Ep. 27: Cancer Treatment and Your Heart

Welcome, I'm Cathy Murtagh Schaefer. And I'm your host for this episode of heartbeats is podcast is brought to you by Shipley cardiothoracic Center and educational series dedicated to providing our patients and the community with information and education about our cardiothoracic surgery program and other issues that affect your health. This today is a second in a series of podcasts dedicated to our female listeners and celebrating the women's cardiac Surgery Center here at health, park in Fort Myers. Today's podcast also celebrates our continued collaboration with our Cardiology colleagues without whom a lot of this would not be possible. Our Guest today is Dr. Anita Arnold who is board certified. In cardiovascular disease, internal medicine and Interventional Cardiology. She did a fellowship in cardiovascular disease at the Cleveland Clinic and today, her practice focuses on cardio. Oncology. Welcome. Dr. Arnold. I'm so happy to have you join us today. Perhaps we can start with you telling us a little bit about yourself and how you became involved in cardio oncology and why this field of Cardiology appeals to you. Thank you so much, Cathy. It's a pleasure being here. And I think this inaugural program is terrific telling everybody. About some of the work that we're doing here at Lee Memorial with the Shipley Center. So let me tell you a little bit about cardio oncology. It is a new passion of mine and cardio oncology is actually a subset as subspecialty of cardiovascular medicine. We do not yet have fellowship designation for that like Interventional, like EP like heart failure because it is so new. It is however not uncommon to have heard of cardiovascular toxicity, with cancer therapies. We know about anthracyclines for many, many years. I personally got interested in cardiology when I was very young, all of my older family members, grandparents, grandma, grandpa. Elderly. Ann's all died of heart disease and I remember being very young asking my father. Why did Grandma not live? And they said the doctors couldn't do anything for her, huh? And that struck me as well. Then we need a better doctor. So in my naivete, I decided I would be a cardiologist. I would marry a cardiologist. I would have cardiac cardiology covered for my whole family. My father had his first heart attack at 40 30, my turned out to be interesting. However, after that everybody, in my family started getting cancer, my father died of cancer, my brother died of cancer. I developed cancer. My mother-in-law got came on my husband. Grandfather died of lymphoma and his grandmother had called. So all of a sudden the exposure shifted and I started reading more and understanding that virtually all of the cardiotoxicity can be associated with some form of cancer therapy. It hypertension, be it. Severe hyperlipidemia, ischemic heart disease, valvular, heart disease. And we're talking about chemotherapy. We're talking about the immunotherapy, Xandra talking about radiation therapy. So all of those Have an effect on heart. Wow, that's a pretty impressive family history for sure. I know you are a board of directors member of the international cardio oncology Society whose goal is to reduce cardiovascular disease in cancer patients. And I was so impressed by the diversity and internationality of the members of this society. I bet this is a great group to be a part of. Can you tell our listeners, what you've seen accomplished by the society and why this group is so important particularly to women Yes, I'd be delighted to. I joined number of years ago, when there was a global cardio oncology Summit in Tampa. And when I saw the variety of people that were involved from a cardiovascular point of view and in oncologic point of view, ikos is an organization for anyone who takes care of cancer patients. So nutritionist physical therapy rehab exercise. Physiology Cardiology. Biology, heart. Failure, Specialists, oncology basic, science members are all involved in. Part of what's interesting. I also chair the education committee and this is really interesting because it's an international group. So, for example, in Poland, they have a separate hematologist and a separate oncologist here in the u.s.a. 15 other here, so it's a little bit different. So seeing how other people not only care for their cancer patients were also looking internationally. For Best Practices. So the education Committee in particular, it has a whole group that's looking at cardio toxicities and how we can avoid them. What we can do up front. What are the best practices? And we're asking people internationally, so, it's very interesting in the United States, were not very biomarker driven in others. For example, Italy, they do it on every cancer, patient. So they can assess whether or not they're having some Cardiotoxicity very early in the in the situation. So, it has been extremely helpful. The