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ADT and the Need for a Multidisciplinary Approach

Insights From: Susan F. Slovin, MD, PhD, Memorial Sloan Kettering Cancer Center; Dipti Gupta, MD, MPH, Memorial Sloan Kettering Cancer Center
Published: Wednesday, Apr 24, 2019



Transcript: 

Dipti Gupta, MD, MPH: Cardio-oncology is a growing specialty within cardiovascular medicine. Here at [Memorial] Sloan Kettering [Cancer Center], we comprise a division of cardio-oncologists that is rapidly growing. Our emphasis is on taking care of cardiovascular comorbidities and optimizing cardiovascular health in patients before, during, and after their cancer therapy. Our main mission is to ensure that patients undergo cancer therapy in an effective, and importantly, in a safe fashion. So we’re not here to hinder therapy, but we’re here to facilitate therapy and to make sure that it is safe and effective, and that we are not just treating one organ system with problems with another organ system.

Susan F. Slovin, MD, PhD: What I am concerned about is the lack of being able to determine among all the patients who do have cardiovascular risk factors, who are those that are really at the greatest risk? How do we identify those people who ultimately may end up going on to bypass, or other interventions? So it’s actually a little scary to think that we’ve been using a drug for so many years but have never really had respect for its [adverse] effect profile, at least from the cardiovascular angle.

So I always make sure myself that I send a copy of my clinic notes and when I start and stop drugs to the outside physicians to keep everybody in the loop. But even now I don’t think a lot of the doctors are aware of the risk that their patients have.

Ted Skolarus [MD, MPH] is part of the American Cancer Society attempt to provide recommendations on how to manage patients who are on hormonal therapy, and I was part of that task force, [which] made multiple recommendations about the treatment associated [adverse] effects, including erectile dysfunction, metabolic syndrome, and the like. Yet if you talk to a general internist, he or she has never seen those guidelines. So who’s reading them? You know we’re going out of our way to really try to educate people, but it’s not being disseminated in a manner to which I find satisfactory.

So we’re making strides. This is very exciting in terms of how we can go forward and try to prevent events from occurring. But we still have a long way to go.

Dipti Gupta, MD, MPH: A couple of points are noteworthy when we are trying to take care of these high-risk prostate cancer patients that are potentially candidates for androgen deprivation therapy.

Number 1) We have to be aware of the cardiotoxic profile. Not only us as providers but patients need to be aware, oncologists need to be aware, primary care providers need to be aware of this relationship and this potential for metabolic aberrations and cardiovascular disease. Awareness is the key.

Number 2) We cannot in this day and age expect oncologists to take on the role of subspecialty medicine. If a patient is going to an oncologist for prostate cancer care, it is unreasonable to expect that the oncologist is willing or able to act as the endocrinologist, to act as a cardiologist, or any other subspecialty medicine.… It is extremely important that we all work in a very close multidisciplinary fashion. We talk to each other. We not only send notes or fax our notes, but we pick up the phone and we talk to each other. And we talk about the patient and we get them as optimized as you possibly can from a cardiovascular metabolic standpoint, so they’re actually in a better shape to then tolerate and finish their cancer therapies.

Last but not the least, I think a diagnosis of cancer does not preclude us from taking care of the general medical health of the patient. Just because a patient has cancer, no matter what the cancer diagnosis is, we have made so many strides in cancer care that it is now more important than ever to pay just as much if not more attention to their general medical and their cardiovascular health, and this applies to all patients with cancer as well as cancer survivors.

Transcript Edited for Clarity
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Transcript: 

Dipti Gupta, MD, MPH: Cardio-oncology is a growing specialty within cardiovascular medicine. Here at [Memorial] Sloan Kettering [Cancer Center], we comprise a division of cardio-oncologists that is rapidly growing. Our emphasis is on taking care of cardiovascular comorbidities and optimizing cardiovascular health in patients before, during, and after their cancer therapy. Our main mission is to ensure that patients undergo cancer therapy in an effective, and importantly, in a safe fashion. So we’re not here to hinder therapy, but we’re here to facilitate therapy and to make sure that it is safe and effective, and that we are not just treating one organ system with problems with another organ system.

Susan F. Slovin, MD, PhD: What I am concerned about is the lack of being able to determine among all the patients who do have cardiovascular risk factors, who are those that are really at the greatest risk? How do we identify those people who ultimately may end up going on to bypass, or other interventions? So it’s actually a little scary to think that we’ve been using a drug for so many years but have never really had respect for its [adverse] effect profile, at least from the cardiovascular angle.

So I always make sure myself that I send a copy of my clinic notes and when I start and stop drugs to the outside physicians to keep everybody in the loop. But even now I don’t think a lot of the doctors are aware of the risk that their patients have.

Ted Skolarus [MD, MPH] is part of the American Cancer Society attempt to provide recommendations on how to manage patients who are on hormonal therapy, and I was part of that task force, [which] made multiple recommendations about the treatment associated [adverse] effects, including erectile dysfunction, metabolic syndrome, and the like. Yet if you talk to a general internist, he or she has never seen those guidelines. So who’s reading them? You know we’re going out of our way to really try to educate people, but it’s not being disseminated in a manner to which I find satisfactory.

So we’re making strides. This is very exciting in terms of how we can go forward and try to prevent events from occurring. But we still have a long way to go.

Dipti Gupta, MD, MPH: A couple of points are noteworthy when we are trying to take care of these high-risk prostate cancer patients that are potentially candidates for androgen deprivation therapy.

Number 1) We have to be aware of the cardiotoxic profile. Not only us as providers but patients need to be aware, oncologists need to be aware, primary care providers need to be aware of this relationship and this potential for metabolic aberrations and cardiovascular disease. Awareness is the key.

Number 2) We cannot in this day and age expect oncologists to take on the role of subspecialty medicine. If a patient is going to an oncologist for prostate cancer care, it is unreasonable to expect that the oncologist is willing or able to act as the endocrinologist, to act as a cardiologist, or any other subspecialty medicine.… It is extremely important that we all work in a very close multidisciplinary fashion. We talk to each other. We not only send notes or fax our notes, but we pick up the phone and we talk to each other. And we talk about the patient and we get them as optimized as you possibly can from a cardiovascular metabolic standpoint, so they’re actually in a better shape to then tolerate and finish their cancer therapies.

Last but not the least, I think a diagnosis of cancer does not preclude us from taking care of the general medical health of the patient. Just because a patient has cancer, no matter what the cancer diagnosis is, we have made so many strides in cancer care that it is now more important than ever to pay just as much if not more attention to their general medical and their cardiovascular health, and this applies to all patients with cancer as well as cancer survivors.

Transcript Edited for Clarity
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