ADT in Prostate Cancer: Managing Cardiovascular Risk - Episode 3
Susan F. Slovin, M.D., Ph.D.: We often say that patients don’t want us to be maternalistic or paternalistic with regard to care. But with your own experience, did you feel that you were proactive, that you needed to be proactive in some way? Did you need to be proactive with your cardiologist or with any other physician that was involved in your care, or that you felt that the doctors made recommendations, but the recommendations themselves were not particularly absolute, they were just recommendations?
Because one of the issues that we have from patients, they’re feeling so terribly overwhelmed that we’re not quite sure what to do. You’re here to give us the information and tell us what to do, yet there are patients who feel just the opposite, as you did, which is, “I know my body. I know how I feel. I know what kind of quality of life I would like.”
Andy Rochester: Right.
Susan F. Slovin, M.D., Ph.D.: “Do you jell with my needs?” And I think that’s where we get into some discussion.
Andy Rochester: Well, you hit the nail on the head. You engender a lot of confidence and, sorry, that’s just the way it is.
Susan F. Slovin, M.D., Ph.D.: Thank you.
Andy Rochester: But that’s what I built my foundation on. I don’t spend a lot of time reading about the details because I’m working with an award winning team that understands all of this. So I’m not coming in with a great deal of questions in terms of comparisons between therapy one versus therapy two.
What I am looking forward to do is to try and be the best patient that I can be. Listen to what my physicians are saying. I point out: “well I’m experiencing this,” so that you’re not in the dark. When the Corning Inc. physician and you both were seeing that I was making progress on getting my body turned around, I got a referral to the Sloan Kettering Lee Jones Lab, and I got a chance to meet Lee. And his cardiologist.
Susan F. Slovin, M.D., Ph.D.: For our audience, Dr. Jones is an exercise physiologist with a lot of experience in exercise physiology in breast cancer patients. And we’ve been trying very hard to have our patients be seen by him, but you managed somehow to get to him before I could even get to him.
Andy Rochester: I know. I felt bad about that. I was there and it was like, “I hope Dr. Slovin approves of this.”
Susan F. Slovin, M.D., Ph.D.: Well enlighten us about your experience and how important it was.
Andy Rochester: It was amazing. The catch is that they really liked what I was doing with weight loss and diet and so forth. And then the cardiologist ran the stress test on me. And then I’m sitting across the desk from him and he said, “I don’t like your EKG [electrocardiogram].” And I said, “But, but here’s the thing.” At that point I think I’d taken off maybe 50 pounds, and my resting heart rate had gone from 76 to 46. And I was really feeling pretty good about myself. And he said, “OK, you’re an athlete with an EKG I don’t like.” And I said, “OK, what do we do next?” And then we did nuclear scans and some other things, and he came back and said, “All right, so I know I don’t like your EKG. You’ve got three coronary arteries that have extensive calcific plaques, so we’ve got to get to work on this.”
And so I said, “What are we going to do,” because basically I’ve got experts to talk to. So he said, “Well, you need to be on statins. In fact, you should have been treated for the last 30 years at least, and so we’re going to put you on statins.” And he said, “The next time you come back,” and I know he was just kidding, for the audience, but he said, “I’d like to see your cholesterol and triglycerides to be zero.” I didn’t quite get to zero. I apologized when I came back for my next checkup, but I did get my triglycerides from 320 down to under 100.
Susan F. Slovin, M.D., Ph.D.: That’s amazing, it’s absolutely amazing.
Andy Rochester: Yeah. I got my cholesterol from 280 down to under 100, and I got my HDLs [high-density lipoproteins] up to nearly 50. So you can do it, but again, it was a surprise to me. You know here’s this heart thing and here’s my dad who died of a heart attack. The only thing I didn’t do that he did was smoke.
Susan F. Slovin, M.D., Ph.D.: Well I think you’ve been very fortunate in having a cardiologist who, number one, knows the literature and knows everything.
Andy Rochester: Yes.
