American cardio-oncologist Richard Steingart: cardiologists and oncologists are obliged to cooperate for the sake of patients
How oncologists interact with cardiologists in local clinics is a mystery covered in darkness.
Cardiac oncology, a clinical area dedicated to the treatment of cardiovascular diseases in patients with malignant neoplasms, grew in the mid-90s from experiments conducted at the junction of two disciplines, quickly developed into a niche format and is now becoming a dynamic segment of the global healthcare industry. The volume of the market of specialized services is already estimated at more than $ 1 billion, and its annual growth, at least until 2020, is projected at 12.2%. Richard Steingart, head of the cardiology department at Memorial Sloan Kettering New York Cancer Center, told one of the pioneers of the cardiology department how the experimental methods of treatment overgrown with infrastructure, attracted specialists and funding, which still interferes with the productive interaction of cardiologists and oncologists and why there is a front line for all signs discipline has not yet received the status of a medical specialty in the United States.
"HOSPITAL IS A STRONG TOWER"
- How and in connection with what cardio-oncology began to develop?
- Discipline began to form when cancer patients began to live long enough, and cancer became, in fact, a chronic disease. Since 1995, the drug Trastuzumab began to be used to treat metastatic breast cancer, a terrible, highly progressive disease. He allowed to turn this terrible, often fatal disease into a curable disease for a huge number of women of different ages. However, it soon became clear that the use of this drug simultaneously with drugs of the anthracycline group [antibiotics with antitumor activity. - Vademecum] gives a high percentage of chronic heart failure.
Then it became clear to oncologists that it is necessary to pay close attention to the side effect of such treatment arising from the cardiovascular system. After all, no doctor wants a patient, whom he cured of breast cancer with such difficulty, to die a year or two later from heart failure. In the United States, one in eight to nine women are diagnosed with breast cancer, one in four - the type of tumor that will show trastuzumab, that is, huge numbers. The main task was to develop such a treatment plan, in which the risk of developing chronic heart failure would be minimized. Here began a dense interaction of cardiologists and oncologists.
- When did you plunge into the topic of cardiac oncology?
- In 2003, when I got a job at Memorial Sloan Kettering. Then this topic was here, as they say, on everyone's lips. Somewhere in 2005–2006, trastuzumab was approved as an adjuvant therapy for early stages of breast cancer, that is, very soon it should have been started to be massively applied in treatment, in particular, HER-2-positive breast cancer in women. Cardiologists and oncologists should together look for ways to reduce the risks of possible heart failure. And here my previous experience came in very handy - before joining Memorial Sloan Kettering, I worked as a cardiologist, did a lot of research related to heart failure. And then a new unique task appeared.
- Was this clinic the first place where cardiac oncology began to develop?
- One of the first. In addition to Memorial Sloan Kettering, then MD Anderson, Mayo Clinic, Harvard, Stanford and, perhaps, all were engaged in cardiac oncology. In these medical centers, the systemic interaction of cardiologists and oncologists in the treatment of breast cancer was born and began to build. By 2011, there were already 10 such centers, in 2016 - 70.
The direction has evolved exponentially, helped by the economic factor. Herceptin is far from a cheap drug, and insurance companies had to prove all the time that patients could take this course of treatment without any risk of heart failure, or at least with minimal risk.
- How did the cardiologists and oncologists work together? Was a special department created?
- No, there was no new branch. We were very lucky at Memorial - we had an oncologist who was inspired by the idea of such cooperation and decided to take over the entire organization of collaboration, in particular - to control the mandatory and regular testing of patients for possible development of heart failure. She was a “voice”, a transponder of the position of cardiologists for oncologists and vice versa, that is, she ensured that oncologists performed everything that was recommended by cardiologists, and this helped a lot.
And now, an effective system for providing cardio-oncological care is built where there is an oncologist who believes in the need for cardiological diagnosis and therapy and becomes a communicator for others. We have an expression: a hospital is a silo tower, that is, a strict vertically managed organization. It is very difficult to implement something new here, but the human factor decides everything: you need to find someone you trust and who your colleagues will trust.
“ON THE INTRODUCTION OF THE RULE TO THE PRACTICE WAS YEARS OLD”
- How much time did it take you for cardio-oncological care to become systemic?
