By the year 2030, there will be around 22 million cancer survivors. And while cancer treatment continues to improve, it’s an unfortunate reality that many of these patients are at increased risk for cardiovascular issues, because of biology or as a byproduct of their life saving treatments. But recently, the field of cardio-oncology has emerged to help cancer patients minimize short and long term risks to their hearts. Dr. Stephanie Feldman speaks about the research pushing this innovative field forward and how it will increase the quality of life for so many patients in the years to come.
As methods for early cancer detection improve and the number of cancer survivors rises, the innovative field of cardio-oncology has emerged to ensure that patients with chemotherapy or cancer-related cardiac dysfunction can be safely, and swiftly, treated for their cancer. Dr. Stephanie Feldman, a clinical cardiologist with focus on cardio-oncology at NewYork-Presbyterian/Weill Cornell Medicine, is one of a growing number of physicians advancing research and pushing care in this field forward with a multi-disciplinary, comprehensive approach to care. Dr. Feldman joins us to discuss the rare risks of immune checkpoint inhibitors, how genetic mutations could put patients at risk for arterial thromboembolism, and how the cardio-oncology field can optimize the course of cancer care for patients at risk for cardiovascular complications.
For more information visit nyp.org/Advances
[00:00:00]
Catherine Price: Stephanie Feldman always knew she was going to be a doctor.
Dr. Stephanie Feldman: That was easy, I'm a third generation physician.
Catherine Price: But she wasn't sure what her specialty would be.
Dr. Stephanie Feldman: My advisors and my program directors will tell you I've always been a pain and that I, I, I like too many things, which means that I'm excited about a lot of things. I liked the longitudinal care of patients, I really liked primary and secondary prevention of disease, particularly cardiovascular disease, so I was thinking about cardiology. Ilike taking care of really sick patients. And then I, uh, also had an interest in benign hematology. I like DVTs and PEs, So when I told my medicine program director this, he said, well, that's great. You can't apply for all of those things.
Catherine Price: That's actually impossible. Right?
Dr. Stephanie Feldman: Correct. Correct. He said, at some point, you'll have to decide.
Catherine Price: But then, she discovered an emerging field during her residency: cardio-oncology.
Dr. Stephanie Feldman: So cardio oncology is the care for patients who have cardiovascular disease and develop cancer, [00:01:00] have cancer and develop cardiovascular disease, or there are some cancer treatments that can cause short and long term cardiovascular issues.
The first drug that we knew caused heart problems was the anthracyclines, doxorubicin, adriamycin. We know that that drug can cause cardiomyopathy. And so that's what traditionally has been associated with cardio oncology.
However, over the years, we have found as we have more targeted therapies to the cancer, as we are activating the immune system with things like immune checkpoint inhibitors, as well as with CAR-T cell therapy, that we're also inadvertently, impacting the heart.
There's more and more evidence that patients who have, cancer are at increased risk for cardiovascular disease.
Catherine Price: Cardio-oncology not only combined Dr. Feldman’s many medical interests-- cardiology, longitudinal patient care, benign hematology-- into one subspeciality. [00:02:00] It also gave her the opportunity to work on the forefront of an innovative field. One that requires intimate knowledge of multiple specialties, plus a willingness to collaborate with a constellation of patient providers.
Dr. Stephanie Feldman: I really like following patients before, during, after cancer treatment and then the multidisciplinary care. I am probably the quarterback for my patients teams where despite everything being in the medical health record, these patients are so complicated and have been through so much. It's really helpful to help them to navigate all of the different providers, um, and things that they need to do to stay healthy.
We know that there are going to be the year 2030, something like 22 million cancer survivors. We are doing much better at diagnosing cancer early. And having better survival rates for our cancers. Those are people who are at higher risk for cardiovascular disease because of shared risk factors, but also because of their treatment exposures.
You know, you work so hard and you go through all of this treatment [00:03:00] to get your cancer treated. I'm here to make sure people don't forget about your heart so that you don't die of a heart attack or stroke after all that you've been through.
Cardio oncology really focuses on patients throughout their care continuum before, during, and after cancer treatment. And really to, optimize the cancer care that patients get so that they can get the best possible treatment for their cancer and minimize the short and the long term risks to their heart.
Catherine Price: I'm Catherine Price and this is Advances in Care. Today on our show, my conversation with Dr. Stephanie Feldman, a clinical cardiologist with a focus on cardio-oncology at New York Presbyterian-Weill Cornell Medicine, and Assistant Professor of Medicine in the Division of Cardiology at Weill Cornell Medical College.
