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Artificial Intelligence in Cardiology: Opportunities for Cardio-Oncology

History was made recently with the inaugural and first ever continuing medical education conference on artificial intelligence (#AI) in Cardiology. While most of the presentations were on artificial intelligence or cardiology or both, several sessions also made reference to other fields in which AI has been or is being used, such as Oncology. There was even one study presented on Cardio-Oncology. As study after study was presented, it became clear to me that perhaps several of these techniques and methodologies could potentially be useful to our patients in Cardio-Oncology.

Every single piece of technology started with one single prototype. Every single new piece of software started with one single algorithm. Every single patent started with one single idea. Every single idea started with the impact that disruptive technology could have for at least one single patient – one single case.

As I view various case reports in Cardio-Oncology, I think about how #AI could influence care delivery to potentially improve outcomes and the experience for each patient and their health professionals.

One example that was reiterated in multiple presentations was that of the ECG. Applying #AI to the ECG has been shown in the studies presented to determine the age, sex, and heart condition of the individual. Details were shown for a case of hypertrophic cardiomyopathy (yes, HCM, not just left ventricular hypertrophy) diagnosed via #AI analysis of an ECG that appeared relatively unremarkable to physicians’ eyes. After the septal surgery/procedure, although the ECG then looked remarkably abnormal to physicians’ eyes, the #AI algorithm could identify resolution of the hypertrophic cardiomyopathy.

Another example reiterated throughout the conference was identifying undiagnosed left ventricular systolic dysfunction, in a general community population and also in patients referred to a cardio-oncology practice at a large referral center.

Recently, #AI in Cardiology has been used most frequently for monitoring and detection of arrhythmias, such as atrial fibrillation. Everyone can purchase their own wearable to determine this. Physicians are also now prescribing these wearables for ease-of-use, given their pervasive presence and coupling with smartphones owned by much of the population or provided temporarily by the physician group. Such wearables are transitioning from standalone electrodes, to watches, skin patches, and clothing (e.g., shirts, shorts).

Many direct-to-consumer #AI applications in daily life actually are not wearable, such as Alexa and Siri. One study described the ability of #AI to help diagnose mood disorders and cardiac conditions and risk factors by simply “listening to” and analyzing voice patterns. The timing of a young man’s “voice breaking” can potentially predict his risk for heart disease!

A popular use for #AI in medicine overall is to assist with interpretation of various imaging, such as chest X-rays, MRIs, or CT scans. This applies in Cardiology as well. Further, in Cardiology, #AI is being used to help guide the procurement of echocardiograms. The algorithms provide visual instructions (such as curved arrows) to indicate directions in which the ultrasound probe should be moved to obtain the standard view, to which the algorithm is comparing the image being procured moment-by-moment. The idea is for #AI to help less experienced sonographers or echocardiographers learn and perform echocardiography even more expediently.

The theme of the conference was current advances and future applications of #AI in Cardiology. Accordingly, a historical perspective was given, describing some of the earliest attempts at #AI in various fields. A video of a possible precursor to current automated vacuum cleaners was shown, from archives dating back to the 1960s. In addition to ways in which #AI is now being studied or applied, future opportunities for using #AI were also postulated, for example for coronary artery disease, since stress tests are not 100% sensitive and the gold standard coronary angiography is invasive. #AI could help stratify patients who needed versus did not need the invasive procedure for recurrent convincing symptoms in the absence of a positive stress test. Of course, coronary CT angiography could help fill this gap, but #AI might assist with decision-making sooner.

There have been studies on #AI in Cardiology, and studies on #AI in Oncology, and at least one study in #AI in Cardio-Oncology – a study I predicted; one that is quite intuitive and mentioned above. I propose that we continue to apply #AI in Cardio-Oncology, so that the field can catch up with the rest of Cardiology and Oncology, and help us continue to develop this emergent and burgeoning multidisciplinary subspecialty.

