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JNCI Podcast: Vol 102 Issue 01 Interview Transcript

Molly Wetterschneider: Welcome to the JNCI podcast, a production of the Journal of the National Cancer Institute. I’m Molly Wetterschneider. As if having a life threatening condition is not enough, increasingly more patients are developing both cancer and cardiovascular problems. Heart specialists treating patients with cardiovascular problems risk missing signs of a developing cancer. And oncologists treating cancer patients, in turn, risk missing signs of serious heart problems. The solution that could address this growing confluence of problems, a new discipline called cardio-oncology. I spoke with Adriana Albini, the head of oncology research at the Multimedica institute in Milan, Italy. In issue one of JNCI she’s contributed a paper that reviews this new field of cardio-oncology. Thanks for speaking Dr. Albini.

Adriana Albini: Thanks for calling me.

Molly Wetterschneider: So how are the fields of cardiology and oncology coming together? How are cancer and cardiovascular disease related?

Adriana Albini: Well we can define the cardio-oncology as a discipline where the expertise of cardiologists, oncologists comes together to approach, prevent, and to overcome the risk of cardiovascular diseases, triggered or worsened by anti cancer therapies, particularly to the-- through the aging of the populations in developing countries. And both the heart and the cancer are the most common diseases in, you know, growing of life expectancies. It is possible, first of all, that the person has a risk for both cancer and heart problems. It also-- sometimes when there’s oncological problem something can happen with the treatments so that also the heart goes worse. And this is an increasing problem that has been really noticed in recent times. It was not so much a problem of the oncologists before. But now there are more and more reports that make us think that the oncologists have to learn a little more of cardiology.

Molly Wetterschneider: So it’s both there is increased life expectancy where older patients are more likely to have cardiovascular problems and also that the therapies for cancer are causing cardiovascular problems.

Adriana Albini: This is a very important point. It has been in increasing evidence that anti cancer therapy can have effects on the function of the cardiovascular system. And this has been noticed sporadically but now that there is more attention it seems like most treatments against cancer when the patient survives so the therapy goes but there might be different kinds of complications for the cardiovascular system. And those cardiovascular adverse events must be evaluated by a cardiologist for each indeed well patient. Now this was sort of a submerged field because with the very beginning of anti cancer therapy very often the patient was treated when he was metastatic, [ph?] and then what happened is the complication was not so important. Now that the life expectancy is longer it happens that we know it is-- that there is complications for heart, and sometimes even a patient that survives cancer but would die of cardiovascular complications. And so obviously the oncologist ____________________________ become aware of this.

Molly Wetterschneider: So what are some examples of cardiovascular problems that can result?

Adriana Albini: Okay, cardiovascular event is a large term. So we can have, for instance, effects directly on the heart. There are certain drugs like the Antracyclines [ph?] that can induce a damage to heart stents, to cardiomyocytes for instance. Then there might be effect that-- on the cardiovascular system in the complex, [ph?] for instance on the coagulation system. Some drugs induce thrombosis and this can affect the heart. There also can be a moderational hypertension, so some drugs would increase blood pressure. And then there’s also electrical function, for instance arterial fibrillation can be induced. And every cancer drug or even ______________________ therapy can affect the cardiovascular system in different ways. So the idea is that if we know that there is a cancer risk, maybe a heart risk, maybe latent, and it is discovered prior to anti cancer therapy, then we can avoid some of the complications that sometimes really come as a surprise.
Molly Wetterschneider: So basically you’re saying that heart complications that could happen include damage to heart cells, problems with the coagulation system that lead to thrombosis, which is blood clotting, hypertension, which is high blood pressure, and electrical problems that cause problems with the heart. And all of these can lead to death from a heart attack, right?

Adriana Albini: Yes, all this can bring to severe cardiovascular damage up to cardiovascular death. In fact there have been clinical trials where it’s been shown that there is a higher mortality for heart problems in patients having anti cancer therapy than the normal population matched for age and sex. Now one interesting point that supports the cardio-oncology encouragement that we launch in this review is that going back to analyze those patients who unfortunately died or had severe problems, those were patients that had some risk that somehow went undetected. So the idea is that if we know ahead of time that there is some risk for a cardiovascular event then we can adjust the therapy, we can monitor the therapy, and we can even try to help with some prevention treatment so that there is a better hope that not only the cancer is cured but also that there’s not a cardio complication.