Catherine Price: Can you walk me through what cancer treatment might have looked like for a patient before cardio-oncology emerged as a field, what would the treatment have been like [00:04:00] then?
Dr. Stephanie Feldman: Before cardio oncology, say we had a patient, say it’s a middle aged woman with high blood pressure, diabetes, and obesity, with breast cancer. And she may have a HER2 positive breast cancer. And so for her treatment, she would probably get some sort of surgery, usually a lumpectomy. She may need radiation and then her cancer treatment regimen’s gonna to include anthracycline. The FDA labeling for the HER2, treatments the Trastuzumab, says you need to have an echocardiogram when you start treatment because there’s risk and we know that patients are increased risk for their heart pump function to have LV systolic dysfunction and they need to have an echocardiogram every three months.
And if along the way on your serial monitoring echocardiograms, she developed a reduction in her LV systolic function, her treatment would be stopped, she would stop getting HER2 targeted therapies, where we know that if we interrupt [00:05:00] HER2 targeted therapy, patients actually have worse cancer outcomes.
Catherine Price: So you really don't want to have a pause in the therapy.
Dr. Stephanie Feldman: Definitely not.
So that's before. That sounds very doom and gloom. So now it's 2024.
So, we know that there are treatment specific factors that put this patient at risk, meaning she's getting anthracycline based therapy and she's getting HER2 targeted therapy.
If you recognize this, we say, maybe I should send this patient to a cardio oncologist. So one of my top priorities in a good cardio oncology program will have the availability to see patients within, you know, a week's time because our input is really time sensitive in terms of cancer treatment.
We take a look at her medications, and we could start this patient on treatment for her blood pressure with preferential use of medications cardiologists are very familiar with for heart failure.
Um, so we would start her on that regimen. We would counsel her. We'll get you on better meds. We'll watch you closely. You can safely continue your HER2 targeted therapy.
Catherine Price: And so, and if I’m understanding correctly, you would hopefully remove some roadblocks or [00:06:00] at least give the go ahead, but potentially flag some issues that might occur and provide some suggestions for potential alternate treatments.
Dr. Stephanie Feldman: Yeah. Yeah, no, exactly.
Catherine Price: So roughly speaking, given that there's so many cancer patients who might be at risk, how does one determine if they should be seeing a cardio oncologist?
Dr. Stephanie Feldman: I think that the patients that benefit most from cardio oncology are those where we've determined before cancer treatment, they either have cardiovascular disease and so they're going to be at higher risk for chemotherapy related cardiac dysfunction or the cardiac toxicities. The other patients would be during the course of treatment who do develop toxicities or adverse events related to their chemotherapy. So, the common ones being LV systolic dysfunction, patients who develop the rare, but it’s associated with high mortality, complication of immune checkpoint inhibitor myocarditis.
And then in some cases, patients who have baseline cardiovascular disease and are going for rigorous, either surgeries or going for rigorous processes like a bone marrow transplant or CAR-T cell therapy, where you want to make sure [00:07:00] that they're optimized before they undergo these rigorous types of treatments or procedures.
And then lastly would be the patients who have had cardiotoxic chemotherapy are at higher risk. Those people should probably be followed longitudinally by a cardio oncologist.
Catherine Price: That sounds like while not everyone needs to see you. There's a lot of people who probably should… I mean…
Dr. Stephanie Feldman: Correct. [Laughs]
Catherine Price: Because how many of you are there? How many cardio oncologists are certified as such?
Dr. Stephanie Feldman: I think the last time I looked and counted it was somewhere on the order of like a hundred to three hundred of us across the country and the world.
Catherine Price: This is an emerging field. So I would imagine there are a lot of unanswered questions, which is part of what is exciting to you, I'm gathering. So what, what are some of these questions that you and your colleagues are particularly interested and excited about?
Dr. Stephanie Feldman: Sure. Cardio oncology can get a bad reputation for, like, being the roadblock to cancer treatment, cardio oncology also gets a bad reputation for over testing.
And so, some of the work I have been involved in is trying to predict who is at increased risk because if we [00:08:00] can better predict who's going to develop chemotherapy related cardiac dysfunction, perhaps we can have more screening for the patients at higher risk or more interventions to try to prevent it and the people who are lower risk. Don't bother them as much.
Catherine Price: So in other words, you're moving more towards a preventative approach to figure out what might cause these cardiac dysfunctions other than, you know, the pre-existing conditions you mentioned, and then treat those issues before they cause a problem.
