Juan Carlos Plana, MD — Cardio-Oncologist

The Annual Report to the Nation on the Status of Cancer published in January 2013 shows that overall cancer death rates continued to decline in the United States for all of the most common cancers, including lung, colon, prostate and breast. Modern cancer therapies garner the credit for this. However, some treatments, such as certain chemotherapies for breast cancer, can have serious cardiovascular side effects.

According to Juan Carlos Plana, MD, breast cancer survivors die more often from heart failure resulting from side effects of chemotherapy than from a recurrence of the breast cancer.

Dr. Plana is a national leader in cardio-oncology — a new interdisciplinary field of medicine in which cardiologists and oncologists work together to avoid, prevent and treat adverse cardiovascular effects resulting from certain treatments in cancer patients. Board certified in internal medicine, cardiovascular disease and echocardiography, Dr. Plana was recruited from The University of Texas M.D. Anderson Cancer Center in 2010 to develop Cleveland Clinic’s Cardio-Oncology Center, which he now co-directs with oncologist G. Thomas Budd, MD.

Dr. Juan Carlos and oncologist Dr. G. Thomas Budd
Cardiologist Dr. Juan Carlos Plana and oncologist Dr. G. Thomas Budd are Co-Directors of Cleveland Clinic’s Cardio-Oncology Center, where a multidisciplinary team of physicians work together to prevent or treat adverse cardiovascular effects in cancer patients resulting from certain treatments. Christine Cifranic, PA-C, MPAS, (shown above) is program coordinator for the Center.

“Toxicity to the heart is a well known side effect of several chemotherapy agents. The most common agents associated with toxicity are Adriamycin and trastuzumab,” says Dr. Plana, whose clinical research has mainly focused on breast cancer patients. “In terms of statistics, the rate of toxicity depends on age. In the young, the incidence of heart failure is about 16–20 percent. In adults older than 65 years of age, that rate doubles, being as frequent as 43 percent.”

Through years of research, inspired by his mother’s development of heart failure as a result of lymphoma treatment, Dr. Plana has developed and put into practice at Cleveland Clinic a protocol for monitoring the hearts of cancer patients while oncologists treat their cancer. This protocol uses an imaging technology called strain echocardiography for early detection of heart damage from the toxic effects of chemotherapy.

Strain echocardiography, also called strain imaging, is a non-invasive method of assessing myocardial function and detecting myocardial damage using ultrasound technology and a special software processing platform.

“Using this technology, we have recognized that asymptomatic left ventricle dysfunction can occur in up to 32 percent of patients undergoing treatment for breast cancer,” says Dr. Plana. “The good news is that, once identified, the damage can be curtailed before it becomes permanent.”

About Dr. Plana

Dr Plana
Dr. Plana has developed and put into practice a protocol for monitoring the hearts of breast cancer patients during treatment. This protocol uses strain echocardiography and special software for early detection of heart damage from the toxic effects of chemotherapy.

Born, raised and educated through medical school in Colombia, South America, Dr. Plana came to the United States in 1997 for residency training in internal medicine at Baylor College of Medicine in Houston, TX. He stayed at Baylor for a fellowship in cardiovascular disease, including a year in cardiac imaging, achieving level III certification in echocardiography and level II certification in nuclear cardiology. Two years later, he joined M.D. Anderson where, in 2006, he became Medical Director of the Echocardiography Laboratory and Director of Cardiac Imaging. He also served as an assistant professor at the University of Texas School of Medicine.

“While I was at M.D. Anderson, there was some preliminary work being done at Harvard Medical School that showed a new technology called strain imaging would be of help to recognize cardiotoxicity in animals,” says Dr. Plana. “So I partnered with them and other investigators in centers in the U.S. and Canada to develop a research project to see if this technology would be of help in humans to recognize chemotherapy toxicity at an earlier stage, when potential administration of treatment would prevent a progression to heart failure and death. And, indeed, we found that it was of help.”

