My Professional Journey

I was fascinated by the body’s circulatory system in high school. I was also concerned about heart disease being the number one killer of adults in the world. I figured I would become a cardiologist and help save hundreds, thousands, or even millions of people over time in personalized and public health care from fatal heart conditions. I suspected then that I would one day be a physician in cardiovascular diseases.

In college, everyone knew. I majored in Physics, spent lots of time in Spanish, and met my humanities and social sciences requirements, yet everyone knew I was destined for medical school. I completed all my premedical studies, volunteered at a local hospital, and shadowed doctors, and pursued research. My high honors senior thesis for the Bachelor’s and my excellent Master’s thesis were ultimately based on analyzing blood samples to determine health and disease and make predictions, using quantitative analytical methods in genomics and transcriptomics (gene expression profiles). Those studies in the blood were the closest I could get to the circulatory system as a physics major doing biomedical research at that time. It was fantastic!

By the time I started medical school, I figured that if I didn’t become a cardiologist, then I would be an oncologist or practice medical genetics (thinking that would be the closest thing to genomics). In medical school didactics, I quickly learned that medical genetics back then wasn’t what I thought it would be, and it didn’t focus on adults as much as I would have liked. Oncology lectures focused less on the conversation with the patient and more on signaling pathways that I had not yet begun to understand. I decided maybe that was not for me either. The physiology of the heart indeed captured my heart; the lungs and kidney were great too. So there I was, back to the heart and its circulatory system.

In my third year of medical school, I faced a dilemma. I enjoyed Psychiatry, Radiology, General Surgery, Orthopedic Surgery, Family Medicine, and Pediatrics, among other rotations, as well as my electives in Cardiology. What was I to do with my life as a doctor? I could almost see myself doing any of those! Almost.

During the PhD of my MD/PhD program, I shadowed a general cardiologist. I noticed that most of his patients were older and already in atrial fibrillation or heart failure. I asked myself, “Where are the 40-60 year olds before this happens?” I decided to create Preventive Cardiology. That was in 2006. I googled and saw that it already existed! In fact, we had just recruited a brand new faculty cardiologist, whose focus was prevention. I quickly became her mentee and spent some time in clinic with her. I realized that when it really came down to it, I saw myself managing and even more so preventing heart disease.

Then one day, I saw an email about a pilot research study in cardio-oncology. Thankfully, I was able to be a part of the study and learn more about this emerging field. This was in 2010. Almost a decade ago, I realized that my calling in medicine was to practice preventive cardiology and cardio-oncology and pioneer the merging of the two.

So, in my fourth year of medical school, I spent lots of time in various Cardiology clinics, to gain knowledge and exposure in other fields within Cardiology. I also had the opportunity to spend time in Medical Oncology and Radiation Oncology clinics, as well as with the radiation therapy technicians, treatment planners, and medical physicists. I performed literature reviews on my own and brought in articles to discuss with the Cardiologists, Medical Oncologists, and Radiation Oncologists. My favorite paper then is still quoted today in many experts’ presentations on ischemic heart disease risk resulting from radiation therapy.

With such incredible exposure to Cardiology, Oncology, and Cardio-Oncology patient care, research, and education, I thought about what I wanted to do most in the world as a professional. It became clear to me in my fourth year of medical school that I wanted to manage and, even more profoundly, prevent heart disease in the general population and in individuals with a current or prior history of cancer, and especially too in women. During that year, I got to present on my learning experiences in patient care, research, and education to the entire Cardiology department.

In 2012, in my last year of medical school and the MD/PhD program, I matched into the highly selective clinician investigator program at Mayo Clinic in Rochester, MN. I signed on the dotted line in advance for Internal Medicine Residency, Cardiology Fellowship, and Postdoctoral Research Fellowship. Everyone, therefore, knew I was for sure destined to #ChooseCardiology.

During my second year of residency, during my Oncology rotation, I cared for a woman with congestive heart failure thought to be due to anthracycline therapy administered many years before. That blew the whole thing open. I informed my faculty and advisors in Oncology, Preventive Cardiology, and Cardio-Oncology that I desired and planned to pursue both Preventive Cardiology and Cardio-Oncology and find ways to merge the two.

Over seven years at Mayo Clinic, I was, therefore, able to focus much of my research and subspecialty training and learning efforts in Preventive Cardiology and Cardio-Oncology (see CardioOncTrain.com). I also had the privilege of several clinic sessions in Heart Disease in Women. To me, all three are related, in so many ways.

My mission, therefore, is to protect the heart from ischemia, arrhythmia, cardiomyopathy, and other ailments in the general population, and particularly those individuals with a current or prior history of cancer (and especially in women).

Thus, I am now a cardiologist, with special emphases in preventive cardiology and cardio-oncology, especially in women. I am also a poet, and writing poetry about science, medicine, and now the heart has truly become one of my greatest joys (see LyricalMezzanine.com).

I share this story with you as an example of an individualized pathway in #ChooseCardiology. Perhaps you too are leaning towards areas in Cardiology to which you have not had much exposure, yet you know somebody has to do it, and that it must be created. Don’t let the unknown obscure the certainty of your calling. Find mentors and advisors who will believe in your potential and vision and spur you on, and who will one day be proud and excited to see your passion become reality.


“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.”


