The “absolute priority” is to develop onco-cardiology guidelines to help clinicians

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Tochi M Okwuosa

In a “Call to action”, published in the Journal of American College of Cardiology, Tochi M Okwuosa (Division of Cardiology, Rush University Medical Center, Chicago, USA) and others outline the challenges of “cardio-oncology”, including whether “onco-cardiology” is a more accurate term. Okwuosa talks to Cardiovascular News about the issues discussed in the paper.

What is “cardio-oncology”?

It is the study, prevention and treatment/management of cardiovascular diseases resulting from cancer and/or cancer therapy.

Why is there a need for “cardio-oncology”?

Cardiovascular disease is the number one cause of death in the USA; cancer is a very close second.  Therefore, when cancer patients have cardiovascular disease, it is a combination that could lead to significant morbidity and mortality.

Also, cancer patients are living longer as a result of progress in cancer therapies; and after secondary malignancy, cardiovascular disease is the major cause of death in cancer patients and survivors. Furthermore, some of the chemotherapeutic drugs, radiation therapies, and even newer targeted therapies that help patients become cancer-free can cause significant cardiovascular toxicities that could sometimes last a lifetime; in some cases, they can lead to significant cardiovascular morbidity and death. There are many cardiovascular problems linked with cancer therapies, such as arrhythmias, coronary artery disease, myocardial infarction, heart failure, hypertension/hypotension, autonomic dysfunction, valvular heart disease, pericardial diseases, and so on.

Cancer therapies may also cause or exacerbate certain cardiovascular risk factors (e.g. tyrosine-kinase-inhibitor-induced significant hypertension). Because the risk of heart disease from cancer treatment can last a lifetime, and cancer therapy is necessary for those that have the diagnosis, proper peri- and post-treatment monitoring is essential for cancer patients and survivors.

Why might “onco-cardiologist” be a better name than “cardio-oncologist”?

While a cardio-oncologist signifies an oncologist involved in care of cardiac patients (one might imagine an oncologist specialising in cardiac cancers); the name “onco-cardiologist” better defines the subspecialty in question—usually a cardiologist dedicated to managing cancer patients with heart disease.

What are the challenges of being a cardiologist who practices as an “onco-cardiologist”?

There are various challenges to this subspecialty as detailed in our paper, mostly related to being caught in between two different and important medical subspecialties with somewhat different priorities and patient-care focus. Additionally, the novelty of the field with current limited recognition presents its own challenges dealing with billing and training/education.

If working as a onco-cardiologist, what are the difficulties of linking up with colleagues working in the same field?

The difficulty lies in the fact that there are few (but it is growing) practising in this field of medicine. That being said, we now have cardio-onco networks through social media; and we also have newly-established national cardio-onco conferences/meetings in which onco-cardiologists can talk and exchange ideas. Hopefully, we are connecting better.

When treating a cancer patient (or a patient with a history of cancer) for cardiovascular disease, what are the specific considerations?

The type and prognosis of the cancer. This includes whether it is metastatic or not; the agent and sort of treatment being used for the cancer (the need for chemotherapy, targeted therapy, surgery and/or radiation); cardiovascular comorbid conditions that might affect treatment; prior therapies for prior cancers that could also portend present or future cardiovascular consequences; and drug interactions between cancer and cardiovascular drugs. All of these factors may affect planned cardiovascular procedures such as transoesophageal echocardiogram (TEE) or cardiac catheterisation with possibly percutaneous coronary intervention (PCI).

Given the lack of guidelines in this area, what are the priorities for developing guidelines?

The absolute priority is to help guide clinicians. The American College of Cardiology (ACC) is working on this, and we are also trying to get the American Heart Association (AHA) involved. The challenge in doing this lies in the myriad of treatment modalities for very many different types of cancers affecting various organ systems.

What are the key priorities for research in this area?

Risk prediction of those at risk for cardiovascular morbidity/mortality for certain cancer therapies—that would also depend on the type of cancer/cancer therapy, effective cardiovascular prevention and management strategies of cardiovascular complications of these treatments.

What do you hope the take-home messages of your call to action will be?

The demand for the onco-cardiologist will only increase as expanding treatment options for cancer patients are leading to more cures and longer survival measured in years. As the growing population of cancer survivors age, the cardiac side-effects of therapy can be expected to compile with common comorbidities. We hope a call to action would entail coalitions to help develop guidelines to aid clinicians in the practice; set up protocols for education and formalised training for trainees; engage trainee interest in this important subspecialty; inform physician groups and academic centres on the importance of this subspecialty to instill willingness to invest resources to better care for these patients; enlighten insurance companies and health management systems on the nuances of the field to allow for easier coding and billing in order to better test and manage patients and cancer survivors with cardiovascular concerns secondary to cancer/cancer therapies; and encourage a focus on patient education and empowerment for improved cardiovascular health as cancer survivors.

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