Late Effects of Treatment

on the HeartJennifer H. Jordan, PhD, MS

William O. Ntim, MD, FACC, FACP

Wake Forest Baptist Medical Center

Panel Speakers

2

Jennifer H. Jordan, PhD, MSAssistant Professor, Cardiovascular MedicineComprehensive Cancer CenterCardiovascular Sciences CenterWake Forest School of MedicineWinston-Salem, NC

William O. Ntim, MD, FACCMedical Director, Cardiooncology ProgramNovant Health Heart & Vascular InstituteCharlotte, NC

Adjunct Clinical Assistant ProfessorCardiovascular MedicineWake Forest School of MedicineWinston-Salem, NC

Wake Forest Baptist Medical Center

Disclosures

3

Jennifer H. Jordan, PhD, MSResearch Grants:Health and Environmental Sciences Institute THRIVE Research Grant (PI)National Institutes of Health Research Grants (Co-I)

National Cancer Institute (R01CA199167)National Heart, Lung, and Blood Institute (R01HL118263, R01HL118740)

William O. Ntim, MD, FACCNone

Wake Forest Baptist Medical Center

Outline

• A growing population of survivors

• What are the late effects of treatment?

• What signs and symptoms should I be aware of?

• Seeking care for late effects

4

Wake Forest Baptist Medical Center

A Growing Population of SurvivorsThe public health perspective

Wake Forest Baptist Medical Center

Growing Population of Older Survivors

6SM Bluethmann et al. Cancer Epidem Biomar, 2016.

Wake Forest Baptist Medical Center

Lifespan is Increasing in Survivorship

7JS de Moor et al. Cancer Epidem Biomar, 2013.

Wake Forest Baptist Medical Center

Survivors have Poorer Health Status

8KR Yabroff et al. JNCI, 2004.

• Comparison of cancer survivors and age-

matched individuals from the National Health

Interview Survey in 2000

• Multiple measures of burden asked

Wake Forest Baptist Medical Center

Survivors have Poorer Health Status

9

Excellent

Very Good

Good

Fair

Poor

CANCER SURVIVORS (N=1817)

Excellent

Very Good

Good

FairPoor

NON-CANCER CONTROLS (N=5465)

KR Yabroff et al. JNCI, 2004.

31% Fair or Poor 18% Fair or Poor

Wake Forest Baptist Medical Center 10

• 1st generation of AYA survivors now entering 4th

and 5th decades of life

• Childhood Cancer Survivor Study

• N= 14,359 childhood cancer survivors

• N= 4,301 siblings

• Classified health conditions with NCI CTCAE

GT Armstong et al. JCO, 2014.

Wake Forest Baptist Medical Center

Earlier Chronic Health Conditions in

Childhood Survivors

11GT Armstong et al. JCO, 2014.

All Conditions Cardiac-Specific

Wake Forest Baptist Medical Center

More Frequent Chronic Health

Conditions in Childhood Survivors

12GT Armstong et al. JCO, 2014.

Wake Forest Baptist Medical Center

What are the late effects of treatment?Understanding cardiovascular side effects

Wake Forest Baptist Medical Center

Cardiac Effects of Cancer Therapies

14J Tromp et al. Clin Pharm Thera, 2017.

Wake Forest Baptist Medical Center

The Snowball Effect

15P Reddy et al. J Geriatric Oncology, 2017.

Wake Forest Baptist Medical Center

Side Effects of Cancer Therapies

16MC Cupit-Link et al. ESMO Open, 2017.

Myocarditis: Immune Checkpoint

Inhibitors?

Wake Forest Baptist Medical Center

Anthracycline Chemotherapies

17

• Daunorubicin (Cerubidine)• Doxorubicin (Adriamycin)• Doxorubicin liposome

injection (Doxil)• Epirubicin (Ellence)• Idarubicin (Idamycin PFS)• Valrubicin (Valstar)

RegimensACTAC

ABVDCHOP

R-CHOPEPOCH

R-EPOCHFAC

Known Risk Factors:Age (children, >65 years)Pre-existing heart disease

Cumulative doseCombination chemotherapy

Mediastinal radiation

Incidence of Heart Failure by Cumulative Dose

400 mg/m2 5%

500 mg/m2 16%

550 mg/m2 26%

Swain et al. Cancer, 2003.

Wake Forest Baptist Medical Center

Targeted Therapies

18E Raschi et al. Int Emg Med, 2012.

Trastuzumab (Herceptin)Bevacizumab (Avastin)

Iapatinib (Tykerb)Sunitinib (Sutent)

Sorafenib (Nexavar)

Wake Forest Baptist Medical Center

Androgen Deprivation Therapy for

Prostate Cancer

19N Bhatia et al. Circulation, 2016.

Wake Forest Baptist Medical Center

What are the signs and symptoms

I should be aware of?Raising your level of awareness

Wake Forest Baptist Medical Center

New Changes to Be Aware of:

• Fatigue

• Dyspnea or difficulty

breathing

• Weight gain

• Edema or swelling

• “Coughing spells”

21

Wake Forest Baptist Medical Center

Chronic Symptoms in Adult Survivors

• Fatigue – persistent in 25%, related to intensity

of prior treatments

• Cognitive difficulties – 15-20%, depending on

the type of treatments

• Decreased physical functioning

• Insomnia

22

Wake Forest Baptist Medical Center

Seeking care for late effectsA growing field of cardio-oncologists

Wake Forest Baptist Medical Center

Cardio-Oncology

24

Wake Forest Baptist Medical Center

Addressing Increased CV Risk

• Health promotion

• Avoiding tobacco, alcohol, weight gain

• Enhanced physical activity to maintain function

• Monitor bone health

• Management of post-treatment symptoms so that

they do not progress or inhibit function

• Discuss your symptoms with your physician as

they may warrant imaging or stress testing

25

Wake Forest Baptist Medical Center

ABCDE Algorithm – Breast Cancer

26K Montazeri et al. Circulation, 2014.

Wake Forest Baptist Medical Center

ABCDE Algorithm – Prostate Cancer

27N Bhatia et al. Circulation, 2016.

Wake Forest Baptist Medical Center

Common Cardiovascular Imaging Tests

28

Echocardiography Cardiac MRI

Wake Forest Baptist Medical Center

Cardiovascular Stress Tests

29

Wake Forest Baptist Medical Center

New Frontiers in Cardio-Oncology

• Improving baseline risk stratification

• Studies of imaging and biomarkers to monitor

cardiovascular changes during and after treatment

• Current studies with common cardiovascular drugs

to reduce cardiac side effects of cancer therapies

• Monitoring cardiovascular complications of new

therapies

• Development of cardio-oncology education,

physician training, clinics, and outreach

30

Thank you!