This is an exciting time for me to be alive. I am an early adopter of artificial intelligence. I look forward to seeing more and more the availability of #AI to enhance our use of electrocardiography, echocardiography, wearables, biosensors, voice analysis, and more in Cardiology, and particularly in Cardio-Oncology, with an emphasis on primary and primordial prevention even before secondary and tertiary prevention in the area of Preventive Cardio-Oncology, and especially in women.

 

 

 

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Preventive Cardio-Oncology: The Role Of High Intensity Interval Training

Heart disease is the number one killer of survivors of cancer1, 2, 3. It is our responsibility to help our patients with cancer understand and mitigate this risk. Prevention of heart disease in these patients should occur at three stages: in Cardio-Oncology prehabilitation2, 4, habilitation2, 4, and rehabilitation2, 4, 5. At all three stages, exercise is a key component and can be optimized with consideration of high intensity interval training (HIIT).

HIIT has emerged as an exercise structure that adds more efficiency and power to typical continuous exercise regimens. Studies in the general population suggest that HIIT is safe and non-inferior or superior to continuous exercise regimens in its effect on fitness6, 7, lipids7, 8, blood pressure9, blood glucose levels9, waist circumference8, body fat percentage7, 8, insulin resistance7, and more. Beneficial findings and safety have also been reported for individuals with cardiovascular disease (including coronary artery disease and heart failure)10, as well as cancer11.

The format of HIIT is just as it sounds – incorporating high intensity intervals into exercise training. This is not necessarily training for marathons, sprints, or triathlons. This is training for life. Life that individuals with cancer fight so hard for. We owe it to these individuals to help them live their best life when their cancer is in remission. Part of that is their best heart health, and incorporating heart-healthy behaviors most seamlessly into their daily lives. One safe, effective, and efficient way to do that is with HIIT. In HIIT, following warmup individuals work out at high intensity for 30-120 seconds, then either rest or work out at low/moderate intensity for 30-120, alternating between the two for the duration of their set-aside exercise time or program. For example, an individual on a bicycle would cycle at 10 mph for 30-120 seconds, then at 0 or 5-9 mph for 30-120 seconds, alternating between the two for the duration of their set-aside exercise time or program. The new physical activity and prevention of cardiovascular disease guidelines provide great additional examples of moderate versus high intensity aerobic exercises12, 13.

A recent article suggested that HIIT may be the answer to meeting the needs of women in cardiac rehabilitation14. Indeed, HIIT may also be part of the solution to meeting the needs of women in Cardio-Oncology prehabilitation, habilitation, and rehabilitation. Yet for several years, clinicians and researchers have noted a myriad of barriers faced by women in cardiac rehabilitation14, 15, and that a plethora of women are not referred to cardiac rehab at all15. Besides time and accessibility limitations, other reported barriers include lower education level, multiple comorbid conditions, non-English native language, lack of social support, and high burden of family responsibilities. It should therefore be noted that while HIIT may serve as part of the answer to meeting the needs of women in cardiac rehabilitation or in Cardio-Oncology prehabilitation, habilitation, and rehabilitation, other solutions will be needed to address the variety of barriers unrelated to time and accessibility. The use of automatic referral and assisted enrollment can improve the participation of women in cardiac rehabilitation15, while incentive-based strategies and home-based programs may enhance program completion15. Additional solutions will be needed to address remaining barriers, such as health literacy related to lower education level, multiple comorbidities, non-English native language, high burden of family responsibilities, and of course adverse effects of cancer therapies.

As we step out into and carry on in our Early Careers, it is important for us to be aware of high intensity interval training and its incredible potential to elevate our care of women and men in cardiac rehabilitation in Preventive Cardiology, as well as in Cardio-Oncology prehabilitation, habilitation, and rehabilitation.

