk of receiving radiation doses. But, Plana Gomez said risks of damage can be minimized with breathing techniques and improved automated treatment planning software that avoids or excludes and radiation to the heart.