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Emerging field of cardio-oncology seeks better tools

October 31, 2016 | Dagny Stuart

Cardio-oncology team

Members of the VUMC Cardio-oncology team include (front row from left) Randy Barret, Terisa Thorpe, Sheryl Kernodle, R.N., David Slosky, M.D., Lisa Mickey, LPN, (middle row, from left) Daniel Lenihan, M.D., Nirman Bhatia, M.D., Javid Moslehi, M.D., Donald Okoye, (back row, from left) Kim Schafer, R.N., Weijuan Li, M.D., and Mary Barber. (photo by Anne Rayner)

Improved therapies have led to a spike in the number of people living with cancer, and today there are more than 15.5 million survivors in the United States. However, some of these therapies can cause toxicities to the heart, the vessels and the body’s metabolism.

In a new article in the The New England Journal of Medicine, Javid Moslehi, M.D., assistant professor of Medicine and director of the Cardio-Oncology Program at Vanderbilt University Medical Center (VUMC), reports that more research and enhanced collaborations among medical disciplines are needed for this emerging field of cardio-oncology.

Early cancer treatments were essentially “poisons” that killed cancer cells (along with healthy cells). In the past decade there has been an evolution in cancer therapy with the introduction of targeted therapies that allow patients to be treated for their specific type of cancer. VUMC and Vanderbilt-Ingram Cancer Center (VICC) have become leaders in this commitment to precision medicine.

“Many of these therapies target essential pathways in the cancer, but these pathways are still important in normal cells like those in the cardiovascular system. As a result, the very therapies that save you from cancer can lead to various cardiovascular and cardio-metabolic issues,” Moslehi said.

Vanderbilt has emerged as a leader in the effort to determine the causes of cardiotoxicity from targeted cancer therapies and to develop preventive and treatment strategies for these complications for patients.

“The uniqueness of the Vanderbilt cardio-oncology program hinges on the close working relationship between cardiologists and oncologists, as well as basic and clinical researchers,” Moslehi said.

Translational science investigators are thinking mechanistically about why cardiovascular issues arise from these new therapies and are working to develop systems to explore the mechanisms of toxicity.

“Development of preclinical laboratory models allow for screening platforms where one may predict which drugs will have cardiotoxicity at the onset,” Moslehi said. “These models can also help elucidate the mechanisms of cardiotoxicity for approved drugs.”

Moslehi adds that cardio-oncology may represent a new platform for personalized or precision medicine. In the published article he writes, “Just as so-called precision medicine has revolutionized cancer treatment, a similar personalized approach must be incorporated in toxicity assessment in drug selection.”

There are patients who are at risk for toxicity and we must get smarter about risk factors, including genetic ones, that predispose to toxicity, he said.

Another new dimension of cardio-oncology is the growing appreciation that common risk factors predispose patients to both cancer and heart disease.

“Some of the risk factors (such as obesity, diabetes and high cholesterol) that we traditionally associate with cardiovascular disease appear to also serve as risk factors for certain cancer types,” Moslehi said.

This concept may be particularly relevant in the cancer survivor who is both at risk for cardiovascular disease as well as recurrence of cancer. The Vanderbilt cardio-oncology program has developed an algorithm (so called “ABCDE” algorithm) to address the cardiovascular health of cancer survivors.

“This same algorithm may reduce the risk for cancer recurrence in these patients,” Moslehi adds.

Indeed, the Vanderbilt cardio-oncology program has emerged as a leader in the field based on this emphasis on scientific inquiry, personalized medicine and collaboration with other scientists and government agencies. Vanderbilt’s Daniel Lenihan, M.D., has helped spearhead an international cardio-oncology society, which held its annual meeting in Vancouver in September.

For Moslehi, such research collaborations need to include other academic centers along with industry and the Food and Drug Administration (FDA). The FDA recently launched an initiative to better understand the cardiotoxicity of new cancer drugs. Moslehi and Lenihan helped organize a recent workshop held at the FDA on the cardiotoxicity of cancer therapies.

For Moslehi, another emerging aspect of this field includes education.

“Cardio-oncology is a growing area in medicine. It is important for us to develop a structured fellowship where we can educate the next generation in this field.”