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ESC position paper addresses cardiotoxicity of cancer therapies
The European Society of Cardiology released a position paper outlining which cancer therapies may put patients at risk for adverse CV events, and measures that can be taken to reduce risk.
“Many patients today do not die due to the cancer but from cardiac complications related to the treatment,” Jose Luis Zamorano, MD, professor of medicine at the University Complutense, Madrid, and chairperson of the task force that wrote the paper, said in a press release. “They need to be monitored by a multidisciplinary team to prevent and treat cardiac complications.”
The paper was presented at the ESC Congress and published in the European Heart Journal.
The paper addresses nine types of CV complications that can be caused by cancer therapies: myocardial dysfunction and HF, CAD, valvular disease, arrhythmia disorders, arterial hypertension, thomoboembolic disease, peripheral vascular disease and stroke, pulmonary hypertension, and pericardial complications.
In each of those nine areas, the paper identifies which types of patients are at risk, how to detect and prevent possible adverse events and how to treat and follow-up patients who develop a particular CV complication.
“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,” Zamorano said in the release. “This position paper provides guidance in this area.”
One recommendation states that although administering anthracyclines and trastuzumab (Herceptin, Genentech) to patients with breast cancer is known to elevate risk for HF, cardiotoxicity can be reduced if there is a drug-free period in between use of those agents.
Cardiotoxicity should be detected by ECG, cardiac imaging and biomarkers, and drugs such as ACE inhibitors and beta-blockers may play a role in prevention of cardiotoxicity induced by cancer therapies, according to the paper.
Encouraging patients to adopt a healthy lifestyle that includes diet modifications, weight loss, smoking cessation and physical activity may also help, according to the authors. “Aerobic exercise is considered a promising non-pharmacological strategy to prevent and/or treat chemotherapy-induced cardiotoxicity,” they wrote.
Clinicians should inform patients of the potential CV risks before cancer treatment begins, should help patients make lifestyle changes and should tell them to report signs and symptoms of CVD as early as possible, the authors wrote.
The paper recommends formation of multidisciplinary teams that include cardiologists, oncologists, nurses, HF specialists and imaging specialists to guide the care of patients being treated for cancer. – by Erik Swain
References:
Lancelotti P.
Suter T. ESC Guidelines 2016 – Overview. Both presented at: European Society of Cardiology Congress; Aug. 27-31, 2016; Rome.
Zamorano JL, et al. Eur Heart J. 2016;doi:10.1093/eurheartj/ehw211.
Disclosure: Zamorano reports financial ties with Abbott, Amgen, AstraZeneca, Edwards Lifesciences, Ikaria, Merck, Novartis, Philips, Pfizer, Servier, Siemens Healthcare, Sorin and Toshiba. Please see www.escardio.org/guidelines for a list of the other authors’ relevant financial disclosures.
Perspective
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This document shows that European societies under the umbrella of the ESC recognize the importance of the cardio-oncology field. Despite a lack of outcome trials, the societies believed it was important to give advice to providers.
At present, there is no common or unified position document about cancer treatment and CV toxicities from the largest U.S. cardiology societies.
That said, there are documents from imaging societies that are important to mention. In particular, a joint American Society of Echocardiography/European Association of Cardiovascular Imaging document published in 2014 (Plana JC, et al. J Am Soc Echocardiogr. 2014;doi:10.1016/j.echo.2014.07.012) addresses some of the topics from the ESC statement. More recently, in 2016 the American Society for Nuclear Cardiology published an information statement on the role and clinical effectiveness of multimodality imaging in the management of cardiac complications of cancer therapy (Russell RR, et al. J Nucl Cardiol. 2016;doi:10.1007/s12350-016-0538-8).
For survivors of childhood cancer, international recommendations were published in 2015 but they did not include (and typically do not reach) adult cardiology readership (Armenian SH, et al. Lancet. 2015;doi:10.1016/S1470-2045(14)70409-7).
The American Society of Clinical Oncology is working on a clinical practice guideline on prevention and monitoring of cardiac dysfunction in adult cancer survivors, but it has not been published yet.
The ESC document is a contemporary summary of broad CV complications from different cancer treatments including targeted cancer therapeutics that practitioners will find helpful.
Specific examples include recommendations of treatment of hypertension associated with vascular endothelial growth factor inhibitors, treatment of thromboembolism associated with cancer treatment and approach to pulmonary hypertension in these patients.
Another important aspect of the ESC document is the focus on prevention and attenuation strategies, including aggressive control of CV risk factors and emphasis on novel techniques to reduce radiation-associated CV complications.
Most of the recommendations represent expert agreement on common approaches but evidence supporting specific CV interventions (such as a specific class of drugs for left ventricular dysfunction) is yet lacking. Continued research will be critical to inform guidelines in the future.
Another important component that I would like to see addressed is professional-society collaboration between cardiology and oncology: How these recommendations are going to affect patient care will be importantly determined by their ability to reach the oncology community. In particular, implementation of CV screening and prevention strategies, prior to or at the onset of cancer treatment, can only occur if oncologists and cardiologists are aware and are following the same recommendations. There is no question that there is collaboration on the individual level, but we all want to practice in accordance with guidelines from our societies. The terminology has evolved in parallel and it will be a huge challenge to forge common guidelines so that practitioners know how to talk to each other.
At present, we have limited data on detailed CV phenotyping across broad categories of patients undergoing cancer treatment. In particular, long-term CV outcomes of patients undergoing cancer treatment are lacking. Most of the data come from a few trials of HER2-targeted therapies in patients with HER2-positive breast cancer that focused on intense monitoring. Inclusion of CV screening and monitoring, with long-term CV outcome collection, in oncology clinical trials, and later monitoring will be critical as new oncology therapies and combination regimens continue to evolve.
This is truly a multidisciplinary field that can advance only with strong partnership between cardiology and oncology.
The ACC has a newly formed section that is poised to collaborate with all stakeholders to advance this field. The mission of the ACC Cardio-oncology Section is to improve CV health of patients with cancer and cancer survivors through education, training, research, development and interdisciplinary collaboration. Key activities so far include the launch of a website, the formation of a patient-education group, participation in an upcoming FDA workshop on CV toxicity assessment in oncology trials, and organization of and participation in meetings and courses, such as one on advancing CV care of oncology patients scheduled for February 2017.