Severe heart damage from cancer immunotherapies may be rare, but how to identify high-risk patients and monitor for incidence is a hot topic. In this video, two leaders in the field of cardio-oncology talk about evolving strategies.
Following is a transcript of their remarks:
Javid Moslehi, MD, Vanderbilt School of Medicine, Nashville, Tennessee: Marielle, I think one of the new, exciting areas in cardio-oncology is the cardiotoxicity that has emerged with cancer immunotherapies. Immunotherapies activate the immune system, and they've been effective for many cancer types. However, we see these rare cases of severe fulminant myocarditis, where the patients, immediately after getting the drug, come in with either cardiogenic shock, had significant arrhythmias, and we've had some fatalities. These are rare cases, again, but we're seeing it more given the explosion of these therapies. I think one of the questions that has come about is how do you diagnose this? How do you treat this? Should screening be implemented for patients who are at high risk? As best as we know, the high-risk patients are patients who get combination therapies.
Marielle Scherrer-Crosbie, MD, PhD, University of Pennsylvania, Philadelphia:
Tell me a bit more about what you heard at ACC or what they have planned, especially I'm really interested on whatever the field is on the screening. What do we think that we're going to do for the screening of these patients?
Moslehi: Yeah. With screening, I think what's interesting is with high-risk patients and these are patients who get two immunotherapies at once. That's the only known risk factor we know. Many oncologists have started screening with electrocardiograms and with cardiac biomarkers, which is troponins. They check this at baseline. They check this after the first dose, and they check another EKG and troponin after cycle two. We don't yet have data whether this is the correct algorithm to use, but that is what many oncologists are using with their high-risk patients, and these are mostly melanoma patients who are getting two therapies at once.
Scherrer-Crosbie: Yeah. I'm especially interested in imaging coming from an imaging background, obviously. My understanding is that there are some very novel ways, especially using MRI to diagnose myocarditis. I mean so...
Moslehi: Yeah, nailed it right on the head. We need, really, to bring in imaging experts like yourself into this because I don't think there is one way to diagnose the myocarditis. Certainly, there's biomarkers and certainly there's biopsy, but what correct imaging modality we use is going to be very important. 50% of these patients have no obvious LV [left ventricular] dysfunction, so the echocardiogram, the EF [ejection fraction] is going to be less helpful. There's some experts who say MRI is the way to diagnose this, yet, the availability of MRI is not uniform in, especially, some of the smaller centers. Then there are others who say PET scans could be something to use. I think we need expertise like yourself into this with respect to imaging, but one thing I would advocate for is I think we have to rethink the biopsy. There's no one fix with imaging. We need a combination of clinical intuition, biomarkers, imaging, and biopsy to really diagnose this.
We had an interesting that came out in Lancet today of 101 cases of myocarditis after getting immunotherapies, and there were 46 deaths from getting the immunotherapies and getting myocarditis, which is a very big number. It's a bigger number than we anticipated. And one of the things that we hope to do and working with many different centers is to really figure out what the incidents of myocarditis is, especially in patients who are high risk who get two different drugs at once.