An update on cardio-oncology

Abstract

Over the past decades, there have been great advancements in the survival outcome of patients with cancer. As a consequence, treatment regimens are being extended to patient populations that would not have qualified in the past based on comorbidities and age. Furthermore, the anti-cancer regimens, which have been and are being used, can cause considerable morbidity and even mortality. In fact, new drugs such as tyrosine kinase inhibitors have yielded unanticipated side effects in frequency and severity. The cardiovascular disease spectrum is an important element in all of these. In order to optimize the outcome of cancer patients with cardiovascular diseases existing prior to cancer treatment or developing as a consequence of it, a new discipline called "cardio-oncology" has evolved over the past few years. Herein, we review the latest developments in this field including cardiotoxicities, vascular toxicities, and arrhythmias. This field is taking on more shape as cardiologists, oncologists, and hematologists are forming alliances, programs, and clinics, supported by the development of expert consensus statements on best management approaches and care of the cancer patient with cardiovascular diseases.

Figure 1

Illustration of the number of Pubmed publications on the search terms “cardiotoxicity” and “chemotherapy” pointing out the greatest increase since 2010.

Figure 2

Illustration of the Cardio-Oncology concept focusing on the cancer patients with pre-existing or developing cardiovascular disease. In most cases, there seems to be a reduced reserve that is challenged further by the cancer, cancer therapy, and environmental factors to yield the various clinical cardiovascular presentations that can be seen in cancer patients.

Figure 3

Illustration of progression of subsets of adult patients undergoing anthracycline therapy. Of those exposed, some will develop abnormalities in myocardial strain early on, and then an increase in extracellular volume (ECV). A subset of patients will progress to a reduction of left-ventricular ejection fraction, and a subset of these will have a reduced left ventricular mass with the worst outcome.

Figure 4

Prediction model for the risk of cardiotoxicity with trastuzumab therapy (generated based on reference 66). Reproduced with permission: Ezaz G, Long JB, Gross CP, Chen J. Risk prediction model for heart failure and cardiomyopathy after adjuvant trastuzumab therapy for breast cancer. J Am Heart Assoc 2014;3:e000472.

Figure 5

Comparison of the risk of heart failure and left ventricular function decline with mono- versus dual HER-2 inhibitor therapy (modified from reference 69). Reproduced with permission: Valachis A, Nearchou A, Polyzos NP, Lind P. Cardiac toxicity in breast cancer patients treated with dual HER2 blockade. Int J Cancer 2013;133:2245–52.