Introduction:
Heart disease and cancer jointly account for over 70 % of global medically related deaths, with cancer patients experiencing a nearly fourfold increase in mortality risk due to cardiovascular complications compared to the general population. This elevated risk persists post-cancer treatment, with a lifetime risk of cancer therapy-related cardiac dysfunction (CTRCD) rising to 15-fold. Cancer's independent association with structural and functional cardiac changes highlights the need for effective cardiac risk assessment and CTRCD identification in cancer management. The expanding population of cancer patients underscores the reliance on imaging for cardiovascular complication diagnosis and monitoring. Recent advances in cardio-oncology and imaging call for updated approaches to multimodal cardiovascular imaging in these patients.
How Did Cardio-Oncology Originate?
The exact origin of cardio-oncology remains uncertain, but its roots may be traced back to the 1970s when patients treated with anthracycline therapy were admitted to the intensive care units of Memorial Sloan-Kettering Cancer Center (MSKCC) in New York due to cardiac failure. Notably, Doxorubicin, a prominent cardiotoxic anthracycline, was developed through collaboration between researchers at MSKCC, Farmitalia, and the Instituto Nazionale di Tumori in Milan, Italy. While anthracycline-induced cardiotoxicity was recognized, the need for a subspecialty did not become apparent until the advent of targeted therapies, initially expected to have fewer toxicities. The unforeseen occurrence of heart failure in breast cancer patients receiving Trastuzumab alongside anthracyclines prompted a shift in cancer therapeutics, leading to interdisciplinary engagement and exploration of the HER-2 receptor's role in cardiomyocyte signaling. This paradigm shift in cancer treatment gave rise to cardio-oncology in the early 21st century.
The objectives of cardio-oncology encompass minimizing disruptions in cancer therapy, reducing morbidity, and preventing mortality in cancer patients by addressing cancer treatment-related cardiovascular toxicities (CTR-CVT). This has evolved into a multidisciplinary field where cardiologists collaborate closely with oncologists, hematologists, primary care physicians, and allied healthcare professionals to cover the entire spectrum of prevention, early detection, and treatment of CTR-CVT in patients with or without pre-existing cardiovascular disease.
Over the past decade, cardio-oncology service lines have experienced substantial growth, beginning in the USA and Europe and spreading globally, including Asia. The increase in cardio-oncology publications reflects heightened awareness and research in this field. Japan and China lead Asia in contributing to cardio-oncology publications, ranking sixth and tenth worldwide in a bibliometric analysis covering 2010–2022. Globally, the USA, Italy, and England have made significant contributions, emphasizing cross-country collaboration in advancing cardio-oncology.
What Are the Contributing Factors?
Cancer treatment-related cardiac dysfunction (CTRCD) is influenced by various factors, primarily the chemotherapeutic agents administered and, in the case of anthracyclines, the cumulative dose. Anthracyclines like Doxorubicin and Trastuzumab (Herceptin) are notable for their association with serious cardiotoxicity.
Anthracyclines, pivotal in treating hematological and solid malignancies, exhibit clinically overt and subclinical cardiotoxicity in 6.3 % and 17.9 % of patients, respectively, according to a meta-analysis involving nearly 50,000 patients. End-stage heart failure, affecting 2 to 4% of patients, carries a dismal prognosis with a 2-year mortality rate of up to 60 %. Despite efforts to mitigate anthracycline-induced cardiotoxicity, such as dose restrictions and the use of cardioprotective drugs, its clinical impact remains significant due to concerns about compromised antitumor efficacy.
Trastuzumab, prescribed for breast cancer patients with HER2-positive tumors, induces a decline in left ventricular ejection fraction (LVEF) in 11.2 % of patients, as per a meta-analysis. Notably, the prognosis of Tastuzumab-induced cardiotoxicity tends to be more favorable compared to anthracycline-induced cardiotoxicity. Timely cessation of Trastuzumab administration often results in the recovery of LVEF in most affected patients.
