New Book: The Clinical Overlap of Cancer and Heart Disease

Gretchen Kimmick, MD, MSDuke Cancer Institute breast oncologist Gretchen Kimmick, MD, MS, is chief editor of a new textbook — “Cardio-Oncology: The Clinical Overlap of Cancer and Heart Disease” (May 2017).

Billed as the first textbook on cardio-oncology to provide comprehensive coverage from a truly multidisciplinary standpoint, it’s targeted to providers who care for patients with both cancer and cardiovascular disease.

The user-friendly chapters, many co-written by Duke authors, provide an overview of epidemiology, basic science, and clinical knowledge.

Each chapter is co-written by cardiologists and oncologists; covering cardiac complications in patients receiving cancer therapy; the treatment of cancer in patients with cardiovascular disease; and the treatment of cardiovascular disease in patients with cancer.

Kimmick and Douglas Sawyer, MD, chief of Cardiovascular Services at Maine Medical Center, first presented on the clinical overlap of cancer and heart disease at ASCO’s Annual Meeting in 2012. They started the process of putting the volume together in Fall 2014.

“After the symposium, I was approached to think about editing a book,” said Kimmick. “There was only one book of compiled articles on cardio-oncology at the time and there was a lot of good information coming along. It made sense to put together a collaborative book that would combine oncology and cardiology insight, and allow us to advance the field and better take care of the patients.”

The book’s editors — which include, in addition to Kimmick and Sawyer, Daniel J. Lenihan, MD (Vanderbilt Heart and Vascular Institute), Erica L. Mayer, MD, MPH (Dana-Farber Cancer Institute) and Dawn L. Hershman, MD, MS (Herbert Irving Comprehensive Cancer Center) — stress that as medicine becomes more and more partitioned, collaborations and cooperation between subspecialties, like cardiology and oncology, are of “paramount importance.”

“If you do get ‘siloed‘ in medicine, a patient’s care may not be as good,” said Kimmick, who has also co-written a chapter, in the new book, on the epidemiology of cardio-oncology, and, with Duke genitourinary oncologist Michael Harrison, MD, a chapter on the management of chemotherapy-associated cardiomyopathy.

An Evolving Discipline

Cardio-oncology, as the book lays out, is an evolving discipline. With improvements in cancer treatment and overall patient health, more and more patients are surviving cancer and living longer with the disease, which presents a whole new set of challenges. After age 25, cardiac disease and cancer are the two most common causes of death in adults.

Plus, a “silver tsunami” of aging baby boomers — those born between 1946 and 1964 — are keeping oncology and cardiology clinics busy.

Kimmick said that in her practice, which is focused mainly on complicated geriatric cases of breast cancer, she often ends up diagnosing cardiovascular disease when she sees patients for follow-ups. She said some cases are unrelated to their cancer history — a function of age or other risk factors — while others are due to side-effects of cancer treatment.

This wasn’t as big of a consideration for cancer patients in years past when many cancer patients would die of cancer long before they might have issues with their cardiovascular system, Kimmick explained.

And, she said, it’s no coincidence that all three of the oncology editors of the new textbook are breast oncologists.

“It just kind of hits home for us more because the breast cancer survivor population is so big,” said Kimmick. “Because patients tend to live a long time, we can monitor them a long time.”

Cardiotoxicity

Michel Khouri, MDOn average, about 20 percent of patients receiving certain classes of anticancer therapies may experience cardiac adverse effects that manifest as either an acute toxic effect or, potentially, a late complication, even ten to 30 years after diagnosis. The risk of this “cardiotoxicity” varies by therapeutic class and agent as well as whether the patient has a pre-existing cardiac condition or other risk factors.

The authors of the new textbook’s chapter on cardiotoxicity of anti-cancer drug therapies — among them Duke hematologic oncology fellow Myles Nickolich, MD — write that cardiotoxicity has become “a complex clinical challenge” and “a major economic and health burden, given the increasing number of cancer survivors.”

In Western countries, they point out, a large number of cancer survivors are at a higher risk of cardiotoxicity-related death than of cancer recurrence.

Duke radiation oncologist Manisha Palta, MD, Duke radiation oncology postdoctoral associate Chang-Lung Lee, PhD, Duke radiation oncologist David Kirsch, MD, PhD, and MD Anderson Cancer Center cardiologist Syed Wamique Yusuf, MBBS, MRCPI, FACC, in another chapter of the book, lay out the potentially cardio-toxic impact of radiation therapy on the heart, with a specific focus on data from Hodgkin lymphoma and breast cancer survivors.

Duke cardiologist/cardio-oncology specialist Michel Khouri, MD, together with Duke cardiologist/cardiac MRI specialist Igor Klem, MD, former Duke cardiology fellow Chetan Shenoy, MBBS, and oncology colleagues from the University of Ottawa, author a chapter on the importance of screening and monitoring for cardiotoxicity.

“When cancer patients come in, I evaluate if they are at higher risk for developing heart disease or complications and intervene to help prevent any issues, including prescribing treatments,” said Khouri who gets patient referrals from a range of oncologists, including Kimmick. “By protecting the heart, it allows us to treat our patients’ cancers as aggressively as possible.”

Kimmick said as an oncologist she’s always weighing the risks of side effects, including to the heart, with the benefits of treatment. The risks and benefit ratios vary depending on the stage of cancer.

“In some cases, we might take a little more risk to get more cancer control, and longer life and fewer symptoms because the medicine is controlling the cancer,” said Kimmick.

What’s Next?

Often, by the time a book is published, it’s already time to get started on the next one, but Kimmick said she’s mainly focused on research projects that will add to the literature in the field of cardio-oncology, so that there will be “more information to guide management of patients.”

This includes her participation, with Duke research cardiologist Chiara Melloni, MD, MHS (a co-author of a chapter on the management of patients with coronary disease and cancer), in a Food and Drug Administration (FDA) group, made up of clinicians and industry-based researchers, who are designing parameters for clinical trials that account for cardiovascular side-effects during drug development.

There’s already a strong history of clinical collaboration between cardiology and oncology at Duke.

The Duke Cardio-Oncology News newsletter, jointly published by Duke Cancer Institute and the Duke Division of Cardiology since August 2015, showcases the growth of homegrown research in the field, to which Kimmick and many others are continuing to contribute.

The aforementioned Melloni, Kimmick, Harrison, and Khouri, as well as Pamela Douglas, MD, James Abbruzzese, MD, Kathryn Pollak, PhD, Michaela Dinan, PhD, and Steven Patierno, PhD, have formed a Duke-based cardio-oncology working group. The group is building a cardio-oncology program — a joint collaboration of the Duke Cancer Institute, the Duke Division of Cardiology and the Duke Clinical Research Institute — that includes both clinical and research components.

There’s an online version of “Cardio-Oncology: The Clinical Overlap of Cancer and Heart Disease” for sale, which includes extra features, and the hardcover (319 pages) is available from the publisher (Springer) and through Amazon. The book is also available for purchase at the Duke Medical Center bookstore.