INTRODUCING A NEW SUBSPECIALTY

OF CARDIOLOGY…

New subspecialty

• Cardio-Oncology

• curtainCardio-Oncology

IntroductionInternational Cardio-Oncology Society

•Consortium of cardiac images supporting oncologists:– Vanderbilt University- Nashville, TN– MD Anderson Cancer Center- Houston, TX– Sloan Kettering Cancer Center- New York, NY– Centro Cardiologico Fondazione Monzino- Milan, Italy– Cardiac Care Critique- Tampa, FL– Moffitt Cancer Center- Tampa, FL– University of Pennsylvania- Pittsburg, PA– Stanford University- Stanford, CA– University of Chicago- Chicago, IL– Huntsman Cancer Center- Salt Lake City, UT– St. Louis University Cancer Center- St. Louis, MO

Monthly conference/webinar of consortium originates from Tampa monthly.

Case Study

• 41 yo Caucasian female• Diagnosed with left breast cancer in Feb 2012

after surveillance mammo, breast US, and core biopsy.

• Breast Cancer (G2) Type= Ductal, ER=pos, PR=neg, HER2 IHC= 3+, HER2 Flsh= N/A, Sentinal Lymph Node= N/A, OncoType Dx= Not available, Menopausal status= Pre-menopausal, BRCA=neg

• PMHx: Hashimoto’s hypothyroidism treated in 2004, iron deficiency anemia- 2009, hysterectomy- 2011, palpitations in past

• FHx: Breast cancer in mother and sister, although BRCA1/2 negative.

• Allergies: Keflex• SHx: Cigs-socially x 5 yrs, but not since

2003. Alcohol: weekly• Current Meds: Zofran 8 mg prn,

Lorazepam 1 mg prn, Vit D qd, Levothyroxine 75 mcg qd, Iron qd.

Case Study

Treatments

• Chemotherapy started March 8, 2012 – Carboplatin + Taxotere x 6 rounds– Herceptin x 1 year, q3weeks

• Double mastectomy August 1, 2012• Radiation therapy to left breast x 25

treatments (August-September 2012)• Reconstruction planned for May 2013

Surveillance

• Echocardiograms q3months– March 2, 2012: EF 63%– June 5, 2012: EF 64%– September 12, 2012: EF 63%– January 7, 2012 @ new site: 48% (BP 103/71- EF

not decreased secondary to increase in afterload)• At this point, patient was referred to our office for

further investigation.

Assessment

• Symptoms: Patient c/o fatigue and shortness of breath on occasion, but not consistent. Has peripheral paresthesias secondary to chemotherapy. Denies chest pain, edema, cough, nausea, SOB at rest.

• EKG– NSR, HR 65, non-specific ST and T wave changes

• Lab work ordered: – Highly sensitive Troponin I: <0.006, negative – Troponin T: negative– BNP: 9.70

Imaging workup

• Echocardiogram:– GE vivid 9E and portable GE vivid-Q- 2D in 2 image

planes as well as speckle tracking. • EF: 65%• Global strain: -19%• Regional strain: normal

• Cardiac MRI: • Normal EF: ~60’s range• Main left, proximal LAD, proximal RCA: all normal

Plan and Follow-up

• Ejection fraction normal• Continue Herceptin treatment• Regular follow-ups with special attention to:

– BP monitoring– HS Trop I & BNP q3mo– Echo with strain upon completion of Herceptin

• Post treatment: – Yearly echos and Coronary MRI, especially LAD for

any changes secondary to left breast radiation.

CHF/Cardiac Toxicity

Cardiac Toxicity

Hundley, 2012

Cardiac Toxicity

Cardiac Toxicity

Cardiac Toxicity

• SEER-Medicare database in the USA showed a cohort treated from 2002-2007 to have a 5 year incidence of heart failure of 18%

• For early stage breast cancer, a patient is more likely to die of heart disease than cancer.

Cardiac Toxicity

Strain Imaging

Cleveland Clinic

Elevated values according to MD Anderson: Trop >0.05BNP >125Strain < 19%

Elevated values according to MD Anderson: Trop >0.05BNP >125Strain < 19%

Markers and Images

Markers and Images

Cardinale, 2012

Markers and Images

Cardinale, 2012

Treatment

Cardinale, 2012

Treatment

Treatment

Recovery of LV dysfunction with standard HF therapy

• Jensen, et al. Annals of Oncology. 2002. 13:499-709.

Jensen, et al. Annals of Oncology. 2002. 13:499-709.

Treatment

Durand, 2012

It is unknown when you stop these treatments- panel said they stay conservative and treat them on low dose ACEI or BB forever. Unless females become pregnant, switch ACE to BB.

It is unknown when you stop these treatments- panel said they stay conservative and treat them on low dose ACEI or BB forever. Unless females become pregnant, switch ACE to BB.

Treatment

Early detection of Type II toxicity during F/U using

Algorithms

Starting ACE-I for Troponin I positive patients

Algorithms

Proposal• Our protocol:

– Strain Surveillance During Chemotherapy for Improving Cardiovascular Outcomes (SUCCOUR) Study

• PI: Tom Marwick from Royal Hobart Hospital, Hobart Australia

• US Centers: Cleveland Clinic (Dr. Juan Carlos Plana) MD Anderson (Dr. Jose Banchs) Mayo Clinic (Dr. Hector Villaraga) Washington Hospital Center (Dr. Ana Barac) FL Cancer Specialists/Cardiac Care Critique (Dr. Eric Harrison)

Proposal 120 patients with increased risk of cardiotoxicity from medications

N=20

Control n=10 Strain n=10EF alone EF + GLS

A: EF drop >5% to <55% Strain+ With Symptoms Start BB&ACEStart BB&ACE

B: Asx drop >10% to <55%Start BB&ACE

Observing: 24 month follow-up

ProposalPilot Project:•Control group: Standard of care, remote locations•Case group

– Baseline: • Complete 3D echo with strain• hsTnI• BNP

– Established intervals• Limited 3D and 2D echo with strain for LVEF• hsTnI• BNP• Cardiac follow-up

Florida Cancer Specialists Locations

Group B

Group ACardiac Care

Critique

Radiation

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Cardiac Toxicity

Radiation Algorithm