Molly Wetterschneider: So cardio-oncology research could help physicians choose which type of therapies they could give patients with different risks?

Adriana Albini: Yeah, in the paper we sort of try to suggest that an international committee provides guidelines. Surprisingly there are still no guidelines for the so called cardio-oncology, and this would be how to deal with a patient that comes to have a cancer treatment and should be analyzed for possible cardiac problems. Then we choose a particular therapy. For instance, if there is a patient that has some sort of risk, maybe Antrocycline [ph?] is not good or Tatutsamum [ph?] is not good, then we have to try something else. Then at onset of therapy the patient has to be monitored for __________________________ parameters. And there are two ways to do that. One is functional. For instance, doing echocardiography ________________________________ and measure the left ventricular function, and also developing bio markers. For instance Troponine [ph?] based on artheretic [ph?] peptides that can be ________________________ diagnostic for risk and then the patient can be monitored and-- if something changes. So if a cardiovascular risk increased with anti cancer therapy then this can be adjusted or changed or some heart protector can be added. So the cardio-oncology’s a continuous talk between oncologists and cardiologists.

Molly Wetterschneider: In your paper you suggest that this international committee’s guidelines could address a concept called the sliding door. What is that?

Adriana Albini: The sliding door is that a patient that goes to the oncologist that has both diseases and goes first to the cardiologist or first to the oncologist might have a different fate because the specialist is going to cure first what his specialty is and sort of oversee the other one in the actual state where everybody’s very specialized. So the idea is that if you have both conditions your destiny can be different if you see the oncologist first or the cardiologist first. This is obviously just for _________________________ because in the actual world people always get the best care possible. But we have the idea that if all the times both specialists can talk to each other then there is no risk to have different fates according to who is the one in charge mainly of the patient.

Molly Wetterschneider: What are some challenges that this committee could face?

Adriana Albini: Well the difficulty with development of this new field is that all disciplines have different languages, so the oncology is very molecular and the cardiology works most in function. So sometimes it’s difficult to compare terms. So for this work for JNCI I put together a team that has the oncologists, the cardiologists, the pathologists, the preventive medicine, the molecular biologists. So we all sat together and tried to come up with a common language. And the other point is that sometimes as oncologists we forget that the cancer is in a body and there is a microenvironment. So every time that we give some drug that targets the cancer, that drug can go around the entire body and therefore effect the tumor microenvironment, which is my major specialty. And so particularly targeted therapy we have to be aware that nothing is really safe, and if something is administered to a patient it can affect also the healthy part of the body. And so we have to be very, very careful that everything is seen in the perspective that we have to compare risk to benefit and also sometimes risk to risk.

Molly Wetterschneider: So cardio-oncology research can better help doctors look at risk analysis.

Adriana Albini: And also we look if there is a way for perfection. I think this is a very crucial part of the work because it is noticed in trials for anti cancer therapy that sometimes people that already had a heart condition paradoxically did better because they had maybe ACE inhibitors or beta blockers already in their regimen and therefore assisted the-- some sort of a ________________________ to the heart system. So the idea is that in the future we can find preventive molecules to do a chemo prevention that protects the heart, and maybe besides the ACE inhibitors or beta blockers even the Viatro [ph?] or the Suclane {ph?] or flavinoids [ph?] or other-- or even aspirin can be something given to the treated cancer patient to protect the heart. So now we can have a-- not only a cardio-oncology but a preventive cardio-oncology. And this is a novel field that can be developed also as a experimental discipline. So far there’s no basic cardio-oncology.

Molly Wetterschneider: Thank you for your insight Dr. Albini.

Adriana Albini: Thank you very much.

Molly Wetterschneider: That was Adriana Albini, head of oncology research of the Multimedica Institute in Milan, Italy. Look for her overview of cardio-oncology in issue one of JNCI. You’ve just enjoyed another edition of the JNCI podcast. Please check back in two weeks for our next audio update and a new issue of JNCI. Until then, we’d love to hear from you. Send an email to podcasts@oxfordjournals.org and let us know how we’re doing. In the meantime you can find even more information on today’s topic, as well as news and commentary about cancer research, online at jnci.oxfordjournals.org. Also, for the latest cancer news and studies, follow us on Twitter at jnci_now. I’m Molly Wetterschneider, thanks for listening.