president right now is Susan Dent, who is a breast oncologist from Duke and she transferred there from Canada where she started the Canadian oncology Network. So she's a very established researcher and just a delight to work with. And so we have a lot of focus on breast cancer and cardiovascular disease is a lot of the studies that are going on in a lot of the efforts are 82 that if someone's going to get cardiotoxicity, it is more likely to be a woman because of the breast cancer and the location preferable to the heart. What a great group though is far, as diversity is concerned so much to be learned from other people's practices and how different things are in Europe or Australia or wherever compared to what we do here, right? There's also a group looking at the genomics of cancer and cancer therapies. In other words, some of the things that we do here are usually driven by research that's male-oriented in white. So for example, in Japan, And obviously we're getting a different populations. So we are trying to look at information that's coming from all over and I think it really speaks to best practices because the education committee is also partnering with the advocacy committee and the patient education committee and there's a nurse's group. That's kind of driving. And so we're working with the team at MD Anderson. There's member from the UK. There's somebody from Washington University someone from Brazil. So when you have that kind kind of energy in a room be in Zoom or otherwise, it's extremely interesting how exciting day to comes out a lot of. What if we try this? What if we said that? What if we looked at this and that's something that in private practice today, you're so overwhelmed with covid. Maybe thing else that's going on that you kind of lose a little bit of this and I call it the energy. The energy from having a discussion with someone else really goes a long way and I think It's going to benefit women in general and cancer, patients, everywhere. I would comment to say that how lucky you are to be working with global energy. There are an estimated 14 million cancer survivors in the United States due to the success of cancer treatment, but one of the major issues survivors have is the development of coronary artery disease or other diseases of the heart. That contribute to early deaths and disability more so than their age matched counterparts who have not had chemo. Is there a particular cancer that has demonstrated more cardiotoxicity than others when combined with chemotherapy and do we know if the cardio toxicity is related to the combination of the type of cancer and treatment? Or is it related directly to the treatment? So you are correct. There are more than 14 million cancer survivors now. And that number is going up dramatically every year to the point that by the time 2020 come 2024. I'm sorry. There will be another 50% most of those patients, 85% of them will be over the age of 50. So it speaks to an older population which is ripe for coronary artery disease, heart disease anyway, and it is predominantly women because women live longer anyway, and so it goes together like that. So it's really kind of interesting. And the group that seems to have the most cardiotoxicity though. To be honest, with you are the Childhood cancer survivors. These are the lymphomas and these are the look young man's radiation. Has most of the childhood. Cancers 85% of those kids are going to survive which is great. But if you take a four-year-old who got for example, anthracyclines, which is a cynic or known for cardiotoxicity, and then 20 years later. There were only 20 War. And so, they will show cardiotoxicity earlier, and it might not be like, foaming in heart failure, but you will see a decrease in exercise tolerance. You'll see arrhythmia. You'll see hyperlipidemia. So what we have noticed is that one is the Childhood Cancer group that we need to keep an eye on. And that's why the Cardiology Department here at Lee, has partnered with golisano, and we will take care of adolescents and young adults. Adults the Aya population. Yeah, they call it these days so that we can get them in with adult Cardiology Because by the time, they're 16, 17 18, they really belong to McDonald's, right? So we will see those patients and so we're trying to work on survivorship with them, which is a most interesting population. We could have a whole one our discussion on how best to treat them and then the other group we work with, are anybody who's getting either in anthracycline derivative, which is a lot of the breast cancers are some of the Salah Reverse some of the immunotherapy 's and then some of the radiation therapies and we're going to talk about that a little bit. But which population every single cardiovascular study that has looked at cardiotoxicity when they look at the Baseline risk. Assessment of that patient, if you have hypertension, hyperlipidemia, diabetes