References
1. Mehta LS, Watson KE, Barac A, Beckie TM, Bittner V, Cruz-Flores S, Dent S, Kondapalli L, Ky B, Okwuosa T, Piña IL, Volgman AS; American Heart Association Cardiovascular Disease in Women and Special Populations Committee of the Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; and Council on Quality of Care and Outcomes Research. Cardiovascular Disease and Breast Cancer: Where These Entities Intersect: A Scientific Statement From the American Heart Association. 2018 Feb 20;137(8):e30-e66. doi: 10.1161/CIR.0000000000000556. Epub 2018 Feb 1.

2. Squires RW, Shultz AM, Herrmann J. Exercise Training and Cardiovascular Health in Cancer Patients. Curr Oncol Rep. 2018 Mar 10;20(3):27. doi: 10.1007/s11912-018-0681-2.

3. Patnaik JL, Byers T, DiGuiseppi C, Dabelea D, Denberg TD. Cardiovascular disease competes with breast cancer as the leading cause of death for older females diagnosed with breast cancer: a retrospective cohort study. Breast Cancer Res. 2011 Jun 20;13(3):R64. doi: 10.1186/bcr2901.

4. https://earlycareervoice.professional.heart.org/preventive-cardio-oncology-the-rise-of-prehabilitation/. Accessed April 20, 2019.

5. Gilchrist SC, Barac A, Ades PA, Alfano CM, Franklin BA, Jones LW, La Gerche A, Ligibel JA, Lopez G, Madan K, Oeffinger KC, Salamone J, Scott JM, Squires RW, Thomas RJ, Treat-Jacobson DJ, Wright JS; American Heart Association Exercise, Cardiac Rehabilitation, and Secondary Prevention Committee of the Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; and Council on Peripheral Vascular Disease. Cardio-Oncology Rehabilitation to Manage Cardiovascular Outcomes in Cancer Patients and Survivors: A Scientific Statement from the American Heart Association. Circulation. 2019 Apr 8:CIR0000000000000679. doi: 10.1161/CIR.0000000000000679. [Epub ahead of print].

6. Su L, Fu J, Sun S, Zhao G, Cheng W, Dou C, Quan M. Effects of HIIT and MICT on cardiovascular risk factors in adults with overweight and/or obesity: A meta-analysis. PLoS One 2019 Jan 28;14(1):e0210644. doi: 10.1371/journal.pone.0210644. eCollection 2019.

7. Fisher G, Brown AW, Bohan Brown MM, Alcorn A, Noles C, Winwood L, Resuehr H, George B, Jeansonne MM, Allison DB. High Intensity Interval- vs Moderate Intensity- Training for Improving Cardiometabolic Health in Overweight or Obese Males: A Randomized Controlled Trial. PLoS One 2015 Oct 21;10(10):e0138853. doi: 10.1371/journal.pone.0138853. eCollection 2015.

8. Stavrinou PS, Bogdanis GC, Giannaki CD, Terzis G, Hadjicharalambous M. High-intensity Interval Training Frequency: Cardiometabolic Effects and Quality of Life. Int J Sports Med. 2018 Feb;39(3):210-217. doi: 10.1055/s-0043-125074. Epub 2018 Feb 2.

9. Batacan RB Jr, Duncan MJ, Dalbo VJ, Tucker PS, Fenning AS. Effects of high-intensity interval training on cardiometabolic health: a systematic review and meta-analysis of intervention studies. Br J Sports Med. 2017 Mar;51(6):494-503. doi: 10.1136/bjsports-2015-095841. Epub 2016 Oct 20. Review.

10. Wewege MA, Ahn D, Yu J, Liou K, Keech A. High Intensity Interval Training for Patients With Cardiovascular Disease—Is It Safe? A Systematic Review. J Am Heart Assoc. 2018 Nov 6;7(21):e009305. doi: 10.1161/JAHA.118.009305.

11. Mugele H, Freitag N, Wilhelmi J, Yang Y, Cheng S, Bloch W, Schumann M. High-intensity interval training in the therapy and aftercare of cancer patients: a systematic review with meta-analysis.
Mugele H, Freitag N, Wilhelmi J, Yang Y, Cheng S, Bloch W, Schumann M.
J Cancer Surviv. 2019 Apr;13(2):205-223. doi: 10.1007/s11764-019-00743-3. Epub 2019 Feb 26. Review.