Dr. Stephanie Feldman: Correct. Exactly right.
Catherine Price: And then you're also focusing your efforts on two areas. Right. So one looks at early symptom diagnosis and then the other one focuses on tumor genetics. And so I actually want to start with that first research area, which is something you alluded to earlier, and that is how to spot the rare, but also very serious risk that when you are being treated with an immune checkpoint inhibitor, you might develop myocarditis.
So I want to know, can you tell me about that?
Dr. Stephanie Feldman: So with the immune checkpoint inhibitors, there's two, if not three specific checkpoints in the immune system that we can now target.
The issue with the immune checkpoint inhibitors, besides [00:09:00] being revolutionary cancer treatments, is that you're activating the immune system. You know we know that when we rev up the immune system, there's always potential for adverse effects.
Basically head to toe any organ system you have can be impacted by immunotherapy. And for the cardiologist, the thing we worry about is inflammation of the myocardium.
So immune checkpoint inhibitor myocarditis is defined as, patient having an elevated troponin above the upper limit of normal. And then there are some other things, chest pain, shortness of breath, patient having new EKG changes would be concerning for ICI myocarditis.
If you look what happens to people who get checkpoint inhibitor myocarditis, it's associated with up to a 50 percent mortality.
Catherine Price: Why do you think that the myocarditis is associated with such an increased risk for mortality?
Dr. Stephanie Feldman: Because it's under recognized. If it's a rare thing, we may not find it, and you may not realize it until it's late and if you don't recognize it early and you don't treat it with steroids early, patients can really quickly deteriorate into cardiogenic shock. [00:10:00]
Catherine Price: Is it easy to miss?
Dr. Stephanie Feldman: Very easy to miss. So, if you think about patients who are being treated for cancer, a lot of the times they may be older with cardiovascular risk factors, and they may present with vague symptoms. Chest pain, shortness of breath. Some of the checkpoint inhibitor myocarditis cases can present looking like an ST segment elevation MI or an NSTEMI, meaning they don't have ST segment elevations but they have troponin elevation.
And so, looking at checkpoint inhibitor myocarditis, how often does it happen? They initially had said it's like 0.01 to like 2%. It's coming out that it's probably closer to about 5% of all people who are on checkpoint inhibitors.
So it's rare, right? Something that happens 5 percent of the time. You may never see it in your lifetime as a clinician, but if you see it, you can't miss it because a patient could die if you miss it. You need to start treatment early and so, first line treatment is going to be high dose steroids.
But, you don't want to give somebody high dose immunosuppression [00:11:00] if they don't need it. And so you don't want to jump on that too early. And if you say that somebody has ICI, myocarditis, then odds are, they may not be able to continue getting treatment for their cancer that may be the best option they have for, curing their cancer.
And so, because of the risk of mortality associated with ICI myocarditis that's why I think it's really important to think about the diagnosis. And, but also to actually make it correctly.
Really, the holy grail will be to try to figure out mechanistically what causes the cardiac dysfunction and, and how do we prevent that, or what could we target to try to prevent that.
Catherine Price: Right. And then continuing on the topic of preventative medicine, I wanted to talk to you about the second area of research that looks at tumor genetics. So I understand you're trying to figure out if there's a gene mutation that puts patients at increased risk. Can you tell me about that study and also what you're learning and then how that might help to personalize patient care?
Dr. Stephanie Feldman: This had started with Babak Navi, who is a neurologist, here at Cornell, [00:12:00] and he had found that patients, like, within the three to six months before cancer diagnosis, patients are at higher risk for arterial thromboembolism, meaning they're at higher risk for strokes, they're at higher risk for MI, and they're, at higher risk for peripheral arterial embolic events.
We also know that there's potentially treatment related factors. There's some chemotherapies that increase your risk for having clots. But there has to be something about the, like, tumor milieu that can cause this. And so we had looked to see were there any tumor specific mutations that increased a patient's risk for developing a heart attack or a stroke, in that period of time.
What we had looked at was, trying to figure out patient's baseline cardiovascular risk factors or if they had previously had ATE arterial thromboembolic events. And then, used natural language processing, to analyze all of these charts quickly to try to figure out which patients did develop arterial thrombotic events. [00:13:00] And it looked like there was a couple of mutations that seemed to stand out.
Dr. Stephanie Feldman: I think our work was hypothesis generating. It's obviously not a proof of concept, but maybe there are some specific mutations that tumors express that increase risk for heart attacks and strokes when you're diagnosed with cancer and being treated. And so now you need the bench scientists I think, to see in the lab, what happens when you have these loss or gain of function mutations. And then are we seeing, like increased risk for arterial thrombotic events when we do this, if this is the case, how do we target this pathway?