are classic cardiac patient, you will do worse. Wow. You worse in the long run based on. Answer and based on cardiovascular toxicity. So there are millions of cancer patients in the United States. We are not saying every single one has to go to a cardio cardio on college, right. Be over around. However, what we're trying to figure out who are the high-risk people. So we already know, it's in childhood cancers. We know certain types of drugs that people get, we need to monitor them closer, and then anybody who has had radiation to the to the chest, so it's breast cancer, esophageal cancer, gastric cancer, lung cancer, those Need to be watched a little bit closer. It seems like a great opportunity for partnership would be with the OBGYNs because women often don't present to a physician after the age of 18 until they have their first child and and there are OBGYNs tend to become their Primary Care. Yeah. Sure. So I think that speaks to two things. One is you and I both know and for years, it seems like the American Heart Association American College. Geology has been trying to get the word out. Heart disease is the number one killer of women in. We say heart disease would mean heart disease stroke, right? Failure altogether, but every time they do a survey of women only about half realize that. So the latest survey that came out was 56 percent of women will say. Yes, heart disease is the number one killer of women. Many women are more afraid of breast cancer, but it's only one in eight are going to get breast cancer. We're wanting to To get heart disease, and there's two women in this room. Right? Right, right. What's a little bit disappointing? Unfortunately, is that the underserved population and the diverse population is not as aware. They're about 30 percent, understanding that, that is a risk factor for them. And what we have also learned the risk factors for coronary, artery disease, and heart disease are the same risk factors for cancer. So diabetes. Yeah, we diet lack of exercise. All alcohol abuse. Yes, they're all related. And so it gives us an opportunity to work with certain groups. For example, one of the groups were working with is Radiology. The radiologist reads mammograms. So they're looking for calcifications that look like a cluster of cancer cells, but we have asked that. Can you please tell me are there cow's? Vacations in the arteries of in the breast. Because if you have calcification there, then we're going to start looking for calcification and other places. Yeah, we have size. So I think your word collaboration is really what we're trying to drive here. We don't need to reinvent the wheel. There's a lot of information, you can get from a good history and physical. And all of the tests that you order when an oncologist orders, a CT scan of the chest. We asked them, could you comment on atherosclerosis? Grocers of the arteries or the, a order, the size of the aorta is a little bit dilated so that you get as much information as possible to take care of that patient. In totality these days, people will survive their cancer, but they are right then for cardiac toxicity afterwards and that, that really is important in a lot of patients are a little distressed by that. Obviously, they don't want to have one problem and then go to another, right? And if you think about it, so many of my patients now that I take care of from a Lee cardiovascular point of view, wind up, getting some form of cancer, the men will get prostate cancer, the moment, get breast cancer, lung cancer, something like that. And so now we need to focus on treating the cancer but not exacerbating the cardiovascular situation. Dr. Arnold, would you explain a little bit by what? Explain what you mean by the term cardiotoxicity? That's another good question because when you look at all the research studies, the FDA, sometimes called cardiotoxicity if the patient complained of shortness of breath. Well, that could be so many different things. Definitely. One of the things we're working on is standardizing the definition of cardio toxicity. In general. We are talking about vascular disease. With whatever therapy they're getting valvular disease, myocardial disease, either early onset pericarditis, Mark myocarditis, especially with some of the car T cells or immune checkpoint Inhibitors. They can cause a raging myocarditis down to heart. Failure in the later stages. Peripheral vascular disease, arterial occlusion Venus, occlusion stroke arrhythmia. You name it? It can have those things happen with those things. So, so when we say cardiotoxicity, it's become kind of a general term for vascular and cardiac abnormalities, including, for example, arrhythmia, in the past. It was a drop in ejection fraction. However, drugs that we know will drop your ejection fraction. We will do screening for that and that we have come up with a definition normal. Ejection fraction is 53 