Since then, Dr. Plana has been principal investigator or co-principal investigator on a number of clinical trials related to chemotherapy and cardiovascular disease, drug safety and heart failure. He has authored or co-authored more than 40 original research articles, abstracts, and book chapters and is a frequent speaker at leading cardiac medicine conferences nationally and internationally. He serves as a reviewer in several cardiac and imaging journals, and he will join the Board of Directors of the American Society of Echocardiography in June. He currently represents the United States on the Inter-American Society of Cardiology, Echocardiography Committee.

Dr. Plana is also Chairman of the writing group of the expert consensus for the echocardiographic evaluation of patients during and after cancer therapy, a joint effort of the American Society of Echocardiography, the European Association of Cardiovascular Imaging and the American Society of Clinical Oncology.

“The research that we have done in this platform will be put in a formal consensus document, endorsed by cardiologists and oncologists, which will be followed on both sides of the ocean,” says Dr. Plana.

The Cardio-Oncology Center

Bruce Lytle
Some cancer patients can present several years later with cardiovascular problems which may require surgical attention. Dr. Bruce Lytle, chairman of Cleveland Clinic’s Heart & Vascular Institute, specializes in surgery for these patients. Photo by Brian Kohlbacher courtesy of Cleveland Clinic

Cleveland Clinic’s Cardio-Oncology Center provides care to patients before, during and after cancer treatment. Before treatment, patients who are at risk for heart disease or are being treated for heart disease undergo evaluation.

“We study the hearts of patients carefully before treatment is started using state-of-the-art technology, including 3-D and strain imaging,” Dr. Plana explains. “During treatment, we continue to monitor them using these advanced tools. Depending on the chemotherapy regimen, we have different intervals for follow-up.”

Dr. Plana also evaluates patients who, during treatment, develop symptoms of cardiotoxicity — weakness or fatigue, swelling of the legs and feet, chest pain, irregular heartbeats and/or dizziness. When an abnormality in strain is detected, cardioprotection measures are initiated.

“Through clinical research, we have established specific thresholds that signal the need to initiate what we call cardioprotection regimens. These include the use of medications typically used for treatment of heart failure,” he explains. “We make it easy for the heart to do its job with the hope that the heart can mend. And we’ve seen in our research that the heart actually does get better. We stop the progression of damage, so the patients don’t end up with heart failure. Early detection is really important. Time is muscle in this condition, as well.”

For patients who had cancer treatment in the past and developed new or advanced cardiac problems, or those who had radiation therapy in the past and need surgical or interventional treatments, Dr. Plana and his colleagues at the Cardio-Oncology Center can help. The team includes specialists from the Sydell and Arnold Miller Family Heart & Vascular Institute and the Taussig Cancer Institute.

“Some cancer patients, especially those who have had radiation therapy, can present several years down the line with problems in their valves, arteries or pericardium (the sac that covers the heart), which may need surgical attention. So we also have surgeons, including the Chairman of our Heart & Vascular Institute, Dr. Bruce Lytle, who specialize in surgery in these populations,” says Dr. Plana. “We also have other surgeons, like Dr. Eric Roselli who specializes in the resection of tumors present in the heart or around the heart. And most recently, we teamed up with the Section of Preventive Medicine here within the Department of Cardiovascular Medicine. So our Cardio-Oncology Center is a true example of multidisciplinary collaboration.”

Dr. Plana recommends that patients who are going to receive breast cancer treatments toxic to the heart, or patients who have already received treatments, be evaluated. An interactive cardio-oncology assessment tool is available online to help referring physicians and their patients know if an evaluation at the Cardio-Oncology Center is warranted. It can be found at my.clevelandclinic.org.

“Surveillance of toxicity of chemotherapy is very important,” says Dr. Plana. “The heart gives us a window of opportunity. If you identify the toxicity within this window, we can stop disease progression.”

For more information about Cleveland Clinic’s Cardio-Oncology Center, visit www.clevelandclinic.org/cardiooncology. To refer a patient, call Christine Cifranic, PA-C, MPAS, program coordinator, at 216-636-4279.

Source: MD News July/August 2013, Cleveland Edition