12. Piercy KL, Troiano RP, Ballard RM, Carlson SA, Fulton JE, Galuska DA, George SM, Olson RD. The Physical Activity Guidelines for Americans. JAMA. 2018 Nov 20;320(19):2020-2028. doi: 10.1001/jama.2018.14854.

13. Arnett DK, Blumenthal RS, Albert MA, Buroker AB, Goldberger ZD, Hahn EJ, Himmelfarb CD, Khera A, Lloyd-Jones D, McEvoy JW, Michos ED, Miedema MD, Muñoz D, Smith SC Jr, Virani SS, Williams KA Sr, Yeboah J, Ziaeian B. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
J Am Coll Cardiol. 2019 Mar 17. pii: S0735-1097(19)33876-8. doi: 10.1016/j.jacc.2019.03.009.

14. Way KL, Reed JL. Meeting the Needs of Women in Cardiac Rehabilitation. Circulation. 2019; 139(10):1247–1248.

15. Supervía M, Medina-Inojosa JR, Yeung C, Lopez-Jimenez F, Squires RW, Pérez-Terzic CM, Brewer LC, Leth SE, Thomas RJ. Cardiac Rehabilitation for Women: A Systematic Review of Barriers and Solutions. Mayo Clin Proc. 2017 Mar 13. pii: S0025-6196(17)30026-5. doi: 10.1016/j.mayocp.2017.01.002. [Epub ahead of print] Review.

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Preventive Cardio-Oncology: A Role For Cardiopulmonary Stress Testing

Cardiopulmonary exercise stress testing can be useful in a variety of ways, particularly for Preventive Cardiology and Preventive Cardio-oncology. The test helps to assess for levels of fitness, causes of functional limitation, and evidence of ischemia. Test results can be used to counsel individuals, guide exercise prescriptions, and reassure, encourage, and motivate individuals for lifestyle modification and behavior change.

The exercise ECG portion of the test gives information regarding evidence of ischemia, exercise capacity, and adequacy of heart rate response, and response of blood pressure to exercise. The information of this portion of the test can help to determine whether there are any high-risk cardiac features that need to be addressed, such as evidence of ischemia or hypotensive response to exercise. Limited heart rate response is also useful to help determine whether rate-limiting medications or pacemaker settings need to be adjusted. Often, when medications like metoprolol or pacemaker heart rate response are adjusted, this can improve the function and experience of patients who are previously limited by their heart rate during activity. The exercise capacity information given by the exercise ECG, such as excellent, good, average, below average, fair, or poor can give an indication of individuals’ ability to meaningfully, safely, and successfully pursue exercise. Oftentimes, some patients who have had prior cardiovascular events may shy away from moderate or intense exercise for fear of cardiovascular injury as a result of exertion. Pursuing an exercise ECG portion of the cardiopulmonary stress test can help individuals in such cases recognize that they can perform moderate or intense exercise safely without injuring their heart. The exercise capacity reported on the test can help these individuals see that their exercise or aerobic capacity is poor because of their hesitation to pursue moderate or intense exercise. This can be motivating for individuals to recognize that they can benefit from doing more and that they can do more safely. This is particularly the case for individuals who have experienced a cardiovascular event from spontaneous coronary artery dissection, which does not have many modifiable risk factors, and understandably leads to apprehension in young women diagnosed with this condition. However, the exercise ECG portion alone lacks several informative parameters important for patient care in Preventive Cardiology and Cardio-Oncology.

