Optimizing Cardio-Oncology Programs for Cancer Patients

Abstract

10.2217/FON.15.128 © 2015 Future Medicine Ltd In the USA and in most industrialized nations the two leading causes of death are heart disease and cancer [1]. CardioOncology or Onco-Cardiology is a specialty that focuses on the intersection of cancer and cardiovascular disease. There are many points along the spectrum of cancer where cardiovascular risk factors or disease may influence the shortand longterm course of patients. From the interplay of shared risk factors between cancer and cardiovascular disease to the use of potentially cardiotoxic therapies that may cause acute or late toxicities; cardiovascular disease impacts overall morbidity and mortality in patients with cancer. Along this spectrum there are several potential points where interventions may lead to improved cardiovascular outcomes and overall health (Figure 1). Chemotherapy can cause direct effects on the heart leading to left ventricular dysfunction (cardiomyopathy). Anthracyclines are the prototypical cardiotoxic chemotherapy and have been used effectively in a variety of cancers for the past five decades. The incidence of cardiotoxicity varies among different studies in part related to different patient populations (survivors of childhood vs adult cancers), different methods of surveillance and different definitions of cardiotoxicity [2,3]. A contemporary prospective study reported an incidence of anthracycline associated cardiotoxicity of 9% [4]. Preventative strategies including prophylactic treatment with ACE inhibitors and β-blockers have shown some promise though further studies are necessary [5,6]. There has also been exciting research into the molecular mechanisms of anthracycline cardiotoxicity, which may allow for more sophisticated drug design or novel approaches to minimize the risk of cardiotoxicity [7,8]. The importance of prompt recognition and management of cardiotoxicity is supported by several studies. An important recent study by Cardinale et al. demonstrated in a large prospective cohort of patients being treated with anthracyclines that 9% of patients developed cardiac dysfunction (defined as a reduction in LVEF of >10% to a value less than 50%) and the overwhelming majority of these patients developed LV dysfunction within the first year after treatment [4]. The majority of these (82%) patients had a partial or full recovery of LV function. This finding challenges the previously held dogma that anthracycline associated LV dysfunction is irreversible. Importantly in this prospective study there was prompt institution of therapy with ACE inhibitors and β-blockers. Unraveling the molecular mechanisms of many cancer types has led to the rapid development of numerous targeted therapies. Many of these are tyrosine kinase inhibitors that have the potential for a OPINION Special Focus Issue: Cardio-oncology