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Manuela Fiúza is the coordinator of the External Consultation of Cardiology at the Santa Maria Hospital (CHLN-HSM) and Assistant Professor of Cardiology at the Faculty of Medicine of the University of Lisbon.

We found ourselves on the first floor, in Heart Techniques, the most obvious place for those who deal with the largest muscle in the body.

Truly friendly, she welcomed me exactly at the time that we agreed, a sign of someone who is rigorous, and likes others to also follow the rules. We sat down in a room amongst stretchers and gadgets only temporarily offline.

She never hesitates when questioned, as she is objective and very focused, which doesn't take away the undisguised sweetness felt as a first impression.

"Since I was a child I wanted to be a doctor". Without the influence of family, who had nothing to do with Medicine, her personality would only allow her this path. A giving person in her core, she has always enjoyed taking care of others, as proven by the protection she provided to her sister, whom she refers to with special tenderness.

Manuela Fiúza is not a cardiologist, she is responsible for the new clinical area of Cardio-Oncology. This match between Oncology and Cardiology was celebrated and pioneered informally at Santa Maria in 2008. And it was made formally official in 2015. In this curious and perhaps heavy name, there is a vast project involved, with consultations simultaneous to training, with a pre and post-graduate component, consolidating the project in its initial stages.

She told me that coincidentally or not, this new program was born by American influence. But also because she lost her father to an oncological disease. A father who she thought she could save, because you always have this aspiration as a doctor and you love someone so much.

It was the combination of Oncology with her vast experience of the heart that made her confront this finiteness of life. What alarms her in this finiteness is the younger patients, because the cycle should not be interrupted so ahead of time.

She is sweet even when she tells me about her patients, as she says that all of them cling to life and to the doctor as the last angel available to help.

Talking with Manuela Fiúza, I came across a tremendous irony in the nature/human relationship, which is that when you close the door on a problem, windows open that challenge us to find new solutions, because new pathologies are born.

But what are we talking about anyway? About cardiotoxicity, which is what happens to the heart when a patient has had oncological treatment.

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How is Oncology linked to the Heart?

This is a very recent area, for which some information already existed. It was once known that some oncological drugs could cause changes to the heart. There are also non-oncological drugs that cause cardiac problems. But let's step back into the past once again. There were only a few oncological drugs and the same drugs were used repeatedly to treat cancer. As many patients were dying early from the disease (cancer), they were never diagnosed for cardiac developments. And the appearance of lesions in the heart has a correlation with the dosage of the administered oncological drug.

Now, with new therapies and also new ways of administering old therapies, and because dosages have also changed, all of this has improved the chances of survival of patients. But, by improving their chance of survival, issues with the heart began to emerge. Do you know the popular saying "when you don't die from the disease, you die from the cure"? What becomes noticeable then? That after being "cured" of an oncological disease, patients later appeared with cardiac issues which limited their activity and their daily lives. And they died of cardiac causes. This evolution of cancer therapies causes the disease to become chronic and this implies a paradigm shift. We realised that it was not only the old drugs that caused problems, the newer ones also cause them. And they may also bring new kinds of problems that we don't know yet. And what problems are these? Hypertension, arrhythmias, besides the Heart Failure that was already perceivable. Radiotherapy causes premature heart attacks due to accelerated atherosclerosis. All cardiac structures can also be affected by cancer treatments, whether it is chemotherapy or radiotherapy, or both, since we have patients who are treated with both.

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So is heart failure the pattern manifesting itself as more prevalent?

We know that it is the most exuberant and that it can manifest itself at a later stage, and not only during the period in which the person is undergoing the therapy. In relation to Radiotherapy, cardiac illness can manifest itself 5, 10 or even 15 years later.

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Knowing of the collateral damages of oncological therapies, how is the relationship between the clinical areas? Do they cohabit in harmony?

