Susan E. Wiegers, MD, FASE, FACC

Last month was Breast Cancer Awareness month. Many of us have been personally touched by the disease affecting relatives, friends, or ourselves. Cardio-oncology has become an important aspect of many general cardiologists’ practice—as well as heart failure specialists’—and echocardiography is an essential tool in that practice. Heart disease continues to be the leading cause of death for women with breast cancer. ASE is reaching out to providers and patient advocacy groups to educate the larger community on the importance of cardiac ultrasound in the care of cancer patients in general and breast cancer patients in particular.

Many treatments for breast cancer carry the risk of cardiotoxicity. In 2014, our society published the Expert Consensus for Multimodality Imaging Evaluation of Adult Patients during and after Cancer Therapy in conjunction with the European Association of Cardiovascular Imaging ( www.asecho.org/wordpress/wp-content/uploads/2014/08/2014_CancerTherapy.pdf ). Anthracyclines such as Adriamycin have long been known to damage cardiac muscle cells. As the total dose of anthracycline given to the patient increases, there is an increasing risk of cardiomyopathy and heart failure. Other anti-cancer therapies, such as Herceptin, can damage the heart as well, but the mechanism is not the same as anthracyclines. Cardiac dysfunction can occur at any time during treatment, unrelated to the total dose. Many patients get both drugs, further increasing the risk of cardiomyopathy. While nuclear studies, such as multi-gated blood pool imaging studies, can assess total left ventricular ejection fraction (LVEF), echocardiography does not carry any risk of radiation exposure and also provides information regarding the right ventricle, valvular regurgitation, and pericardial disease. The Expert Consensus document clearly states that “Echocardiography is the method of choice for evaluation of patients before, during and after cancer therapy.” Furthermore, the use of strain and strain rate imaging can detect subclinical decreases in cardiac function before the LVEF falls. Several studies have demonstrated that abnormal global longitudinal strain develops prior to a fall in ejection fraction and precedes the appearance of clinically apparent heart failure. The early detection of cardiotoxicity allows initiation of appropriate medications without a change in chemotherapy regimen in many cases. ASE is working to ensure that strain imaging, the critical test to detect these changes in heart function, is widely available and patients understand the need for this testing.

Our society recently advocated for a CPT code for strain imaging and as the initial step a category III code (a tracking code) was established. While not yet reimbursable, we encourage everyone who uses strain imaging in the appropriate clinical setting to record this code. We plan to seek reimbursement for this code in the future and need the recorded data to help justify the reimbursement. We also have worked with vendors and the EACVI to standardize strain measurements between vendors ( www.onlinejase.com/article/S0894-7317(14)00831-1/fulltext ). “How to” sessions on measuring strain have been featured in our learning labs, courses, and scientific sessions. Commercial contrast is another important part of the diagnostic tools available, often transforming technically poor studies into ones in which LVEF can be quantified and regional wall motion assessed.

However, as important as monitoring cardiac function during cancer therapy is, many patients do not receive the appropriate tests. A disturbing paper published this year in the Journal of Clinical Oncology examined more than 2000 woman with full Medicare coverage who were receiving Herceptin and entered into two registries. The guideline recommendations for Herceptin treatment is a baseline echocardiogram followed by a limited study every three months. In this study, only 36% of the patients had optimal cardiac monitoring during therapy. As we know, real world practice is often less optimal than registry data—a scary thought in this case. ASE has partnered with WomenHeart: The National Coalition for Women with Heart Disease to bring the value of cardiac ultrasound to the attention of patients, providers, and legislators. ASE co-sponsored WomenHeart’s 15 ^th Annual Wenger Awards event and sponsored the Congressional Briefing they held in April. We continue to reach out to other organizations to make sure that women being treated for breast cancer are receiving optimal imaging. It is essential that the importance of monitoring echocardiograms during therapy be widely known to patients and providers. We have also worked to deliver the message directly to the public; Dr. Juan Carlos Plana, the lead author on our recent Guideline, has recorded a YouTube message in both English and Spanish on the importance of imaging in cancer care. This public health message is one that we are proud to be a part of—and proud of our many members who provide this essential care to their patients.

Susan E. Wiegers, MD, FASE, FACC is Senior Associate Dean of Faculty Affairs and a Professor of Medicine at Temple University School of Medicine.