- Everything did not happen as quickly as we would like. There are a lot of difficult questions. No one wants to take the burden of responsibility, for example, to cancel therapy in case of heart failure, there is evidence that if you stop the course ahead of time, nothing good will come of it.
Therefore, doctors can say: "Let the patient have heart failure better than she does not complete the course and will remain with breast cancer and metastasis." We believe that you can do everything at the same time: monitor the heart, warning heart failure, and at the same time give a full course of therapy, and explain it to colleagues.
But here is an example. Only recently, that is, 15 years after the start of work, we were able to introduce a mandatory rule for issuing drugs to patients only after the doctor signs under what he saw the results of heart monitoring and what to give the drug safely. That is, it is now necessary to confirm that the problem of heart failure is being monitored, the doctor looked at the tests, confirming that the results are in order, you can give medicine. But the introduction of this rule into practice took years.
True, we have to admit that not everything in the organization of this system depended solely on us. There are recommendations that patients with breast cancer should be screened regularly for possible development of heart failure. Studies show that only 40–60% of patients follow these guidelines. In Memorial, things are better - at the level of 65–70%, but the numbers are still disappointing. They say that a huge number of patients, unfortunately, ignore the recommendations.
It is necessary to understand that cancer is hard, traditional methods of treatment of this disease are exhausting physically and morally. And then the patients are told: “You should go to another clinic for an additional examination.” Even if the insurance pays for such a diagnosis, it is difficult for patients to gather strength for any additional procedures. Therefore, we at Memorial tried to make this procedure as comfortable as possible for patients. For example, we schedule an examination on the same day when the patient is undergoing chemotherapy, the treatment room is located next to the room where the heart is diagnosed. That is, we are trying to eliminate barriers that prevent the passage of necessary diagnostics.- How has the death statistics for cancer patients in the USA changed after trastuzumab therapy, accompanied by cardiological monitoring?
- When the drug was approved, the death rate from this disease immediately decreased, in absolute numbers by about 15–20%, and this is an amazing result. Now in the US, it has become standard practice for patients to receive such therapy with appropriate tumor markers. The average age of patients who are prescribed such treatment is 49-50 years, that is, they are young women. With age, it is this type of cancer that is becoming more and more rare, HER ‑ 2 ‑ negative type of breast cancer occurs more often, women are 60–70 years old. If women are diagnosed with cancer later, it becomes a great tragedy, because trastuzumab can be used in the early stages. Combined therapy allows to increase the life expectancy of a woman up to 10 years after the start of treatment. We now have an 87% survival rate after diagnosing cancer at an early stage, and 10 years after starting treatment, most women feel normal.
"A wave of new oncological drugs has swallowed us"
- Do cardiologists and oncologists interact in the treatment of other types of malignant neoplasms?
- Of course. Now we see a trend - those types of cancer that were once not cured, develop into chronic diseases. So, for example, happened with a germ cell tumor - the one that was Lance Armstrong [famous American cyclist. - Vademecum]. This tumor is treatable, but in patients undergoing chemotherapy, premature heart attacks were recorded, and, of course, you need to constantly monitor them.
Another example is people who survived cancer in childhood, children with leukemia or lymphoma who were exposed to radiation or were taking anthracycline, and they also need to be constantly monitored by cardiologists. Therefore, we are trying to work with these groups. Of course, there are fewer such patients than women with breast cancer; they occur occasionally, so it is much more difficult to control this situation.
And we are overwhelmed by a new wave of drugs for the treatment of cancer, many of which have side effects from the cardiovascular system. These are hundreds of drugs. It all started with a single drug, and now we have a lot of them, and almost everyone has their own history of side effects on the heart to varying degrees. Therefore, the interaction of cardiologists and oncologists becomes mandatory.
But the problem is also in the fact that in the USA a huge part of oncological assistance is provided outside the large centers. How oncologists interact with cardiologists there is a mystery covered in darkness. All the data that we have is information from the main specialized medical centers, but this is not even half of all oncological assistance provided in the country. Now we are trying to understand how it would be possible to improve the interaction between oncologists and cardiologists in local clinics. A lot of problems.
- How is cardiopulmonary care now organized where interdisciplinary dialogue took place in the same large clinical centers?