The specific addition to the test provided by the ‘cardiopulmonary’ portion involves oxygen consumption. If oxygen consumption (or VO2) is below average, limited, or poor, there can be several reasons for this. The most common reasons include cardiac impairment, pulmonary impairment, deconditioning, excess weight, and limited heart rate reserve. There are various parameters in the cardiopulmonary stress test results that will indicate whether deconditioning plays a role, whether BMI plays a role, whether cardiac impairment plays a role (in which case this could be due to low flow from systolic dysfunction or due to diastolic dysfunction or even heart rate), or whether pulmonary impairment plays a role (which could be of varied etiology). This addition to the test also helps patients to objectively see data supporting the suspicion that they have become deconditioned after a cardiovascular event or after cancer therapies. They get to see that the cancer therapies or their subsequent levels of activity following their cardiovascular event could currently or potentially affect their function, and may explain any current functional limitation or in fact set them up for functional limitation going forward. The test can also help patients see the effect of any excess weight on their compromised oxygen consumption. Given that cancer therapies for breast cancer, for example, will often include radiation, surgery, and chemotherapy that can injure the heart and/or the lungs, it is helpful to determine the suggested underlying causes of functional limitation as assessed by oxygen consumption in these patients who have had treatment involving the chest. Performing the cardiopulmonary stress test at baseline before treatment helps individuals see their level of fitness, deconditioning, weight effect, cardiac impairment, or pulmonary impairment, even before ever undergoing cancer therapy. Given that fitness levels and injuries to the heart or the lungs can be affected by cancer therapies, then repeating the test after therapies can show patients the change that has occurred as a response to therapies. This can be helpful for patient to have a sense of their original baseline and goals that they can work towards to supersede even that baseline. For individuals who are not going to undergo cancer therapies, obtaining a baseline also helps individuals with a sense of how much they could potentially achieve. Then, once they have achieved a particular goal, the test can be repeated to show the improvement and continue to inspire motivation. This objective collection of evidence and data that can be used for motivation, reassurance, counseling, and exercise prescription is all key for lifestyle modification and behavior change in Preventive Cardiology and Preventive Cardio-Oncology. Thus, for all these reasons and more cardiopulmonary stress testing will evolve to play a large role in Cardio-Oncology prehabilitation, habilitation, and rehabilitation1,2,3, as we help individuals prepare for, experience well, and long outlive their cancer therapies.

 

References

  1. https://earlycareervoice.professional.heart.org/preventive-cardio-oncology-the-rise-of-prehabilitation/. Accessed April 20, 2019.
  2. Squires RW, Shultz AM, Herrmann J. Exercise Training and Cardiovascular Health in Cancer Patients. Curr Oncol Rep. 2018 Mar 10;20(3):27. doi: 10.1007/s11912-018-0681-2.
  3. Gilchrist SC, Barac A, Ades PA, Alfano CM, Franklin BA, Jones LW, La Gerche A, Ligibel JA, Lopez G, Madan K, Oeffinger KC, Salamone J, Scott JM, Squires RW, Thomas RJ, Treat-Jacobson DJ, Wright JS; American Heart Association Exercise, Cardiac Rehabilitation, and Secondary Prevention Committee of the Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; and Council on Peripheral Vascular Disease. Cardio-Oncology Rehabilitation to Manage Cardiovascular Outcomes in Cancer Patients and Survivors: A Scientific Statement from the American Heart Association. Circulation. 2019 Apr 8:CIR0000000000000679. doi: 10.1161/CIR.0000000000000679. [Epub ahead of print].
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Preventive Cardio-Oncology: The Rise of Prehabilitation

Figure 1 Prehabilitation: optimization of overall health, wellness, and fitness prior to initiation of therapies that might adversely alter fitness, strength, quality of life, or function.

Figure 1 Prehabilitation: optimization of overall health, wellness, and fitness prior to initiation of therapies that might adversely alter fitness, strength, quality of life, or function.

