Author + information
- Marielle Scherrer-Crosbie, MD, PhD (, )@PennMedicine
Although the cardiotoxic effects of anthracyclines and radiation have been known since the 1970s, and important papers were published during the late ′70s and early ′80s using radionuclide angiography monitoring, patients with concomitant cancer and cardiovascular diseases were, until recently, mainly followed by internists or general cardiologists. There has been a growing call for the 2 specialties of oncology and cardiology to grow closer as patients survive longer and develop both comorbidities. This increasing awareness was considerably boosted by the seminal paper by Slamon et al. (1) in 2001, which reported both the prognostic-changing effect of trastuzumab on the very aggressive HER2-positive breast cancers and a rate of 27% of impaired left ventricular ejection fraction in patients receiving this treatment. There are now >600 tyrosine kinases in development, many of which, by direct or off-target effects, affect the cardiac or vascular system, and novel immunotherapies carry specific cardiac myocarditis risks.
Additionally, underlining the need for a cardio-oncology subspecialty, the patients referred by the oncologists are complex, with multiple comorbidities. These patients have an extensive list of medications, many of which are unknown to the general cardiologists, most of them with side effects and pharmacological interactions. The oncology treatments that they have received result in specific conditions that may require different treatment than other patients, as is the case for radiation-induced valvular disease.
Ganatra and Hayek make a case for structured training for fellows interested in cardio-oncology, and they are absolutely on target. To develop the cardio-oncology subspecialty, we need standardized accredited training. The authors are correct that barriers remain. As principal investigators and mid-career or senior faculty, we still have many fundamental questions about how to best manage cardio-oncology patients, such as what the usefulness and the ideal method and frequency are of cardiac function monitoring during and after potentially cardiotoxic anticancer treatment, and which therapeutic route to follow when there are differing results from monitoring. Many cardio-oncology programs have their homegrown common-sense approach to these questions, creating variability in the approach. We are still missing the large clinical trials to answer these questions.
A very important factor that is crucial to cardio-oncology is the necessity to have a multidisciplinary team and a multidisciplinary approach to cardio-oncology patients. The buy-in and involvement of oncologists are necessary, and the time in the oncology wards should be considered. Close collaborations with cardiology subspecialties (electrophysiology, heart failure, and so on), cardiovascular surgery, and other specialists (neurologists, nephrologists, and so on) are necessary for successful cardio-oncology program implementation. Multidisciplinary meetings and rounds need to be incorporated in the fellowship.
Although the number of cardio-oncology programs is growing, there are presently only a handful of homegrown fellowships in cardio-oncology. As Ganatra and Hayek remind us, fellows-in-training are eager to enter the cardio-oncology subspecialty. The ACC’s cardio-oncology council and all established cardio-oncologists should recognize the enthusiasm of fellows-in-training. We should work to structure and standardize the education of future cardio-oncologists who will develop and improve this important field.
- 2018 American College of Cardiology Foundation