percent or higher and Global longitude. Strain, which we can talk about in a minute is a new parameter that we started measuring in oncology patients that has to be minus 18 or a higher number than that and then we look at the drop and if it's a significant drop more than 10% of either of those, then we start to worry, or if you start seeing a pattern somebody has injector 75%. Then the next time, 65 years in the next segment, that's telling you and that's where the Europeans love to use. Occurs because after your chemotherapy if we draw, let's say a troponin and it's elevated that would speak to some cardio time City during that infusion. And so maybe we'll watch you a little bit more carefully. And I guess one of the comments that I would make to that is we are we know our patients tend to drift from Doctor to doctor and so you might see a patient that has an EF of 65 percent. But it had been 70 but you don't know that and you're considering that normal as would I. And then the next Doctor sees the patient and it's 55 percent and we don't realize we've dropped from 7255 and I think again that speaks to the universality of trying to coordinate. Yeah records and you know here in Florida. We have the snow bird population. So someone's treated up North and then comes down. They really don't bring all their records. Right. The oncology team is usually pretty good and that care everywhere has been helpful, but you're exactly right. Because a lot of the times the patient's I try and educate my patients. The more they know the more they can help me or they can help the next Doctor. So I explain to them exactly what I'm looking for and why that's important. That doesn't mean let's say the person is so jacked up when they go get their first at go because they've been told it has to be normal. Yeah. Right chemo. And then, you know one thing leads to another and the I'm thinking, oh my God, this person is because now their blood pressure is sky-high. Guys, my heart ejection fraction. 75%. The next time they come in. They're feeling good. Everything's okay. The blood pressure is better. So it's definitely related to their loading conditions or blemish at needs to be looked at because we have seen, as you're saying people being told, you can't have any more chemo because you dropped from 65 255. Well, the first thing I do is repeat it with the same loading condition, relax. Yeah, hurts and stuff like that. And if it's perfectly normal, We we can address that but I think that's really important. Every cardio oncology meeting. We have. We hear horror stories of people who are told, you can't have any more chemotherapy because your heart that's devastating. It's best. If devastating puts the patient in a very awkward position because they were told by a quote, The Specialist. Right? Right, and the oncologist said we have to press forward, seems like it might be helpful useful to also educate our Sonography staff. So that they understand when a patient comes in and they're the anxiety level. Is that high? It might pay to take a little bit of time. Yes, just relax. Yeah, absolutely. As you mentioned we used to judge cardiotoxicity mainly by measuring the left ventricle function or what we know as the ejection fraction and for our listeners, the ejection fraction is a measurement of how much blood the left lower chamber of the heart pumps out into the aorta. When it squeezes and as Dr. Arnold mentioned, 55 and above is considered normal. Are there other markers that indicate toxicity? You mentioned biomarkers? Yes. So let me just back up for 10 seconds when we report an echo, as I'm sure, you know, we usually do a five percent 50/50. Yes, 1415. The reason for that is because visually your brain in your eyes, can only distinguish a 5% change. So it's not that exact. Okay. So now I do a report. Says 45 to 50 and they go to the oncologist. And the oncologist says, what was it 45 or is it 50? Because I can give a drug, if it's 50. I can't give a drug fits 45. So they were pushing us very hard. Find a more elegant way of assessing is, so, people were using muga scans for a while where you inject a radioactive materials. And then, basically, it just counts the number of particles, that leads heart and it gave you a number. However, it's radioactive. And that's kind of the last thing I want to get, right. Right radiation to the heart. So that kind of fell out of favor and what became more interesting is, you know, when we do Echo, we do multiple views and so there was a group of Engineers who said, well, we can do a better job by looking at smaller sections of The myocardium. So what they did was they did this speckle. So they put little tiny dots all the way around The myocardium and then they Wait, how much? Yeah, so now I have multiple views multiple points and I can calculate very elegantly because you can have a normal ejection fraction and have lost one whole wall of your