Tackling cardiac toxicity of anticancer therapies

Professor Patrizio Lancellotti (Belgium), Task Force Co-Chairperson, said: "The good news is that cancer treatment has improved and more patients now survive. Unfortunately there has been a progressive increase in cardiovascular events because radiation and anticancer drugs can be toxic to the heart. It is expected that among cancer survivors, cardiovascular disease will be the most important cause of death."

Professor Jose Luis Zamorano (Spain), Task Force Chairperson, said: "We need to treat the whole person because at the end of the day the patient is not a cancer, but is a person with a heart. Many patients today do not die due to the cancer but from cardiac complications related to the treatment. They need to be monitored by a multidisciplinary team to prevent and treat cardiac complications."

The document reviews how the different anticancer treatments may harm the heart. The cardiovascular complications of anticancer therapy are divided into nine categories: myocardial dysfunction and heart failure; coronary artery disease; valvular disease; arrhythmias; arterial hypertension; thromboembolic disease; peripheral vascular disease and stroke; pulmonary hypertension; and pericardial complications.

For each type of complication, the authors outline which patients are at risk, and how to detect and prevent the possible side effects. Recommendations are given on how to treat and follow up patients who develop that type of cardiotoxicity.

For example, coadministration of anthracyclines and trastuzumab in patients with breast cancer markedly increases the incidence of heart failure. But cardiotoxicity can be reduced significantly by introducing a drug-free interval between the two agents.

Cardiotoxicity is detected using electrocardiogram (ECG), cardiac imaging, and biomarkers. Prevention and treatment may involve the use of cardioprotective drugs such as angiotensin converting enzyme (ACE) inhibitors or beta-blockers and adopting a healthy lifestyle including a healthy diet, not smoking, exercising regularly and controlling body weight. "Aerobic exercise is considered a promising non-pharmacological strategy to prevent and/or treat chemotherapy-induced cardiotoxicity," state the authors.

Regarding long term surveillance for cancer survivors, patients should be informed of their increased risk of cardiovascular disease at the outset of chemotherapy, and supported to make lifestyle changes. They should be instructed to promptly report early signs and symptoms of cardiovascular disease.

The paper emphasises the importance of establishing multidisciplinary teams to provide the best care for cancer patients and survivors. These should include cardiologists, oncologists, nurses, and heart failure and imaging specialists. Ultimately, cardio-oncology centres with a structured service are needed.

Currently, under- or over-diagnosis of cardiovascular disease sometimes results in failure to prevent adverse events or inappropriate interruption of a potentially life-saving anticancer treatment. "We need to be clear when it's a must to stop the treatment, when we should reduce the dose, or when we can continue with the therapy," said Professor Zamorano. "This position paper provides guidance in this area."

Professor Lancellotti said: "We hope the paper will increase awareness about heart disease in cancer patients and survivors and stimulate more research in this area. More information is needed on when to screen and monitor patients, and on the cardiovascular effects of new anticancer therapies."