It is very good. It's absolute cooperation, they have a lot to thank us for. In Cardiology we try to never interfere with oncological therapy, but of course we have to resolve the cardiac problem. And if we have to interfere with the oncological therapy, we try not to stop it completely. Stopping an oncological therapy is very rare, but it can happen. We usually attempt drug substitution, some dosage reduction, only for a little while to see if the heart recovers, and later we restart with the oncological therapy. Our aim is to stop the heart from decomposing. That is why, as you see, we have a complete openness with the Oncologists and the Radiotherapists, because if we treat their patients well, they will also have more time and better conditions to continue to treat them. But I want to tell you something else: Cardio-Oncology isn't just related to drugs. Why? Firstly because cardiovascular and oncological diseases, in that order, are the diseases with the highest mortality rates, worldwide and in Portugal. We know that cancer survivors have a higher risk of cardiovascular propensity, but there is another perspective, which is that by increasing the life of the population, the probability of having these two diseases increases even more. Therefore, cardiac patients appear that later will also have an oncological pathology. The problem, as you see, isn't only looking at the cardiotoxicity, it is trying to conjugate these diseases that may be concomitant.

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The relationship is explained, but it does not totally eliminate another curiosity. Somewhere along the path of our lives, we make concrete choices, because something points us in one direction and not another. If you go back in time, can you identify why you are treating this new clinical area today?

Yes, I can tell you very objectively. Firstly, in 2007, a friend of mine was involved in a study of a certain oncological drug, and the question that he had was whether the dangers of heart failure would arise from treatment with the drug. As he knew me and due to our friendship he began to involve me in the questioning process. That's when I started to study the matter. And we thought together, what can we do to draw the attention of Oncologists to this issue? It was then that we started to have meetings with oncological services in different hospitals all over the country, at oncology institutes and with various people from the most varied areas. The idea was to do some brainstorming and understand the ground on which we were standing. And we were plotting our way like this. How is this progressing here in the Hospital? My father died with an oncological disease and at the time he was being treated by a friend, Professor Luís Costa, who is the Director of Oncology at the Santa Maria Hospital. Professor Luís Costa and I had a great friendship. What I thought was that I was already too involved in Oncology and its effects on the heart. This led to a meeting at MD Anderson Hospital - one of the world's best cancer treatment hospitals - with the motto “Cancer and the Heart”. At this meeting I understood that in the United States they had already talked about this problem and that some hospitals were already developing this area. And do you know why else the meeting was fantastic? Because I discovered that the Dean of the University was of Portuguese descent (Prof. Ronald de Pinho, whom I met 2 years later at a meeting in Portugal and to whom I was able to present the research that I had begun at the hospital). Notice the coincidence. When I arrived back from this meeting, I went to Professor Luís Costa and explained this idea of trying to understand the connection between oncological diseases and Cardiology. He was very receptive and then, informally, he passed me some of his patients and we had a few meetings with him and other Oncologists at his service, to see how we could manage all the information that was appearing. Also, informally, I started to see patients with the same pathology and so I followed the first cases, complemented with echo-cardiograms, and I provided my suggestions. The process was starting to consolidate itself, more and more articles appeared and everything was advancing at the same time. It was then that I spoke to Professor Fausto Pinto, of whom I am a friend, and by that time he was Director of Cardiology Department and I proposed to him not only to consult him on Cardio-Oncology, but more than that, and since we are at a university hospital, I called it the Cardiology Program. In addition to the consultations that were already taking place, there would be a pre and post-graduate training, so I created a "tripod" on the subject of Cardio-Oncology. He accepted the idea immediately and we had the authorisation from the Board of Directors for the consultation to be formalised. More recently, such consultations have begun in other hospitals and some of these people have even taken postgraduate internships with us. So you see, this is a never-ending world. Our students also come by here, especially during the 4th year, which means that the snowball and the volume of information is increasing.

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The training part is really a baby in your hands...