How Are Cardiovascular Health and Cancer Related?
The overlap of risk factors for cancer and cardiac disease is common, with 62 % of cancer survivors being overweight or obese, 55 % having hypertension, and 21 % having diabetes. Some cardiac risks in cancer survivors may stem from treatments like chemotherapy, while other studies suggest elevated risks exist at cancer diagnosis. Controlling cardiac risk factors through lifestyle measures and ideal cardiovascular health metrics not only aids in managing cancer-related complications but also influences cancer incidence and outcomes.
Cardiovascular medications like Metformin, antihypertensives (ACE inhibitors, ARBs, β-blockers), statins, and Aspirin show varying impacts on cancer risk and outcomes. Understanding this connection is crucial, demonstrated by improved cancer survival when managing cardiac comorbidities. Collaborative assessments by oncologists and cardiologists before chemotherapy initiation can identify at-risk patients, informing discussions on the benefits and risks of cardiac toxic medications. Better collaboration between these specialties is essential for both primary and secondary prevention.
What Is Precision Medicine in Cardio-Oncology?
Precision Medicine in Cardio-Oncology:
Precision medicine has transformed oncology by tailoring treatments based on tumor genetics, improving survivorship. However, both traditional and new cancer treatments pose diverse cardiovascular complications, making cardiovascular issues relevant in short and long-term care. Recent attention to vascular and metabolic dimensions in cardio-oncology highlights the need for a more personalized vascular approach.
Precision cardio-oncology addresses this need by considering three factors: individual cardiovascular risk, the specific cancer, and the associated treatments. The first aspect involves screening and managing traditional cardiovascular risk factors, family history, and lifestyle. The second aspect focuses on understanding the treatment risks of oncologic care, considering the varied side effects associated with different therapies. The third aspect involves cancer-specific risks of cardiovascular disease and expected survival, tailoring screening and treatment accordingly.
The evolving landscape of cancer therapies necessitates a personalized approach in cardio-oncology. Precision cardio-oncology, by considering individual cardiovascular, treatment, and cancer-specific risks, equips cardio-oncologists to manage the complexities of modern cancer care. Future efforts aim to optimize treatment protocols for cardiovascular risk factors, ensuring compatibility with oncologic treatments for improved long-term cardiovascular outcomes.
What Are Cardio-Oncology Advances?
Cardiovascular events in cancer patients can stem from concomitant risk factors, anti-cancer therapies, and the cancer itself. A 10-year study on breast cancer survivors revealed an increased risk of mild LV dysfunction in those treated with chemotherapy or radiation. Shared risk factors between heart failure (HF) and cancer were explored, emphasizing systemic inflammatory status. The CANTOS trial exhibited reduced cardiovascular events with Canakinumab, suggesting a potential link between inflammatory pathways and cancer. CV problems in cancer patients extend beyond therapy-related cardiotoxicity, affecting resting heart rates and influencing mortality. Diagnosis involves cardiac imaging methods, with echocardiography and blood biomarkers aiding in risk stratification.
Prevention strategies focus on patient stratification, screening tools, and long-term surveillance for high-risk individuals. Cardio-oncology services play a crucial role in optimizing cancer treatment and preventing cardiotoxicity. Treatment strategies for cancer therapy-related cardiomyopathy include HF medications, with ongoing research exploring additional therapies. Immune checkpoint inhibitors pose challenges, requiring a deeper understanding of their underlying mechanisms. Endothelial dysfunction is hypothesized to play a role in the development of both cancer and HF.
Conclusion:
Recent advances in cardio-oncology have shed light on the intricate interplay between cancer and cardiovascular health. The recognition of cardiovascular events in cancer patients arising from concomitant risk factors, anti-cancer therapies, and the cancer itself emphasizes the need for a multidisciplinary approach. Cardio-oncology services have emerged with novel treatments from improved diagnostic tools to optimizing cancer treatment and cardiovascular complications.
