Permissive Cardio-Toxicity with Charlie Porter, MD

Recently Dr. Charlie Porter published a landmark article in JACC Cardio-Oncology titled "Permissive Cardiotoxicity: The Clinical Crucible of Cardio-Oncology" You can read the article here Our hosts Dr. Stephen Caselli and co-host Dr. Arjun K Ghosh are interviewing Dr. Charlers Porter to discuss the following topic “Permissive Cardiotoxicity”. Dr. Caselli is the executive director of ICOS, and Dr. Ghosh is a consultant cardiologist at University College London Hospitals and Barts Heart Centre. Dr. Porter is the founding Medical Director of cardio-oncology at the University of Kansas Medical Center. Dr. Porter has been actively involved in heart failure and cardiac transplantation for over thirty years in Kansas City. He worked with Dr. William Reed to help launch the third heart transplant program in Missouri and the first in Kansas City in 1985. He was a co-author of the research paper that introduced and validated the Kansas City Cardiomyopathy Questionnaire which has subsequently become one of the leading patient-centered quality-of-life surveys in the world. He had a recent review article published at JACC Cardio-oncology with the following title “Permissive Cardiotoxicity: The Clinical Crucible of Cardio-Oncology”.1 Episode Pearls   1. Permissive Cardiotoxicity is a novel term that represents an essential concept in the field of cardio-oncology and among practicing cardio-oncology specialists. It emphasizes a proactive rather than reactive approach to the continuation of lifesaving cancer therapies to achieve the best oncologic outcome while mitigating associated and potential cardiotoxicities. 2. Permissive cardiotoxicity–based treatment strategies often start with the recognition of this urgent need to commence anticancer therapy and for cardiology evaluation of CV risk factors without delaying important cancer treatment. Such patients may require a cardioprotective strategy implemented without the luxury of a few weeks of escalating GDMT for patients with HFrEF or the scheduling of several diagnostic studies over a period of days or weeks before the patient is deemed ready for cancer therapy. 3. A common example eluding how permissive cardiotoxicity as a concept is important, is trastuzumab interruption (about 62% in the study by Sardesai et. Al) in HER2-positive breast cancer demonstrated worse disease-free (adjusted HR: 4.4) and overall survival (adjusted HR: 4.8) after adjusting for age, stage, grade, estrogen receptor status, node status, and trastuzumab-associated cardiotoxicity.2 4. Another example is that developing severe hypertension as a side effect of VEGF inhibitors is associated with improved cancer outcomes in some tumors sensitive to VEGF inhibitors.3 5. Mindset needs to be changed from treating cardiotoxicity to screening and early detection of cardiotoxicity and from “Should this therapy be discontinued?” to “How can this therapy be continued?” 6. Implementing permissive cardiotoxicity needs collaboration and clinical care needs to be delivered in a multidisciplinary fashion involving the patient, oncologist, pharmacist, and cardio-oncology specialist.   References   1. Porter C, Azam TU, Mohananey D, et al. Permissive Cardiotoxicity: The Clinical Crucible of Cardio-Oncology. JACC CardioOncol. 2022;4(3):302-312. Published 2022 Sep 20. 2. Sardesai S, Sukumar J, Kassem M, et al. Clinical impact of interruption in adjuvant Trastuzumab therapy in patients with operable HER-2 positive breast cancer. Cardiooncology. 2020;6(1):26. Published 2020 Nov 5. 3. Cai J, Ma H, Huang F, et al. Correlation of bevacizumab-induced hypertension and outcomes of metastatic colorectal cancer patients treated with bevacizumab: a systematic review and meta-analysis. World J Surg Oncol. 2013;11:306. Published 2013 Nov 28. Thank you to our show notes writers for this episode: Abdelrahman Ali, MDCardio-Oncology FellowMD Anderson Cancer Center Department of Cardiology Alana Quadros

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