As I near the end of my job search process and prepare to review offers and sign a contract, it is absolutely incredible to me to consider that I am completing training at just the right time for me in cardiology. While sitting in a preventive cardiology team room, I overheard two exercise specialists describing a project that they plan to present in several weeks at a national conference. I overheard them use the word ‘prehabilitation’. While the word is not brand new in their professional world or even in cardiology, at that time the word was novel to me. I felt excitement rise within me as I recognized the word ‘prehabilitation’ as a concept that I have envisioned for quite some time to be key to what I would like to achieve and develop in the emerging field of preventive cardio-oncology. As a senior cardiology fellow, my training has been particularly enriched in cardio-oncology (see CardioOncTrain.Com), preventive cardiology, heart disease in women, and precision medicine. I plan to have a heavy emphasis on prevention in my practice, and with eventual incorporation of maturing tools in precision medicine. If you too are interested in preventive cardiology and cardio-oncology, you may want to consider a combined practice of preventive cardio-oncology.  If you are also interested in heart disease in women, then you may want to consider preventive cardio-oncology particularly in women, e.g., women with breast cancer.  Yes, that is quite focused, but can be an incredible niche.  Yet, let us take a step back from the idea of preventive cardio-oncology in breast cancer or any other cancer and first consider how far we have come in the broader field of cardio-oncology.

In the burgeoning field of cardio-oncology, one could argue that we are doing quite well as a community with epidemiology and management of cardiovascular toxicities from cancer therapies. Our ability to completely predict cardiovascular toxicity in individuals is still in progress. Nevertheless, the field has come so far regarding what we now understand about pathophysiology, risk factors, and incidence of cardiovascular toxicity. In particular, due to the continuous and rapid innovation in cancer therapies, cardio-oncology continues to grow exponentially. If you are interested in or planning to join the field, now is a great time!

While the main focus in cardio-oncology has been on secondary and tertiary prevention of cardiovascular toxicity and its sequelae, an era is approaching that may focus even more so on primordial and primary prevention of cardiovascular toxicity. What if we could figure out ways to prevent cardiovascular toxicity before it even happens? What if we can even avoid development of risk factors themselves? These two questions point towards a focus on primary and primordial prevention, respectively. Indeed, for decades we have been focusing largely on secondary and tertiary prevention in Cardio-Oncology. Perhaps it is now time to focus more on what would appropriately be termed preventive cardio-oncology, a merger between preventive cardiology and cardio-oncology.

A hallmark of preventive cardiology has long been cardiac – and in fact cardiopulmonary – rehabilitation. This usually would occur in the setting of secondary or tertiary prevention. As such, ‘rehab’ generally has at least a few purposes. One purpose is to help individuals get back to the level of cardiopulmonary function they had prior to their cardiovascular event. A second purpose is to actually optimize their cardiopulmonary function, regardless of their original preexisting starting point, and help them develop a sustainable lifestyle modification program that can hopefully help prevent another event. A third purpose is to provide support and camaraderie that can help individuals regain the confidence they need to develop and maintain heart healthy lifestyle habits, by knowing they’re not alone in the process. For young patients, such as young adult women with spontaneous coronary artery dissection, this third purpose can be particularly beneficial.

Studies are now showing that cardiopulmonary rehab can also be useful in patients who have completed cancer therapy – in a sense as their ‘event’1,2. This is in part because cancer therapies can impact the heart, vasculature, and lungs, as well as other organ systems. In addition, while undergoing therapy for cancer, individuals often tend to lose fitness, energy, strength, and motivation for lifestyle modification, which is entirely understandable. Studies are therefore also showing that individuals who pursue exercise in the form of ‘habilitation’ while undergoing cancer therapies will also often have improved fitness and cardiovascular function and outcomes following the completion of therapy1,3.

Notably, newer studies are suggesting that exercise prior to the initiation of cancer therapies can further improve fitness, strength, quality of life, and cardiovascular function during or upon completion of cancer therapy1,4. This concept of ‘prehabilitation’ is catching on and will most certainly become a centerpiece and hallmark of primary prevention and perhaps even primordial prevention of cardiovascular toxicities.

