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Practice Changing Canadian Research in Eastern CanadaSharon L. Mulvagh MD FRCPC, FACC, FASEProfessor of Medicine, Dalhousie University, Halifax, NSProfessor Emeritus, Mayo Clinic, Rochester, MN

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• My background and perspectives

• Current cardio-oncology practice

• Research projects

• Future Opportunities

Objectives

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• None relevant to this talk

Disclosures

Click to edit Master title styleMayo Cardiotoxicity Risk Prediction Model

Medication-related risk Patient-related risk factors(one point each)

High (risk score 4):

Anthracyclines, Cyclophosphamide,

Ifosfamide, Clofarabine, Herceptin

Intermediate (risk score 2):

Docetaxel, Pertuzumab, Sunitinib,

Sorafinib

Low (risk score 1):

Bevacizumab, Dasatinib, Imatinib,

Lapatinib

Rare (risk score 0):

e.g. Etoposide, Rituximab, Thalidomide

• Cardiomyopathy or heart failure

• CAD or equivalent (incl. PAD)

• HTN

• Diabetes mellitus

• Prior or concurrent anthracycline

• Prior or concurrent chest radiation

• Age <15 or >65 years

• Female gender

Overall risk by Cardiotoxicity Risk Score (CRS)

>6: very high, 5-6: high, 3-4: intermediate, 1-2: low, 0: very low

+

Herrmann J et al. Mayo Clin Proc. 2014 Sep;89(9):1287-306

Management Rec’s guided by CRS : monitoring, Rx

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• serial monitoring (imaging, biomarkers) • recognition of cardiotoxicity; strain can detect early• management interventions

Larsen CM, Mulvagh SL. Echo Res Pract 2017 Mar;4(1):R33-R41

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• 40 pts (Mayo, SBGH) • VEGF-i Rx

– sunitinib, pazopanib, bevacizumab

• 8% - clinically asymptomatic CTRCD• 30% - decreased GLS (>15% change)

– baseline abnormalities in GLS predictive

• 30% - new or worsening HTN

Nhola LF…Jassal D, Mulvagh SL. J Am Soc Echocardiogr 2019;32:267-76

Newer agents and CV risk:

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Click to edit Master title style• Within HFC:

– Established:– Patients seen:

• Within WHHC:– Established: October 2017– Breast CA survivorship patients only

• Other provinces (NB, PEI, NFLD) - ?

Cardio-Oncology Clinic – QEII

Click to edit Master title styleWhere Can Exercise be Used in the Cancer Continuum?

9

Ann Behav Med. 2001 Fall;23(4):263-72.

Can exercise reduce the negative physiologic and psychologic effects of cancer and its treatment?

25+ years of research is showing that PA/exercise plays a vital role in cancer prevention, control and supportive care and cancer outcomes

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Benefits• Exercise prevents decline in cardiovascular function• Exercise prevents decline in quality of life• Exercise prevents increase in fatigue

Feasible & SafeChallenges: Access, travel/transportation, adherence

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EXACT

N=10

Min

ute

s o

f ex

erc

ise

pe

r se

ssio

n

45

ZON

E 1

ZON

E 2

ZON

E 1

ZON

E 1

ZON

E 1

44

43

42

41

40

ZON

E 2

ZON

E 3

ZON

E 1

39

38

37

36

35

ZON

E 2

ZON

E 1

ZON

E 2

ZON

E2

ZON

E2

ZON

E 3

ZON

E 2

34

33

32

31

30

ZON

E2

ZON

E 4

ZON

E 4

29

28

27

26

25

ZON

E 1

ZON

E 3

ZON

E 4

24

23

22

2120

ZON

E 1

ZON

E 3

ZON

E 4

19181716151413121110987654321

DAY 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2

WEEK 1 2 3 4 5 6 7 8 9 10 11 12

TARGETINTRO/ BUILD ENDURANCE

INTRO/ BUILD ENDURANCE

INTRO/ BUILD ENDURANCE

INTRO/ BUILD ENDURANCE

RECOVERYVOLUME

MAINTENANCE

INTENSITY/ VOLUME

MAINTENANCE

INTENSITY/ VOLUME

PROGRESSIONCV MAXIMIZATION CV MAXIMIZATION CV MAXIMIZATION

RECOVERY/ ADAPTATION

ZONE 1: 35%-45% HRR

ZONE 2: 45% - 55% HRR

ZONE 3: 55% - 70% HRR

ZONE 4: 75% - 85% HRR

EXERCISE RXheart rate reserve (HRR) = % of target intensity (HRmax − HRrest) + HRrest