- As a rule, a couple of cardiologists who work as cardiac oncologists work there. They are given one day shift or half day to examine patients for whom oncologists have relevant concerns. In the hospital there are individual specialists who monitor possible problems of the cardiovascular system. Memorial Sloan Kettering and MD Anderson are exceptions to the rule.
We have 14 cardiologists who are immersed in the topic, but at the same time, there are only two or three doctors who can say about themselves, “Yes, I’m not interested” in such wonderful hospitals as the University of Pennsylvania, Massachusetts General Hospital. cardio-oncologist. "
That is, it is usually a couple of interested people who have completed a course of study that helps to understand all aspects of this topic. In fact, you need to learn anew for a new specialty, it is difficult and not for everyone to do. Here you need to understand the patient's medical history, find out what cancer problems he encountered, and then also determine what is in his heart. It takes a lot of time.
- The initiators of the interaction, as a rule, are cardiologists or oncologists?
- In the case of adult patients, the discipline providers were cardiologists, while treating children, oncologists became the initiators, who saw how their work was nullified by the toxic effects of chemotherapy. But then again, all the work here comes down to the initiatives of one or two oncologists who have realized the destructive nature of the toxicity of the therapy for the cardiovascular system and pulled the cardiologists after them.
If we talk about opinion leaders, popularizers of cardiac oncology in the United States, first of all it is Sandra Swain, the former head of ASCO [American Society of Clinical Oncology - Vademecum], a cancer specialist, she involved a huge number of cardiologists in the history of trastuzumab. George Bozl was such a man in the study of a germ cell. For me, they are the champions leading the whole cardiac oncology.
"THE FUTURE OF CARDIONOLOGY IN RUSSIA IN GOOD HANDS"
- During the years of your work, has the discipline been somehow fixed in the regulatory field of the American health care system?
- We communicated with representatives of accrediting bodies that deal with such narrow specialties as, for example, electrophysiology or treatment of heart failure, but they told us that at the moment they are not interested in registering a new narrow specialty. Meanwhile, every year it will be more and more difficult for us to do it: now there are too many new certifications, requirements for securing a new specialty, and therefore, more and more barriers. So while the systemic development of cardiac oncology is the prerogative of professional communities.
There is a large, constantly growing interest in discipline on the part of academic medicine. But even here, the lack of specialty status in cardiac oncology hampers the development, in particular, the receipt of research grants. There are several institutes in the USA where we can receive appropriate grants, including, for example, the National Heart, Lung and Blood Institute (NHLBI), the National Cancer Institute (NCI), and they are in turn under the leadership of the National Institutes of Health (NIH).
So, if I apply for a grant to NIH or NHLBI, and the grant will deal with interdisciplinary problems arising at the interface of breast cancer and cardiovascular diseases, I will most likely be told: National Cancer Institute. And vice versa. When there are requests for research subsidies in such a hybrid area, you need to gather in one room specialists from different fields who have sufficient expertise to consider such proposals, and this is a difficult additional work.
Pharmaceutical companies are also not eager to maintain discipline, and this is understandable - when you develop a new drug treatment, you don’t really want to understand all of its monstrous side effects on the cardiovascular system. Side effects that may affect their drug approval are the last thing they want to explore.
- In which countries do you think cardiac oncology is most developed now?
- In addition to the United States, of course, this is Italy and Canada. Many interesting things are doing in China. As I said, the initiative requires one or two people who will have enough desire and energy to advance this story. In each of the countries listed, one such person can be called. In Italy, this is my colleague Daniela Cardinale, in Canada, Susan Dent, and in the United States, Dan Lanichen. That is a separate person. The Europeans, by the way, in the field of regulation of cardiac oncology went further than the Americans: they developed standards, guidelines, curricula for medical specialists. In the US, these materials have not even begun to be developed.
In other words, it is necessary to recognize that the European Society of Cardiology and the European Society of Medical Oncology have been more active in structuring cardio-oncological care than similar American trade-union organizations. We see interest in this topic from Russia as well. Three to four years ago, your doctors came to us in New York to see how our department was organized, to observe the process. And I was shocked by their level of knowledge and desire to develop this topic in my clinics. So, I think, the future of cardiac oncology in Russia is in good hands.
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