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Opportuni/es for Collabora/on, Research and Educa/on
Dr. Susan Dent Medical Oncologist, The Ottawa Hospital Cancer Center Associate Professor of Medicine University of Ottawa President of CCON
Dr. Daniel Lenihan Cardiologist Professor of Cardiovascular Medicine Director of Clinical Research President of ICOS – North America Vanderbilt University Medical Center
Friday, September 30th, 2016
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Click to edit Master /tle style Chemotherapy Targeted agents
radia/on
Click to edit Master /tle style VSP InhibitorsHypertensionHeart Failure Thrombosis
Her2 Targeted TherapiesCardiomyopathy
AnthracyclinesRadiationHeart FailureCAD
Anti-metabolites (5FU)IschemiaVasospasm
PI3K InhibitorsHyperglycemiaMetabolic?Myocardial/Arrhythmia
BTK InhibitorsIbrututinib:Arrhythmia/Atrial Fibrillation
MEK/RAF TKICardiomyopathy
Drugs Affecting UPSImmunomodulators (IMiDs): thrombosisProteasome inhibitors (e.g. bortezomib, carfilzomib): vascular
HDAC inhibitorsArrhythmia
Cancer Immunotherapies????Cancer Survivorship
CML TKIsImatinib: ?protectiveDasatinib/Nilotinib/Ponatinib:PAH/Vascular/Atherosclerosis
Adapted from Moslehi, Cheng. Science Transla,onal Medicine, 2013. Moslehi, NEJM. In press.
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Op/mize Cardiac Health Best Cancer Care
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England
Italy
Israel
Poland
India
Brazil
Cardio-‐Oncology Clinics
Click to edit Master /tle style Rapid access to
cardiologists with an understanding of systemic /targeted
therapies.
What does a clinic offer ?
Educa/on of pa/ents and health care providers
Resident/fellowship training Preceptorship
Mul/disciplinary rounds
Rapid Access to a collabora/ve research environment. This can include basic and
transla/onal research (if this infrastructure exists – such as in an academic medical center) or
clinical research.
Click to edit Master /tle style Establishing a Cardio-‐oncology program
Sulpher et al, 2014-‐2015 Report Card on Cancer in Canada
JACC, volume 66, No. 10, 2015
Click to edit Master /tle style Impact of Cardio-‐Oncology Clinics
Progress in Pediatric Cardiology, 2015
Click to edit Master /tle style Cardiotoxicity: Recovery Registry (CTR) The purpose of the Cardiotoxicity: Recovery Registry is clarify the mechanisms of cardiovascular toxicity, recognize the typical presenta/on and discern the best methods for clinical detec/on, describe op/mal therapeu/c op/ons as well as iden/fy poten/al strategies for preven/on of cardiac dysfunc/on. The specific aims of the cardiac safety registry are: § Iden,fy the cancer therapeu,cs and the cancer condi,ons in which cardiac dysfunc,on,
poten,ally as a result of cancer therapy, can recover back to pre-‐chemotherapy levels or improve substan,ally with effec,ve cardiac treatment
§ Describe the clinical tools that are most useful and cost effec,ve at enhancing recovery of cardiac dysfunc,on
§ Detail the therapeu,c strategies that are most useful and cost effec,ve at promo,ng recovery of cardiac dysfunc,on
Click to edit Master /tle style • Mul/disciplinary cardio-‐oncology
rounds • CME presenta/ons • Preceptorship programs • Cardio-‐Oncology Training
Educa/on
• website (www.cardiaconcology.ca) and ICOS (www.icosna.org)
• Cardio-‐oncology mee/ngs (GCOS) • Posi/on statements/guidelines
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§ Evalua/on and Management of Cardiovascular Complica/ons of Cancer Therapy. Canadian Journal of Cardiology, July 2016
• ASCO Survivorship Guideline
§ Preven/on and Monitoring of Cardiac Dysfunc/on in Survivors of adult cancers: ASCO Clinical Prac/ce Guideline, accepted for publica/on JCO September 2016
• ESC PosiHon Paper
§ 2016 posi/on paper on Cancer treatments and Cardiovascular Toxicity Eur Heart J. August 2016
Guidelines/Posi/on Statements
Click to edit Master /tle style Cardio-‐Oncology Journal
h[ps://cardiooncologyjournal.biomedcentral.com/about
Click to edit Master /tle style There are many challenges…... • How can we predict who will develop cardiotoxicity ?
• What are the best preven/on strategies ? • How do we monitor those at risk of cardiotoxicity ?
• What are the best management strategies?
Click to edit Master /tle style • Long term sequelae of these agents in the non – clinical trial pa/ents (registry data)
• Cardiotoxicity associated with ‘mul/ple’ hits • Cardiac monitoring long term (survivors) • Monitoring of pa/ents on long term therapy (e.g pertuzumab/trastuzumab in MBC)
• If cardiac medica/on is started when do you stop ? • Effects of radia/on and targeted agents?
What we don’t know
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Onco logist
HCP
Cardiologist
React-‐EF Op/miza/on of cardiac monitoring
Survivorship
Early detec/on of cardiotoxicity using markers of apoptosis SAFE study
Cardiac protec/on
during cancer treatment
Interna/onal cardio-‐oncology registry
Risk predic/on of
cardiotoxicity
RESEARCH
Click to edit Master /tle style Cardio-‐Oncology studies • PREDICT (anthracycline therapy) • PROTECT (proteasome inhibitor therapy) • CREST (an/-‐VEGF based therapy) • VITAL Amyloidosis (NEOD001-‐an/ AL amyloid ab) • PACE (Breast Cancer observa/on of cardiac outcomes)
• Biomarker Pilot (cardiac biomarker feasibility) • HGF levels (novel biomarkers) in Cardiac Amyloidosis
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Op/mize Cardiac Health Best Cancer Care
Click to edit Master /tle style • Cancer and heart disease are significant causes of morbidity and
mortality
• Improvement in cancer therapies has resulted in long term survivors who may be at risk of cardiotoxicity.
• Individuals with heart disease may develop cancer and require poten/ally cardiotoxic cancer therapy.
• Close collabora/on among health care providers is needed in order to provide the best cancer care while op/mizing cardiac health.
Take Home Messages
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Topics include: • How to deliver a Cardio-‐Oncology service • Training in Cardio-‐Oncology • eHealth and Cardio-‐Oncology • How do I measure the quality of my service? • Role of primary care in cancer survivors • Immunotherapy and emerging cardiotoxicity • Personalised medicine & gene/cs • EP session –who should have abla/on, ICDs, CRT? • An/coagula/on and an/thrombo/c (AF, ACS) • Radia/on-‐induced cardiotoxicity • Managing cardiac issues during BMSC transplants • Cardiac tumours, carcinoid valvular disease, amyloid • Hormone therapy and CV risk
Click to edit Master /tle style Thank-‐you Nadine !!!!!