Essentially, we need to recognize the impact and power of hysteresis, which suggests that the cardiopulmonary fitness starting point for a patient diagnosed with cancer will determine their cardiopulmonary fitness endpoint after treatment for cancer. This of course is intuitive, but not usually the focus early on in cancer survivorship. Since one in three individuals develop cancer in their lifetime5, it would be reasonable to recommend that all individuals optimize their cardiopulmonary fitness and prioritize lifestyle modification to ensure a desirable cardiopulmonary starting point if ever one is unfortunately diagnosed with cancer. If we take a step back, we realize that is quite similar to the argument for optimizing cardiovascular health in the general population. One in three individuals dies from cardiovascular disease each year6. It is therefore reasonable to recommend that all individuals optimize their cardiovascular health and prioritize lifestyle modification to hopefully help avoid cardiovascular events. When we view (i) cardiopulmonary fitness after cancer therapies and (ii) cardiopulmonary fitness associated with cardiovascular health in the general population through similar lenses, it becomes clear that preventive cardiology and cardio-oncology could potentially come together in an emergent subspecialty of preventive cardio-oncology.

For all individuals, the overarching goal is optimal cardiovascular health based on life’s simple seven: diet, physical activity, obesity, cholesterol, diabetes, blood pressure, and cigarette smoking, in the context of non-modifiable and also nontraditional modifiable risk factors. For individuals with cancer, who become survivors at the moment of diagnosis7, additional goals are preserving  strength, endurance, quality of life, and function.

To achieve long-lasting success in preventive cardio-oncology, we will need to consider three Ps: protocols, partnerships, and payments. In this hot new field of preventive cardio-oncology in which you and I might be trailblazing, together we need to develop standard protocols that can be used across the nation – and in fact across the world – to provide the best care for our patients. We will need Scientific Statements and Guidelines as the backbone of our practice. To facilitate evidence-based prevention, we will need a combination of retrospective, cohort, and case studies, as well as clinical trials. We will need to be sure to practice team-based care and forge lasting partnerships among clinicians, exercise specialists, and others in order to guide patients along gentle, individualized pre-habilitation, habilitation, and rehabilitation care plans. Importantly, relevant payment structures will need to be developed and adequately compensated by government, state, and private insurance.

An exciting path is before us Early Career folks in preventive cardio-oncology, as we shape the opportunity to practice in cardio-oncology from the perspective of primordial, primary, secondary, and tertiary prevention in women and in everyone.

 

References

  1. SquiresRW, Shultz AM, HerrmannJ. Exercise Training and Cardiovascular Health in Cancer Patients. Curr Oncol Rep. 2018 Mar 10;20(3):27. doi: 10.1007/s11912-018-0681-2.
  2. Lee K, Tripathy D, Demark-Wahnefried W, Courneya KS, Sami N, Bernstein L, Spicer D, Buchanan TA, Mortimer JE, Dieli-Conwright CM. Effect of Aerobic and Resistance Exercise Intervention on Cardiovascular Disease Risk in Women With Early-Stage Breast Cancer: A Randomized Clinical Trial. JAMA Oncol. 2019 Mar 28. doi: 10.1001/jamaoncol.2019.0038.
  3. https://journals.lww.com/oncology-times/pages/articleviewer.aspx?year=2019&issue=02050&article=00014&type=Fulltext. Accessed April 4, 2019.
  4. https://www.acc.org/about-acc/press-releases/2017/03/08/14/42/history-of-exercise-helps-prevent-heart-disease-after-breast-cancer. Accessed April 4, 2019.
  5. https://www.cancer.org/cancer/cancer-basics/lifetime-probability-of-developing-or-dying-from-cancer.html. Accessed April 4, 2019.
  6. https://professional.heart.org/idc/groups/ahamah-public/@wcm/@sop/@smd/documents/downloadable/ucm_503396.pdf. Accessed April 4, 2019.
  7. Rock CL, Doyle C, Demark-Wahnefried W, Meyerhardt J, Courneya KS, Schwartz AL, Bandera EV, Hamilton KK, Grant B, McCullough M, Byers T, Gansler T. Nutritionand physical activity guidelines for cancer survivors. CA CancerJ Clin. 2012 Jul-Aug;62(4):243-74. doi: 10.3322/caac.21142.