Precision Cardio-Oncology

Abstract

Modern oncologic therapies and care have resulted in a growing population of cancer survivors with comorbid, chronic health conditions. As an example, many survivors have an increased risk of cardiovascular complications secondary to cardiotoxic systemic and radiation therapies. In response, the field of cardio-oncology has emerged as an integral component of oncologic patient care, committed to the early diagnosis and treatment of adverse cardiac events. However, as current clinical management of cancer therapy-related cardiovascular disease remains limited by a lack of phenotypic data, implementation of precision medicine approaches has become a focal point for deep phenotyping strategies. In particular, -omics approaches (a field of study in biology ending in -omic, such as genomics, proteomics, or metabolomics) have shown enormous potential in identifying sensitive biomarkers of cardiovascular disease, applying sophisticated, pattern-revealing technologies to growing databases of biologic molecules. Moreover, the use of -omics to inform radiologic strategies may add a dimension to future clinical practices. In this review, we present a paradigm for a precision medicine approach to the care of cardiotoxin-exposed cancer patients. We discuss the role of current imaging techniques; demonstrate how -omics can advance our understanding of disease phenotypes; and describe how molecular imaging can be integrated to personalize surveillance and therapeutics, ultimately reducing cardiovascular morbidity and mortality in cancer patients and survivors.

Keywords: -omics; cardio-oncology; cardiotoxicity; precision cardio-oncology; precision medicine.

FIGURE 1.

(A) Current approaches to cardio-oncology patients involve phenotyping with demographics, exposure history, and clinical evaluation (including basic lab tests and imaging). This method identifies disease phenotypes such as decreased LVEF to broadly guide therapeutic management. (B) Individuals with same phenotype (e.g., LVEF < 50%) can be further stratified through precision phenotyping and applying -omics to elucidate defining biologic data (e.g., genomic biomarker, molecular imaging, metabolome profile), resulting in more targeted management and better outcomes.

FIGURE 2.

Myocardial perfusion SPECT images before and 6 mo after RT for left-sided breast cancer demonstrate development of new perfusion deficit in anterior wall and apex consistent with radiation-induced myocardial damage. SA = short axis; VLA = vertical long axis.

FIGURE 3.

Radiation-induced myocardial injury in dogs. (A) Dose distribution contrast-enhanced cardiac CT. (B) ¹⁸F-FDG PET/CT showing no myocardial uptake before RT. (C) Focally intense ¹⁸F-FDG uptake along left ventricular apex matching irradiated field 3 mo after RT. (Adapted with permission of (40).)

FIGURE 4.

Radiation-induced pneumonitis, pericarditis, and myocarditis in patient with cancer of left upper lung near left ventricular lateral wall. (A and B) Before surgical resection and RT, cancer (arrows) is seen on PET and CT. (C and D) About 6 mo after treatment, medium-sized pericardial effusion (C, arrows) and pneumonitis changes (D, arrows) can be seen, along with possible focal ¹⁸F-FDG uptake along left ventricular lateral wall on PET/CT. (E) Fibrotic changes can be seen on CMR; patchy late gadolinium enhancement and focally increased uptake can be seen along anterolateral and inferolateral wall segments on CMR and PET/CT, respectively; and pericardial effusion can also be seen on CMR and PET/CT. SA = short axis; HLA = horizontal long axis.