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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  

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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  

Click  to  edit  Master  /tle  style  •  CCS  Guideline  

§  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    

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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  !!!!!