Multi-Disciplinary Approach And Decision Sharing In Geri-Cardio-Oncology

Incorporating a geriatric assessment tool into the care of the geriatric cardio-oncology patient is crucial. The use of comprehensive geriatric assessments has been shown to improve overall survival, quality of life, and physical function, while decreasing hospitalizations and nursing home placement in the geriatric population. While cancer is the number one cause of mortality in patients between 60 and 79 years, heart disease is most common in people aged 80 and older. More than 40% of these cancer survivors above the age of 50 will develop cardiovascular (CV) disease. In general, older patients are affected by a number of factors, including concomitant comorbidities as well as other physiologic and functional changes that can affect prognosis, treatment, and outcomes of cancer.

Cancer therapeutics including traditional chemotherapy, targeted therapy, radiotherapy, and hormonal therapy all have short- and long-term systemic effects, often involving multiple organs. However, CV toxicities have been most concerning and can result in irreversible CV damage or reversible cardiac dysfunction. These cardiotoxic manifestations can include left-ventricular (LV) dysfunction and heart failure, myocardial ischemia and infarction, hypertension (HTN), and arrhythmias such as QT prolongation. Less frequently, these complications consist of myocarditis or pericarditis.

Anthracycline-induced cardiotoxic effects are dose dependent, and those who develop late cardiotoxicity have a high mortality. Risk factors include cumulative dose, bolus administration, high single dose, prior radiotherapy, simultaneous use of other cardiotoxic agents, female gender, bimodal age distribution, existing CV disease, elevation of cardiac biomarker during and after cancer treatment, as well as time since completion of cancer therapy. A second class of frequently used cardiotoxic agents are targeted therapies including monoclonal antibody-based tyrosine kinases (bevacizumab, trastuzumab) and small molecule tyrosine kinase inhibitors (sorafenib, sunitinib, lapatinib). HTN is a common adverse event whose mechanism is not well understood but has been attributed to the inhibition of vascular endothelial growth factor.  Progression of or acceleration of ischemic disease is more common with radiation therapy Agents such as bleomycin, etoposide, cisplatin, 5-fluorouracil have been implicated in the development of myocardial ischemia including myocardial infarction.

Risk factors for chemotherapy-related cardiac complications should be assessed in all patients diagnosed with cancer who are being considered for cancer therapy, whether it be the administration of biologics, chemotherapy, or radiation therapy. Given that advancing age has been associated with cardiac complications from chemotherapy using anthracyclines or trastuzumab-based treatments, it is recommended that all elderly patients prescribed these medications should be educated about risk stratification and risk modification. Risk stratification remains difficult in elderly patients at risk for cardiotoxicity. A comprehensive evaluation of CV comorbidities such as HTN, diabetes, dyslipidemia, and smoking needs to be evaluated prior to start of therapy.

Those patients receiving high-dose anthracyclines, high-dose radiation, and history of prior cardiac disease are at greatest risk for cardiac dysfunction are at highest risk for cardiotoxicity. Cancer-specific mortality is often higher in older patients, likely due to the impact of age-related factors. Pre-treatment evaluation of LV systolic function is a standard part of many treatment protocols. However, the utility of this approach has been debated due to a low prevalence of asymptomatic LV systolic dysfunction, with this strategy missing most patients that will ultimately have cardiotoxicity. Serum biomarkers may be useful in predicting cardiotoxicity and the role of baseline assessment of serum biomarkers prior to cancer treatment in predicting cardiotoxicity is being evaluated. An echocardiogram is the most important tool for serial evaluation of the heart during cancer therapy. Ejection fraction should be determined using biplane method of discs, according to the American Society of Echocardiography guideline. Current recommendations for imaging surveillance include monitoring of LV systolic function during treatment with both anthracyclines and trastuzumab. Current National Comprehensive Cancer Network guidelines suggest cardiac monitoring at baseline, 3, 6, and 9 months after initiating therapy for trastuzumab therapy, upon completion of treatment, and every six months for 2 years following completion of treatment.

Collaborative assessment by oncologists, cardiologists and geriatricians before the start of chemotherapy can lead to early identification of patients at risk as well as discussions about the utility and benefits of cardiotoxic medications as opposed to potential alternative therapies. In some situations, alternative noncardiotoxic chemotherapy regimens may be considered. A lower-intensity chemotherapy regimen, however, should not be prescribed based simply on a patient’s risk factors or concern for potential cardiac complications, as this has been shown to potentially worsen clinical cancer outcomes. Cardiologists and oncologists may be less familiar with and often have limited to no training in routinely performing geriatric assessments and systematically evaluating for frailty. Within the gericardio-onc collaborative framework, the geriatrician is well positioned to take an active leadership role in advocating for the patient, assisting with decision-making, and facilitating screening and long-term monitoring of CV complications.

Cardiac dysfunction developing during or after the completion of cancer therapy is a growing heath concern that should be addressed in a multidisciplinary setting. There is a need for research on early biomarkers of toxicity as well as monitoring, surveillance, and treatment of older patients with cancer receiving potentially cardiotoxic therapy. The results of several studies are imperative in determining how best to risk-stratify and treat elderly patients with cancer while preserving their quality of life and functional outcomes.


Fawaz Alenezi Headshot
Dr. Fawaz Abdulaziz M Alenezi is a post-doctorate associate at the Duke University Health Systems. He conducts medical research on the derivation and validation of novel echocardiographic approaches to myocardial deformation and a new echocardiographic technique which assists patients with heart ventricular function.