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On Blood and Bridges: Remembering Congressman John Lewis

I was recently reading a Time magazine article, which included previously unreported coverage of Congressman John Lewis, the Civil Rights icon, who succumbed to cancer last week. When asked why he continued to tell his story, he responded:

          …it affects me — and sometimes it brings me to tears. But I think it’s important to tell it. Maybe it will help educate or inspire other people so they too can do something, they too can make a contribution.

As history tells us, Congressman Lewis, then a 25-year-old leader of the Student Nonviolent Coordinating Committee (SNCC) and coordinator of “Freedom Rides,” helped lead a march for voting rights from Selma, Alabama towards the state capital of Montgomery over the Edmund Pettus Bridge. The protestors were met with force by the state and local police. Mr. Lewis’ skull was fractured by the strike of a club. His was just one of numerous injuries endured by protestors. This fateful day—“Bloody Sunday”—March 7, 1965, is commemorated annually. People at home watched in shock and dismay as the protestors were brutalized. The ferocity of the images pricked the consciousness of the nation and resulted in many joining the cause. Their humanity wouldn’t allow them to sit passively and watch other humans decimated.

          I gave a little blood on that bridge

Fast forward 55 years…

On March, 13, 2020, the US declared a state of emergency in response the COVID-19 pandemic. US citizens across the country were advised to shelter-in-place to slow the spread of the novel coronavirus that had invaded our shores. Away from typical distractions of work, traffic, and the hustle of everyday life that usually occupies our minds, many sat fixated on the television as we watched cases and mortality increase. Amidst this vacuum, we were confronted by shocking visuals: a video of a police officer kneeling on the neck of an unarmed black man for 8 minutes and 46 seconds. In the context of social distancing, Americans were challenged to face themselves. The reality of racial inequities in the US, previously shielded by a cognitive dissonance (e.g., “we don’t know what happened before the video”), was now proximal and palpable. We had nowhere to go. We had to sit with it. As in the 1960s, we were outraged by the inhumanity – as we should be.

As a Black woman, it’s difficult to think of a time when I wasn’t completely aware of race relations in this country. Seeing others enlightened and even corroborating the stories of injustice in the US that I have known to be true as early as middle school was encouraging. However, I’d like to challenge our comfort a bit further. The same racism that cracked the skull of a peaceful protestor and kneeled on the neck of an unarmed man is the racism that ignores a black mother’s request for medical attention, dismisses the reports of pain of a black patient with a clearly broken bone, or assumes that black bodies die sooner as a matter of biology. Racism is both the lifeblood and the heartbeat of racial disparities in health and healthcare.

Racism built the communities in which we live, the public schools we are able to attend, and the types of businesses in our neighborhoods that provide basic necessities, such as food. It built our Capitol building and the home of our nation’s chief executive. It even built our most premier educational institutions and their medical and research empires. Racism lives in our silence as much as (if not more than) it lives in violence. It quietly sits within the foundations of our institutions and leaches its contaminants into our social spaces in a way that is both proliferative and reinforcing.

So, where do we go from here? Congressman Lewis once recounted a story of hearing Dr. Martin Luther King, Jr. speak. He spoke of:

          …the “spirit of history” inviting him to take his place.

Though it may mean protesting, it may also be interpreted as taking an active role in addressing health disparities in our respective places. If you’re reading this, your place is probably in healthcare, research, policy, or in the community; if not, it could also be finance, criminal justice, human resources, or administration. Regardless of your position, everyone can and MUST make a contribution if we desire to see the best of what our society could be. As during shelter in place, if we can steady ourselves long enough, we will hear the echoes of humans in despair beckoning our individual and collective humanity to act. Together, we have to “slow the spread” of racism—a pandemic1 that stretches as far back as our nation’s earliest years.

Let’s honor Congressman Lewis. This is our bridge. Let’s be human.

 

References

  1. Williams DR and Cooper LA. COVID-19 and Health Equity—A New Kind of “Herd Immunity” JAMA. 2020;323(24): 2478-2480.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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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.

 

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Chronic Kidney Disease: The Silent Killer

“He felt well, so he didn’t follow up with his doctor.”

Our nephrology team was gathering history about a patient who had landed in the Emergency Department with advanced kidney failure and its consequences: confusion, severe anemia, metabolic acidosis, and a high blood potassium threatening to push him into cardiac arrest.  We asked the family: Did he have any known kidney problems?

“His doctor mentioned abnormal kidney function 3 years ago.  But he’s felt really healthy, and has been too busy to go back to the clinic.”

Convincing someone they have chronic kidney disease can be tough.  “But I feel fine!” is a common response along with a look of disbelief or suspicion (like they’re not sure if I’m trying to sell them something).  This is usually followed by: “What can I do to make my kidneys better?”  This part is a real downer because they find out I actually don’t have anything to sell – there isn’t any therapy that can regenerate kidney function.  It’s all about preventative measures to preserve the functioning nephrons – we focus on improving lifestyle practices and treating comorbidities so as to avoid further kidney injury.

World Kidney Day has been recognized on the 2nd Thursday of March every year since 2006 and tends to pass by with little fanfare.  Public awareness and media coverage of kidney disease is relatively low compared to conditions such as heart disease or cancer.   However, the statistics associated with chronic kidney disease are downright scary.  Chronic kidney disease doubles the risk of mortality from cardiovascular events or infection.  Every year, more Americans die from kidney disease than from breast cancer and prostate cancer combined.  End-stage kidney failure requiring dialysis has an average survival of 10-15 years.  If an individual transitioned to dialysis at the same time that he welcomed a baby to the family, he might not live to see his child graduate from high school.

person shruggingAbout 1 in 10 people worldwide, and >20 million in the US, have chronic kidney disease.

The functioning unit in the kidney is the nephron, and humans are born with 900,000 to 1 million nephrons per kidney (or less, if born premature).  No new nephrons form after birth.  We are actually born with more kidney function than we need to maintain electrolyte and fluid balance – evolutionary proof that the kidneys are so important!

In most cases of progressive kidney disease, the body is remarkably adept at adjusting to the buildup of toxins.  The person “feels well” until the kidney function falls below 15% at which point the “crash” happens and they feel terrible.

Research is ongoing to develop saliva tests that quantify levels of toxins that have diffused from the blood, as a measure of kidney function.  These are yet to be validated and commercialized.  For now, periodic blood tests (inconvenient and painful, but necessary) are the only way we can reliably monitor chronic kidney disease to guide treatment recommendations.

Wei Ling Lau Headshot
Wei Ling Lau, MD is Assistant Professor in Nephrology at University of California-Irvine, where she studies vascular calcification and brain microbleeds in chronic kidney disease. She is currently funded by an AHA Innovative Research Grant, and has been a speaker for CardioRenal University and the American Society of Nephrology.