Susan F. Slovin, M.D., Ph.D.: But did he ever discuss with you about the role of androgen deprivation therapy [ADT] and cardiovascular risk? Because we all can find a cardiologist, and even internists don’t seem to have the scope of knowledge as to what hormonal therapy will do. We know that it does put people at higher risk. You know a lot of our patients are older than 65, so there’s inherent cardiovascular risk, but what do you do when you know there’s risk and it’s been untreated for a number of years, and how do you really deal with it?
Andy Rochester: He was concerned about the stability of the plaques and so he was cognizant of the implications of the ADT.
Susan F. Slovin, M.D., Ph.D.: Right.
Andy Rochester: But what he was basically having me do is he said, well as far as the exercise point, what kind of exercise are you doing? How much are you doing? What’s your pulse rate and so forth? So we made sure that that was right. And then the next part was the duration of the exercise.
Susan F. Slovin, M.D., Ph.D.: Well you had told me something that Dr. Jones says that you were overdoing, and you may just want to….
Andy Rochester: I’ll put it on the table. I swim 30 miles a week and I do about the same distance on treadmill. And when I was in that phase I was burning just under 5,000 calories a day to take weight off. And so we were trying to be careful of my heart, and I was doing a type of exercise called HIIT [high-intensity interval training]. It’s an interval type of training that puts the heart under more stress.
As we’re going along with that, one thing that my heart would do is it would throw something called a preventricular contraction, it would throw PVCs. And so we came to a good discussion point, which is what level of exercise would work? I wasn’t looking for a straight number.
Susan F. Slovin, M.D., Ph.D.: Right.
Andy Rochester: So when I’m doing all of my swimming and so forth, I swim at the level just below throwing PVCs.
Susan F. Slovin, M.D., Ph.D.: Do you know how you do it?
Andy Rochester: It’s pretty easy to control how hard you’re swimming. And so that’s worked very well for me.
Susan F. Slovin, M.D., Ph.D.: I have to salute your cardiologist for the level of aggressiveness in which he pursued your treatment and immediate control. Because I think one of the issues that we face is how often should people be monitored for cardiovascular issues while they’re in androgen deprivation therapy. I think all of our patients tend to think that we are the internist and therefore we should be the one-stop shopping, and they don’t realize that as good as we all may be, we don’t really have the nuances regarding hypertensive management, especially cardiovascular.
We as medical oncologists don’t often say every three months let’s run your lipid profile, let’s look at other factors that are very important. And I think that’s because we assume that the internist or the cardiologist does it. But I do think that there’s probably a breakdown in our communication with these doctors because I don’t think they realize very often that we are increasing the risk of cardiovascular, or what we call major cardiovascular events, in these things.
Andy Rochester: He urged me to be careful, and so I would follow the criteria that we came up with and, as you said, the physiologist was particularly concerned about the fact that I wasn’t working out every other day. And I said, “But here’s the thing. In the first five months I went from I believe would be called stage 4, because I had distant metastases.
Susan F. Slovin, M.D., Ph.D.: That’s correct.
Andy Rochester: And then when you scanned me for radiology in May, all the METS [metastasis] in the vertebra, in my spine and lymph nodes were gone. And so that was just about the time that I was talking to Lee and the cardiologist, and I said, “Well here’s the thing. I know that the studies are showing maybe 180 minutes a week of aerobics is considered a game changer in favor for people with breast cancer and the other thing.” But in my case I said, “I think that I’m not going to change anything because it’s working for me. I enjoy feeling younger. I mean I feel at least 20, 25 years younger than I started, and I’m back to the same size I was in 1974.”
Susan F. Slovin, M.D., Ph.D.: That’s amazing.
Andy Rochester: It’s completely remade my life, and I think, you know what, I don’t mind exercising a little extra. My joke for the audience is that my little friends don’t take a day off, so I don’t. And my little friends, of course, are the cancer cells.
Susan F. Slovin, M.D., Ph.D.: Right.
Andy Rochester: So why should I give them a beak if I don’t feel like; if I’m coming down with a cold or something. They’re not taking a day off; I don’t either.
Transcript Edited for Clarity