Several critically important patterns that have occurred in healthcare mandate the improved management of the cardiac status of patients being treated for cancer, says Daniel Lenihan, MD:
- The long-term survival of patients identified with nearly all cancers has dramatically risen, such that cardiovascular (CV) concerns after treatment become a major issue.
- Patients receiving therapy are older and have more complex co-morbidities than ever before.
- Therapeutic protocols are now so complex that concerns about cardiac safety have become commonplace.
- Understanding of the biological overlap between targets of cancer therapy and critical pathways in CV tissues is continuously evolving.
With extensive developments in therapeutic options for both cancer and CV treatment and a wide spectrum of knowledge needed to address both the oncologic and CV needs of patients with cancer exposed to cardiotoxic therapy—including chemotherapeutic agents, targeted therapies and radiotherapy—“It is virtually impossible for a clinician to stay on top of all of these areas of medical care,” notes Dr. Lenihan. To attempt to summarize best practices for the care of this patient population, the European Society for Medical Oncology published consensus recommendations on the management of cardiac disease in cancer patients throughout oncological treatment. “The recommendations cover all aspects of cardiovascular complications related to all cancer therapy,” says Dr, Lenihan, and “there should be no essential difference between ESMO and the American Society of Clinical Oncology in terms of hematology and oncology practices, especially in regard to cardiac safety.”
Among the most important inclusions in the vast paper, according to Dr. Lenihan, is a spreadsheet of information on anticancer therapies associated with CV complications or toxicities; those with a common frequency of these CV side-effects are summarized in the Table. Along with patients who are or will be treated with these therapies, the consensus statement includes the following common clinical factors that may indicate a patient at higher risk for cardiovascular dysfunction during contemporary anticancer treatment:
- Prior anthracycline-based treatment
- Elderly (>75 years)
- Prior mediastinal or chest radiotherapy
- Hypertension (before or at the time of treatment)
- Smoking exposure (current or previous)
- Very young (<10 years)
- Previous combined treatment with trastuzumab and an anthracycline
- Elevated cardiac biomarkers before initiation of anticancer therapy
- Baseline abnormal systolic LV function with LVEF less than 0.50
- Pre-existing diabetes mellitus
Included in the recommendations is a proposed monitoring and management approach for patients undergoing potentially cardiotoxic anticancer therapy, which Dr. Lenihan notes is a general strategy for monitoring for cardiac dysfunction with any therapy that could be associated with heart failure or cardiac dysfunction. “An emphasis on early cardioprotective therapies so patients can remain on effective cancer therapies without having to interrupt those life-saving treatments because of a CV side effect differentiates the approach from previous algorithms focused on cardiac dysfunction,” he adds.
Notes of Importance
Dr. Lenihan notes that leaders in cardio-oncology published recommendations in cooperation with the American Society of Clinical Oncology (ASCO) in 2017, adding that the latest recommendations include major comprehensive updates and a dramatically broadened scope. “In 2017, we focused on cardiac dysfunction in cancer survivors,” he says. “These recommendations cover all aspects of cardiovascular complications related to all cancer therapy, including current and previous therapies. There should be no essential difference between ESMO and ASCO in terms of hematology and oncology practices, especially in regards to cardiac safety. We aim to improve communication and provide the best CV care for patients with cancer here in the US, but also around the world. I would certainly emphasize that we are on the same team as all US hematology and oncology experts: the team that wants to eliminate cancer but protect the person!”
Management of cardiac disease in cancer patients throughout oncological treatment: ESMO consensus recommendations