Jean-Bernard Durand, MD, discusses implantable cardiac devices and how patients may be able to continue their treatment regimen.
Jean-Bernard Durand, MD
Implantable cardiac devices are providing a more nuanced understanding of how technology can extend care to the patient’s front door, according to Jean-Bernard Durand, MD.
According to data from The University of Texas MD Anderson Cancer Center, survivors of cancer are more likely to die of heart disease than their cancer, and should be carefully monitored for heart problems both during and after cancer treatment. Approximately 3% to 50% of patients have heart failure during chemotherapy, depending on the systemic drug used.
“When caring for cancer survivors, it’s important to recognize their vulnerability to atrial fibrillation and heart failure caused by previous chemotherapy, and to be vigilant for these heart problems,” said Durand, associate professor in the department of cardiology at MD Anderson. Chemotherapy and radiation therapy can increase the risk for cardiovascular problems such as severe hypertension, cardiomyopathy, ischemia, atrial fibrillation, and congestive heart failure, he added.
Though the symptoms of systemic drugs vary, cytotoxic chemotherapeutic drugs weaken the heart muscle. Taxanes can cause abnormal heart rhythms during treatment in some patients, and angiogenesis inhibitors can cause increases in blood pressure, risk for blood clots, and heart failure.
With implantable cardiac devices like the CardioMEMS and Reveal LINQ systems, Durand hopes to eliminate the need to discontinue cancer treatment in order to prevent heart failure. In an interview with OncLive, he discussed the new medium and how patients may be able to continue their treatment regimen.Durand: There is a relatively common problem we all have in our practice, and that is when we have patients who see us from all over the city, all over the state, and all over the country, how do we communicate with these patients and monitor them? Historically, we have always managed this by patients coming to our clinic and having a face-to-face encounter with them. Then we make our decisions about therapies, diagnostics, and diagnosis.
Now, with all these new technologies that have come along, we have some new tools that we can use, specifically using web-based technology where we can not only monitor patients remotely but also diagnosis. What is happening in parallel to these new technologies is that governmental agencies are now recognizing the importance of being able to communicate through web-based technology with patients who cannot get to our offices.
Think about the patient who lives very far away and then has to get into the city to see our doctors. How do we communicate with those individuals? We now have this web-based technology. Web-based technology is the ability to monitor and track patients with different diagnoses, in particular for cardiovascular disease. We now can use noninvasive, FDA-approved technology that we can implant within the patient’s body, and we can monitor them anywhere they are around the world and anywhere the provider is around the world.
That information is transmitted through cellular technologies, so as long as there is a cell tower around them, they can transmit information either to our computer or our smartphone anywhere in the world. The importance of how that relates to oncology is, we already know there are many oncology drugs that have side effects, in particular that affect the heart. Typically, we require these patients to come into our clinic.
Now with the implantation of this technology, we can monitor these patients remotely. We can look on our smartphone at a dashboard, for example, at their blood pressure or their heart rate, and whether their heart rate is fast or slow and what type of rhythm it is. Based on what we see on our smartphone or computer, we can call the patients and either adjust their medicines or start new medications without them ever coming into our offices provided they’re stable.
Patients who are sick need to have a face-to-face encounter, but now we have the ability to monitor these patients and make decisions in real time, anywhere around the world, so that they don't have to get into a cab, onto a train, find transportation to get here, and wait many hours to be seen. It is cutting down on our time to make real-time decisions.
How else does that relate to oncology clinical trials? What about drugs that have a predisposition? Now, we can monitor them and we can detect exactly what their burden of cardiovascular disease is. Throughout the course of their clinical trials, and as these trials are completed, we have objective data that we can give the FDA about the cardiovascular side effects of these clinical trials in oncology. It is already being used at The University of Texas MD Anderson Cancer Center. We use it real time; it is part of our practice. We have found it very helpful for particular types of drugs that we know can cause rhythm disturbances. For patients with cancer, the goal is to successfully get them through their treatment with minimum toxicities. When these toxicities show up, our go-to move is to stop a life-saving drug.
For example, [there are cardiotoxicities with] ibrutinib (Imbruvica), which is approved for chronic lymphocytic leukemia and certain lymphomas. Now we have the capabilities to identify these problems, treat them, and prevent patients from stopping their crucial life-saving oncology drugs. That is where I see the biggest advantage in practice. Data show that if you discontinue drugs such as ibrutinib for just 8 days, that impacts how long patients live. We really need to do a better job of making sure patients get on their cancer therapy, but also stay on them so they can maximize their outcomes.
This is likely something that can be useful during natural disasters when patients cannot come in for treatment, specifically when there was a hurricane in 2017 in Houston, where MD Anderson is based.
No doubt about it. That is an example where, because cell towers were for the most part functional and because we didn’t have wind, we had water, they were functional. Many patients could not get into the medical center, and that allowed me to pull up their information on my smartphone to see how they were doing. When there were events, I was able to call these patients anywhere in the United States and make my adjustments in real time, without interfering with their cancer therapy. It is done as an outpatient procedure. The technology now is moving more into the cardiovascular space so that we do things as fast as we can, as minimally as we can, and the technology is as small as it can be. Most of these devices can be placed through a vein into the heart or placed under the skin. The procedure [where the device] is placed under the skin takes less than 5 minutes with local sedation. The procedure where we have to go into a vein, for the most part, takes less than 30 minutes with conscious sedation. You don’t go on a respirator and can leave 2 hours after the procedure. We are now at a place where governmental agencies are realizing these problems of having access to healthcare, and they have requested that we start to develop current procedural terminology codes so that physicians and oncologists have the ability to communicate with their patients through whatever method and are able to identify ways to communicate with patients.
Where is this going for the future? We need better clinical trials. We can define problems much earlier; this is about pattern recognition. As we start to work from a dashboard and manage patients, we will start to recognize important patterns that can affect how a patient feels and their risk for having an event. Conversely, patients will learn things they never recognized about their weight, their rhythm, symptoms that they have, and identify these things much earlier, so they can warn their healthcare providers and a decision can be made earlier. The learning curve is going to be very important in the future, both for the provider and the patient.
The most important thing for the future is patient engagement. We already know from many clinical trials and studies that the more the patient is engaged, the better their outcomes are. It is a win-win for the patient and a win-win for the healthcare provider, but also for a system through which patients have access to their doctors without physically having to get to their clinics all the time. They can communicate with their local cardiologist. Usually, this is done with an electrophysiologist, the field within cardiology. They are electricians, if you will, and they are already very savvy about the use of web-based technology, cellular technologies, and using dashboards to be able to identify diagnostic problems, as well as to treat.
Delsigne, Jill. Implantable devices monitor for cardiac events in cancer survivors and patients on chemotherapy. Oncolog. 2016;61(3):5-6. http://bit.ly/2GAtz5G.