heart because yes, hyperdynamic parents to know that we need to know that wall is no good. So it's called Global longitudinal, strain GLS and because the the particles came together, that's a smaller number. So you want a big negative number, which is so you want - 18 - 19 - 20. Well, it was okay. So let's say we have an ejection fraction of what's red is 50 55, but the global longitudinal strain, is minus 14. Okay, that is abnormal. If the global longitudinal strain is -20, then you'll feel a bit better about that. So, we use both of those numbers together. The other thing we use is MRI to see if there's late guys. And um enhancement and that's kind of helpful. Are you starting to get some fibrotic changes? Are there other things, we use it, also for myocarditis, but then you check point Inhibitors. So that's been quite helpful as well. But MRI is a different animal numbers. Things like that. There are other issues. We use, CT scans to help. And then the biomarkers, because the biomarkers are helpful in telling me, do you have ongoing? So it's not just the troponin. It's also the BNP would speak to a heart heart failure. Not as vigorous as you can like it to be. Yeah, what can be done when a woman comes to you, with what I call toxic heart syndrome. Is this a permanent condition? Okay. So any patient who has had cardiotoxic therapy, automatically is called stage a heart failure. Meaning they're more susceptible of something else were to happen. So the first thing we do is look at what are the other things? What is their blood pressure? What is their diabetic status? What is their Exercise capacity? Things like that? Do they have ischemia stage? A doesn't necessarily mean they're actually feeling sick. Is that correct? Okay, faculty. They actually feel pretty good, but they are considered high risk for the development. Okay. It's like a woman has preeclampsia is more prone to getting hybridizing attention. Yeah, so we look at that and And if they have had a drop in ejection fraction or cardiac function, we have medication, that can help them. So is it permanent? Not necessarily? It also depends what stage in their their cancer Journey, their treatment. If they have just finished around a bath recycling, then probably not the best time to make an array. An opinion about it. Yeah. So really when I see patients, every single patient, you know, even if their stage 4 cancer because stage 4 cancer. Can still live for a long period when it means metastatic outside of the initial organ affected and I want them to live as healthy as possible and have the best function. So all of their risk factors need to be addressed even cholesterol. It used to be that you would say. Well, you know, they have so many other pills. Yeah. I was laying not feeling so great. I don't want to give them a Statin on top of that, but it is really quite helpful. So there's anecdotal evidence and this Is what's really interesting about when you read everybody else's literature? When you look at breast cancer survivors. All comers women who are on statins, do better from a cancer point of view. Hmm. Then I mean, not on stands. Statins are not the treatment for breast cancer, correct, but it is an interesting signal, interesting Association. Yeah, if you think about cholesterol, the blood boil, water things like that. What a cancer cell tries to do is get where it's not supposed to be so that it can take over that cell. Cholesterol has to be transported into the cells. And so they have this layer. It's called a lipid raft. Wear a blue piece of cholesterol. Molecule goes in there and then gets transported into the cell. It makes it much easier to have this gunk out for yourself. Yeah, get in. Well, there is some cancer therapies that use that hitch a ride. Yes. So statins, destroyed the lithographs. Huh? So think about that, huh, maybe that is maybe that's the yeah, so there are people much smarter than I, who are trying to look at that and say, wow, could that that's fascinating, but that work is. So that's what we are looking at since the risk factors are so similar. Can we do two birds with one stone? Can we try and help people on multiple levels? So I think some of the stuff that we're going to hear about in the near future is going to be. That is fascinating. Yeah. Yeah, absolutely. What are some of the risk factors that a woman needs to be aware of prior to starting chemo or radiation therapy regarding her heart? Obviously, it's a big risk factor if she already has been identified as having heart disease, but what other things put a patient at high risk of developing heart disease after cancer treatment, you mentioned that the typical diabetes, high blood pressure Etc, right? So the better shape that In is in prior to starting any type of therapy for cancer, even the surgery, the better off they're going to be. So the first thing we do is we look at their blood pressure. We look at their