CARDIOVASCULAR FUNCTION

13

40

50

60

70

80

90

100

110

Res

ting H

R

Pre Post0

20

40

60

80

100

120

140

160

Sy

stoli

c B

P (

mm

Hg)

Pre Post0

20

40

60

80

100

Dia

stoli

c B

P (

mm

Hg)

Pre Post

CARDIOVASCULAR FUNCTIONAEROBIC CAPACITY (n=9)

14

0

5

10

15P

eak

ME

Ts

Pre Post

CARDIOVASCULAR FUNCTION:AEROBIC CAPACITY

15

0

2

4

6

8

10

12

14

16

18

P1 P2 P3 P4 P6 P7 P9 P11 P13 P14

Pea

k M

ET

s

Pre Post

73% adherence

EXACT 2.0 – PENDING 2019

• Collaborative study with SBGH (Dr. Davinder Jassal)

• Breast CA patients

• Home-based 12 week exercise program

• Hemodynamic assessments + Echo/strain

16

17

Translating exercise research into care for cancer patients/survivors….

WHY ARE WE WAITING?

17

18

Established September, 2018

The Program

• Free 12-week supervised exercise program.

• Based on the Alberta Cancer Exercise “Program”

• Drs. Margaret McNeely and Nicole Culos-Reed

GENERAL ASCM GUIDELINES FOR CANCER PATIENTS AND

SURVIVORS

• Program in individualized for the participant.

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AEROBIC

• 150 min/week

• moderate intensity

STRENGTH

• 2-3x’s/wk

• 6-10 exercises

• 6-12 reps

• 1-4 sets

FLEXIBILITY

• Most days of the week

IndividualizationInverted Pyramid Approach

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Tumor Type

Cancer Continuum

Treatment

Type

Individual

Factors

Adapted from Culos-Reed & Capozzi, 2016

Hospital Site

Dickson Building, 5th Floor, Room 5118

Programming runs Monday through Thursday.

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61 Active participants. 11 participants have completed the program.

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Community Partners

Rath EastlinkCommunity Centre

21 active participants 8 active participants

Phase II: Expansion

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Program Flow

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Clinic

Primary

Healthcare

Provider

Self-

Referral

Certified

Exercise

Physiologist

(CEP)

High Risk

Participants

Low Risk

Participants

Hospital:CEP, Thrive Certified

Instructors

Community:CEP and/or Thrive

Certified Instructors

157 Referrals to date!

The Participants

25

0

5

10

15

20

25

30P

rosta

te

Lung

Eso

ph

ag

ea

l

Bre

ast

Co

lon

He

ma

tolo

gic

Ga

llbla

dd

er

Me

lan

om

a

Re

cta

l/A

na

l

Bone

Bla

dde

r

Gyn

eco

log

ic

Re

na

l

Th

ym

om

a

Th

yro

id

Ora

l

Te

sticu

lar

Bra

in

Ga

str

ic

Oth

er

Pa

rtic

ipa

nts

0

2

4

6

8

SocialBenefits

IncreasedEnergy

DecreasedStress

OverallEnjoyment

IncreasedMotivation

ImprovedFitness

ImprovedEmotions

DecreasedFatigue

ImprovedHealth

An

sw

er

Fre

qu

en

cy

Program Benefits

THE FUTURESupporting improved rates of exercise adoption

and adherence to an active lifestyle will lower rates

of disease recurrence, secondary cancers, and will

improve health outcomes and patient quality of life

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• Cardio-oncology clinic established

• Research focus: exercise protocols (EXACT, 2.0)

– Stable/Improved CV parameters, QOL, fatigue

– Biomarkers and imaging (Echo/strain)

• Established clinical exercise intervention program (ACCESS); add biomarker/imaging subset

• Collaborative opportunities

Summary - Practice Changing Canadian Research in Eastern Canada

Acknowledgements

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• Dr. Scott Grandy (Co-PI)

• Dr. Melanie Keats (Co-PI)

• Dr. Chris Blanchard

• Dr. Nick Giacomantonio

• Dr. Miroslaw Rajda

• Dr. Tallal Younis

• Dr. Lori Wood

• Dr. Stephanie Snow

• Dr. Rob Rutledge

• Dr. Gabriela Ilie

• Dr. Nicole Culos-Reed

• University of Calgary

• Dr. Margaret McNeely

• University of Alberta

ACCESS Team

• Joy Chiekwe (CEP)

• Alyssa Dickinson (RA)

• Student Volunteers

• Dr. Drew Bethune

• Judy Purcell

• Many others

All of past, current and

future participants.

Click to edit Master title styleThank You! - Q&A

sharon.mulvagh@nshealth.ca smulvagh@mayo.edu

@HeartDocSharon