Yes, it is... For that very reason, and because it is not yet known, I proposed to Prof. Fausto a postgraduate course on cardio-oncology, about which I said: "Listen, lets have a maximum of thirty participants in the course". And he said: "No, make it fifty". My concern was that no one would participate, as we had very little time to divulge it and the course was starting in January.

Suddenly seventy entries appeared, all professionals of different specialities, and in the room we had more than one hundred people participating and watching. The postgraduate update course on Cardio-Oncology was a success.

You can't imagine the feedback that we received, we were told that it was a review of all areas of cardiology, that we did a total review of cardiology through the eyes of oncology. Researchers from iMM representing basic and translational research also participated, since we only developed the clinic.

We created a website dedicated to the course, but we decided to keep it and it now serves as an official database for training.

You can't imagine how all this work is rewarding, I always tell my patients that "we only provide good news here." You know why? Because the patients come with suspected illnesses and we treat them or at least control their symptoms. And when we broaden the time between appointments they get very worried that they should come more often and in a shorter time interval. We tell them that we are always here, it's just that these longer periods are actually a good sign.

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How do the patients react to the news that they don't just have cancer, now they also have a cardiac issue?

Psychologically, this affects everyone, but there are people with a fantastic ability to come out on top. In lesser cases, some people break much more. But in general, they take it well. Without escaping the truth, we make things simple for them, we present the situation and the therapeutics as a solution and show the regression attempts of the disease. Then we have several scenarios, either the damage is final and we're only able to control it, or it's transient and we're going to observe it, or everything is okay and we keep it under control. I'll give you a very concrete example: kidney cancer has drugs that cause hypertension. Although this is a good sign, as it means the cancer is being controlled, it's actually bad for the heart. So, in this case, we only treat and control the tension throughout the cancer treatment.

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And do cardiac drugs clash with oncological ones?
 We don't think so. Which is great news. I'll give you another situation of compatibility: there are patients who have tachycardia (very high heartbeat, between 80 and 100) after the treatments, and complain that they are very tired. So we find a way to slow the heart down, which does not affect the effectiveness of other treatments.

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What is an uncommon case that becomes a burden?

I have some cases that are more advanced and which are harder to solve. For example, cardiac insufficiencies may be refractory to therapy. I also have patients with valvulopathies, such as aortic tightening. Surgeries are very risky but now we have other solutions without resorting to surgery. I have one such case that went very well. These patients can present several problems, have anaemias, or worse haemorrhages, and all this debilitates them. These are new scenarios with which we are always learning.

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I know there are guidelines that say what you should do, but don't you have cases that run away from these standardised lines?
Of course, the guidelines are only recommendations to standardise the therapies, indicating what tests to run and when, but they are not static, we must always add information. We know that immunological therapies are great and totally revolutionary, but have been found to cause heart failure. That is, in the treatment against cancer, they are very advanced, but then cause problems to the heart. And this information arose in this last year and a half of treatment and research.

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You told me that you lost your father a few years ago due to illness. As a doctor did you think you could save him up until the end, or were you aware of your human limitation?

(This is the first time she looks at me suspiciously) I always thought I would save him from everything. It is a brutal frustration when we realise that nothing more can be done, because I never give up and giving up is painful. You cannot imagine how frustrating that was. I am always fighting for the lives of others and there comes a time when I am forced to give up.

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Do you feel this frustration even with those you barely know and for whom you have less affection as you did for your father?

It's the same thing, because you're asking "what more can I do"? And you know you have nothing else to offer the patient. Having nothing to else to give is the worst role of a doctor. We spend our lives helping and facilitating and suddenly... And we often treat without medication, just paying attention and talking, optimism is not in the prescriptions, nor is it sold at the pharmacy. There are patients who sometimes close themselves off too much and one has to come in to cheer them up. I know life is finite, but at least it should be comfortable.

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Upon saying goodbye, a lot of Manuela Fiúza's patients say they hope to be alive until the next appointment where they shall meet again. She smiles and calmly replies "Wonderful, I hope to be alive too".

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Joana Sousa

Editorial Team