heart rate. We look at their weight. We look at the diabetes. So all of those things are important, then we look at what is the cancer therapy? This person is going to get, are they going to get anthracycline? So we have a scoring system. Whereby you get one point for this one point for that and it's interesting because if you looked at the HACC risk calculator and let's say 22. Year-old woman who has triple negative breast cancer, who's going to get anthracycline? When you do her calculation, her 10 year risk of cardiovascular disease is not. There's nothing to us to say. I don't remember cancer or write anything being included in that. It's not. So now, when we use our cancer score in plugin for points for anthracycline therapy, all the sudden that patient is at high risk spell card. Excessively. So that's why the risk calculators are just not that good. And so we are trying to score every single patient. And then say, based on that score. They should probably you don't have to see Cardiology every time, but maybe just check in at the beginning, maybe the middle and that their Enterprise, we cry and go over everything. What did you get? So the drugs are going to get whether or not, they're going to be exposed to radiation. Ionizing radiation, if they're going to have him, you know, Oh therapy. If they're going to have hormonal manipulation to Mossman versus AI women on ATT therapy, those make a difference. Even some of the oral agents for let's say colon cancer can cause severe severe severe hyperlipidemia, that needs to be treated really badly. I mean, they can go from having a normal triglyceride to having a truck. That's red. That's 5,000. Wow. So that's really important because set up for a Crea Titus. Yeah, so, That's why it really depends on what treatment they're going to get. Are the oncologist on board with all of this focus on heart treatment. The oncologist in this area are so spectacular. Yeah, cannot speak. Highly enough. I get patients. Can you please check this person? Because I'm going to give them this drug the QT and I'd like to move Alleyway. Wow, that's great. Yeah. I've started giving this drug, the QT was normal. And now it's abnormal. Can you please check them out? Somebody's complaining of chest pain. I know they're on a Drugs that can cause or to check them out. Or a lot of my surgeons. We do a lot of pre-op work. So, for example, someone who's having extensive head and neck surgery where they're going to have flaps put in and stuff like that. If they don't have a good enough cardiac output. They're not going to heal. Well, and I and that bathrooms or may not may not do won't feed the flats. Right? So we need to help them and optimize their status as much as possible. A lot of them. Lung cancer patients, obviously have been smokers for a long period of time. They have cardiovascular risk. May have PVD, they might be put on a new therapy that can cause venous or arterial young girls. And so, all of those things need to be changed. They don't need a million-dollar workup. They need a really good physical examination. And then some things, and of focus workup on ecology and they're becoming more and more aware and it's becoming absolutely amazing. Some of the drugs coming down the pike. They are just yeah. Yeah. Wow. Since we began having weekly valve conference. I've noticed that many of our female patients, have what we call a hostile chest, meaning that they've had radiation to the chest wall. Usually, for breast cancer lymphoma, and that radiation has damaged the tissue of the chest, making it extremely fragile and difficult to operate on. In fact, one lady had radiation for breast cancer, many years ago, and then more radiation. Lately due to lymphoma. I'm curious as to what radiation does to the valves of the heart. And is there anything that can be done to protect the valves? The answer is yes, we get a lot of our information about radiation. Unfortunately, from the Japanese and the atomic bomb, of course, you know, Ground Zero. And as you follow them out for years. And so, we know that radiation can cause valvular heart disease. It causes. Both the valves, the pericardium, The myocardium starts getting fibrotic and stiff. So in the valves get stick similar to aortic stenosis or mitral stenosis. Did doesn't work very well and those valves are not easy to do valvuloplasty or something like that on. They need to be replaced. The only difference with that is tavr has been extremely successful in quote hostile chest. Yeah, because you don't want to open that. It's very difficult. It's like, cutting through tremendous amount of scar tissue layer after layer after layer, just makes It's like cement when you go in there. Yes, it's very difficult. So then the question comes up. Radiation oncology. So 20 years ago, radiation oncology would just kind of Blast away because the focus was the cancer need. We didn't have all the drugs. We