Catherine Price: So it seems like an exciting step towards the idea of more personalized treatment.
Dr. Stephanie Feldman: Exactly. So that the patient and the providers can try to risk stratify patients a little bit better and figure out really who's at higher risk and what should we be doing for those high risk people.
Potentially thinking about alternative treatment options if there are equally equivocal treatment options. And if not, what interventions can we use for these high risk patients? And so defining what those treatments would be to prevent chemotherapy related toxicities. [00:14:00]
Catherine Price: I'm wondering if you could summarize what you see happening in order to make what is currently an emergent subspecialty into an established field. What are the pieces that need to come together for that to happen?
Dr. Stephanie Feldman: So I imagine we will see cardio oncology become a subspecialty fellowship to do after general cardiology. I know a couple of places have started them and each kind of does their own thing.
But then more globally I think there's more bench research, clinical research, and hopefully finding the answers to some of our questions so that we can have more targeted therapies for prevention and for treatment for cancer therapy related cardiac toxicities.
The other part is that if you only have a small number of patients that develop chemotherapy related cardiac dysfunction, a small number of patients that develop ICI myocarditis, you really need to collaborate with your friends, across the country, across the world, to try to get enough patients to have meaningful information. So like one registry we are planning to participate in is the global cardio oncology registry or GCOR and so trying to [00:15:00] help us systematically collect information about our practice here at Cornell.
There's that collaborative nature as like, I don't know the answer to this question. Do you, or what would you guys do? To get that input and feel like people really want to help each other at the end of the day, really just want to help patients.
Catherine Price: So, what's going on in terms of establishing cardio oncology as a specialty at NewYork-Presbyterian? Also, what is it about the culture at NYP that makes moving this work forward possible for you?
Dr. Stephanie Feldman: I think there are a couple of key features that make us unique here at NewYork-Presbyterian and at Cornell. First of all, we also have a cardio-oncology program at Columbia that's led by Jay Rykelkar. It's really nice to have a partner in crime that we're, we're equally as excited about cardio oncology and we approach it from a little bit different perspectives, him being advanced heart failure and transplant and me being more of a general cardiologist and cardiac imager.
I think we have really strong cardiology subspecialties, whether it's our interventional cardiologists, our structural heart [00:16:00] program, our cardiac imaging program. When you're caring for complex cardio oncology patients, you don't want just any interventionalist, any cardiothoracic surgeon. You want somebody who's going to be mindful that they've had radiation to their chest and they may have different anatomy.
And then lastly, we're part of a big health system, right, with NewYork-Presbyterian. And we have the opportunity to build standardized processes for screening for cardiotoxicity or for baseline risk stratification to build them here and then potentially roll them out to the other parts of NewYork-Presbyterian so that all patients can get some sort of standardized cardiac screening and, uh, monitoring during their cancer treatment.
And the goal would be you could do a model of something like that. You know that you could share throughout the country really.
MUS IN
Catherine Price: Ultimately, what do you love the most about practicing this specialty? Because I can tell that you do love it.
Dr. Stephanie Feldman: I love cardio oncology because I get to be a part of a patient's journey and it may not be a journey [00:17:00] that they want to be on. But I like that I get to be a constant source for them and to help them ride the waves, you know, the ups and the downs, and I like that I get to be part of that.
Hopefully it's to help with good outcomes. Unfortunately, that's not always the case, but I think it's developing the longitudinal relationships from patients I care for in the CCU to who I care for in the clinic… you know, trying to take something that can be scary and overwhelming and just making it approachable.
Catherine Price: Well, thank you so much for making the time to speak with me today.
Dr. Stephanie Feldman: Sure. Thank you so much for being interested in cardio oncology, for asking good questions and hopefully helping people to learn a little bit more about the field.
Catherine Price: Thank you so much to Dr. Stephanie Feldman for speaking with us today about this emerging specialty that's going to affect so many patient lives in the years to come.
I'm Catherine Price. Advances in Care is a production of NewYork-Presbyterian Hospital. As a [00:18:00] reminder, the views shared on this podcast solely reflect the expertise and experience of our guests. To listen to more episodes of Advances in Care, be sure to follow and subscribe on Apple Podcasts, Spotify, or wherever you get your podcasts.
And to learn more about the latest medical innovations from the pioneering physicians at NewYork-Presbyterian, go to nyp.org/advances.
[00:18:30]