More than five percent of the American population are cancer survivors, and that number is expected to grow exponentially over the coming years. By 2032, the National Cancer Institute projects there will be 22.5 million cancer survivors living in the United States, which would be a nearly 25 percent increase over today.
Encouraging as this news is, it’s not the whole story. As one survivorship study published last year in an American Cancer Society journal put it, "Many cancer survivors must cope with the physical effects of cancer and its treatment, potentially leading to functional and cognitive impairments."
Chester County Hospital is ramping up a program that’s designed to better detect heart health issues in cancer survivors that can stem, in part, from their treatment.
"We're really trying to innovate and find different ways to minimize toxicity and other health-related issues because we want to focus our survivors on their recovery and wellness as they move forward with their lives," says Sandra Moffat Camarota, MSN, CRNP, AOCNP, the Survivorship Program Coordinator at the Abramson Cancer Center at Chester County Hospital.
Roughly 15 years ago, Joseph Carver, MD, the current Chief of Staff at the Abramson Cancer Center at the University of Pennsylvania, anticipated what was coming and began developing what is known today as Penn Medicine's cardio-oncology program. Essentially, Abramson oncologists started collaborating with cardiologists to identify patients who were at elevated risk for heart disease related to their cancer treatment.
"This is not intended to be an urgent consult," Camarota says. "Rather, it's meant to be an evaluation by the cardiologist to determine risk and plan interventions to help mitigate that risk."
About five years later, in 2013, Dr. Carver met with several providers at Chester County Hospital's Abramson Cancer Center, including Camarota. William Clay Warnick, MD, FACC, the Medical Director of the hospital's Cardiovascular Service Line, was in attendance, too. Dr. Warnick studied and trained under Dr. Carver, who, on this day, laid the groundwork for bringing the cardio-oncology program to Chester County Hospital.
Camarota and Dr. Warnick have largely steered the effort since, although they receive guidance from a larger network. From 7 to 8 AM on the first Friday of each month, Dr. Carver leads a virtual meeting of representatives from every Penn Medicine hospital to discuss strategies and insights into detecting heart disease in cancer survivors sooner and treating it more effectively. They’ve been doing this for the last seven years or so.
The group also includes Bonnie Ky, MD, MSCE, the director of The Penn Cardio-Oncology Translational Center for Excellence and, according to Dr. Warnick, one of the field's foremost experts.
Many of the most sophisticated cancer treatments being performed today are done at the Abramson Cancer Center at the University of Pennsylvania. Thanks to these monthly conferences, Dr. Warnick says he's able to learn how the newest drugs can potentially affect the heart well before they're more widely used.
"Cancer therapies have truly exploded over the last several years," he says. "Without this group, I'd have a more difficult time deciphering them and anticipating their potential impacts."
Streamlining Risk Assessment
According to Dr. Warnick, the most prevalent types of cancer treated at Chester County Hospital are breast, prostate, and lung. This has enabled him and Camarota to focus on drugs like doxorubicin and trastuzumab. These drugs, which are used to treat some types of breast cancer, can potentially elevate a person's risk for heart-related issues.
"We look at the medical history for other risk factors like obesity, diabetes, hyperlipidemia, hypertension, and atrial fibrillation," Camarota says. "Even family history of heart disease can elevate risk."
Occasionally, Dr. Warnick and his team are asked to offer guidance on patients who develop changes in heart function during their cancer treatment. Still, most patients referred by Camarota have completed their cancer treatment and are in remission.
"They may be completely asymptomatic at the time of our visit, but I always say to the patient, 'I'm not worried about your heart right now. I'm worried about your heart five to 10 years down the road.' And I try to encourage them to seek consultation," Camarota says. "Ideally, we like for them to follow up with a cardiologist within a year after treatment is completed because, according to the National Comprehensive Cancer Network, the risk elevates for many patients when they reach the five-year mark. The goal is to do the cardiovascular risk assessment and see if there's anything that can be done now to avoid or minimize the progression of any cardiovascular issues in the future."
Dr. Warnick says he's learned from Drs. Carver and Ky that age is a key variable in determining someone's risk for developing heart trouble after their treatment. Also on that list is the strength of their heart. "We want to know what their heart looks like because there are medications that can put them at risk of fluid retention or congestive heart failure," he says.
He also asks about other conditions – hypertension, high cholesterol and diabetes are all significant risk factors – and lifestyle. Research has shown that the more active you are, the better you should be able to tolerate therapy.
"I can also easily access all of their imaging, including the CT scan of the chest or abdomen that’s typically done during a staging workup or in a diagnosis," Dr. Warnick says. "That allows me to quickly see if there’s evidence of any type of atherosclerotic disease present in their coronary arteries and/or aorta or vasculature, which then gives me further insight into their risk."
Improving with Demand
Since moving toward a more formalized referral process, Dr. Warnick says they've made the greatest inroads with detecting potential heart issues related to breast cancer therapies. "We've really sharpened our skills as far as imaging of the heart muscle during an echocardiogram with strain" – a newer ultrasound test that enables providers to identify subtle changes in heart function – "to be better predictors of complications of therapy, specifically with trastuzumab and doxorubicin," he says. "We can now predict earlier, much earlier than we were able to just five years ago, who is at risk of having a complication of breast cancer therapy."
Recently, two cardiologists in Dr. Warnick’s practice, Sharayne Mark Coffin, MD and Adrian Richard Pearson, DO, also began doing cardio-oncology consultations. (Dr. Pearson will return to the practice in July 2024 after completing a yearlong fellowship at the University of Pennsylvania.) Dr. Warnick says their help became a matter of necessity.
"Because of our aging population, the advancements in cancer treatment, and all the phenomenal work that Sandy and her group are doing, the need for cardiology-oncology is only going to continue to grow," he says. "Originally, it was just kind of a niche. But from our own experience and those shared with us throughout our network, it's clear now that it’s here to stay."