had, we didn't have all the immunotherapy and so they needed to upfront. Do the kill the viola cancer. So, so in order to increase survival, they they trade made some trade-offs nowadays. They do some really interesting so far. A for breast cancer. If I ask you to take a really deep breath, you're going to expand the Press away from your heart. And so they do now deep inspiration breath-hold. And so they teach the woman, take a deep breath. And so they practice that. It's so when she goes in to get her therapy, it's when she takes a deep breath. And she only has to hold it for like 15 seconds or something. And if, for example, she coughs and let's go the machine stops. And also kind of elegant. The other thing if you think about it, if you go prone, so they have Special tables. We have press. Yes, and then the heart is above the table depressed or below the table and then they can and they can radiate that way. I also was at a conference three days ago where the zoom Conference of course, and they were showing pictures of how the radiation oncologists. Now, we'll take the CT scan and map exactly where they want to go. Trying to get the best, the best angle angles, and so, they don't get the heart. And so they usually Make several treatment plans. And then they calculate the mean heart dose. And then go to one that has the smallest meet hard. Do so, they're getting much much better. So really, anybody who gets radiation now for as an adult is probably going to be. Ok. I tell them in about ten years is the first time I would do something check an echo from time. I thought this function or do a cardiac MRI to see how you started to get fibrotic myocardium or pericardium. It's the children. We still have to keep an eye on. Because their life expectancy is pretty good. So they will develop, they will develop them issues later on. And my last question are there, clinical trials, locally investigating, this particular aspect of cancer and treatment regimens. So there are a lot of studies going on. Specifically coming from a cardiovascular point of view. It's limited. Most places are pretty much doing their own studies. So for example, Sloan-Kettering in New York, Dana Farber, MD, Anderson pain, Moffat had some Vehicle trials in cardiothoracic, but not so much. So we don't have a lot. We are looking actively. This is the type of Center that would do very well with doing biomarker studies ejection fraction studies. Honestly, if you enrolled a group of breast cancer women and then just followed them longitudinally with markers and things like that. What's difficult is getting all the accouterments you need for a research study as you know, right? And then There's no way of getting around it. Medical Care in the United States is still very siloed. Yes. So it helps. When you have your cardio oncologist, very close to where your oncologist is. So there's a lot of interaction going on there. So I think we still have some work to do but things will be coming. Absolutely. I'm actually amazed at the advances you've been describing today. It's fascinating because I do remember way back when There just wasn't a whole lot out there. And we just slammed women in particular with these anthracyclines and radiation and and, and crossed our fingers essentially rate. And I still have a number of patients who have gotten anthracycline, who do not do well with it. And we struggle with how best to take care of that person. Because at some point depending on their age, if they survive their cancer long enough, they will be heart, transplant candidate, which is all Another ball of wax and not something they expected when they started their cancer Journey. So, we still have that issue. And really, the biggest thing is trying to figure out what is cardioprotective. This has certainly been a very informative conversation and I think our listeners are going to gain a lot from our conversation. Is there anything you'd like to add before we sign off? Yes, I'd like to thank you for the opportunity. I'm so happy that you came over. Thank you. You to discuss some of the passions in my world and I refer people to we have a website at Lee which you can put some cardio oncology and the regional Cancer Center also has a website. There's some Cardio, oncology information there and patient-centered cardio source dot-org is from the American College of Cardiology and the international cardio. Oncology Society also has a website where there's a lot of interesting information and most of that is available to the general public as well. So when we post this podcast will make sure to include in the information those those links. Thank you so much. Dr. Anita Arnold. This has been a great conversation. Until next time. I'm Cathy murtagh Shaffer. And this has been heartbeats Shipley. Cardiothoracic centers podcast, dedicated to Bringing research, Innovation, and education to our patients and the community.