“What is Cardio-oncology and/or Oncocardiology and why do we have this dual terminology going around?” With this provocative question, professor Dimitrios Farmakis opened his talk to introduce his presentation titled “Introduction to the evolving field of Oncocardiology,” delivered within the context of the ICTHIC webinar “Insights and challenges in Cardio-Oncology.” You can watch Dimitrios Farmakis’s lecture in the video below and the full webinar recording here.
Cardio-oncology or oncocardiology?
In the debate over the appropriate terminology to use, the linguistic rule stating that “the head occupies the second position of the structure and is responsible for transmitting to the compound its grammatical category and basic meaning” has been applied. Therefore, the correct term to use is “oncocardiology” since it represents the domain of cardiology that focuses on patients with oncology-related conditions [1].
In fact, the objective of cardio-oncology is to assess, treat, and monitor cardiovascular (CV) health in cancer patients and survivors, to prevent CV diseases, ensure timely diagnosis, and provide effective treatment. The ultimate goal is to optimize the overall fitness of cancer patients, enabling them to receive the most effective anticancer therapies without any compromises or interruptions caused by CV issues [2].
An evolving field
Why do we need Oncocardiology? It is estimated that in the coming years, the percentage of people affected by cancer will increase [3]. However, at the same time, the population of cancer survivors will also grow, thanks to the improved effectiveness of therapies [4].
Unfortunately, a significant portion of these patients will succumb to cardiovascular diseases rather than cancer itself [5] because many cancer therapies may be cardiotoxic. The growing need for interventions in this field is supported by the sudden increase in the number of dedicated oncocardiology centers in the United States and worldwide.
Furthermore, dedicated societies and journals have also emerged, such as the ESC Council of Cardio-Oncology, HFA (Heart Failure Association), IC-OS (International Cardio-Oncology Society), and the journal Cardio-Oncology (“all wrongly written” professor Farmakis joked). The ESC has decided to publish the first guidelines related to this evolving field, providing recommendations for managing and treating oncology patients presenting with cardiovascular disorders [6].
The determinants of vascular diseases in oncology patients
The determinants of vascular diseases in oncology patients are primarily three: cancer therapies, the cancer itself, and the patient’s background in terms of cardiovascular diseases and risk factors.
Cancer therapies can be cardiotoxic and can affect various parts of the cardiovascular system, leading to a wide array of cardiotoxicities, ranging from heart failure to myocarditis to valvular diseases, and so on [7].
Antitumor therapies involve the use of drugs that can have varying degrees of cardiotoxicity.
Professor Farmakis highlighted two specific examples: VEGF inhibitors, extensively used and recognized for their hypertensive effects, but which can also lead to other forms of cardiotoxicity; and immune checkpoint inhibitors (ICIs), known to cause myocarditis but also capable of inducing other types of cardiotoxicity.
These examples highlight the possibility that different drugs within the same class can have diverse effects on the cardiovascular system. Taking as an example the pathophysiology of heart failure in oncology patients, it can be caused by the direct effects of therapies on the cardiovascular system, as well as indirect effects manifested as vascular toxicity. Additionally, the cancer itself can also have an impact on the cardiovascular system.
This brings us back to the second determinant of vascular diseases in oncology patients. Cancer can be associated with various forms of cardiovascular diseases, such as the well-known cancer-associated thrombosis [8] or even atrial fibrillation [9]. Other specific cardiac conditions associated with cancer include cardiac tumors, carcinoid syndrome, and AL amyloidosis.
The third determinant listed by the professor is related to the risk factors for cardiac dysfunction and heart failure. Advanced age, comorbidities such as diabetes, and pre-existing cardiovascular diseases are identified as risk factors. The risk factors for cardiovascular diseases in oncology patients are the same as the risk factors for thrombosis [10].
In addition to all of this, we cannot overlook the role of genetic factors, which can either increase or decrease the risk of cardiotoxicity and the development of cardiovascular diseases.
Cardiovascular approach to the oncology patient
From Professor Farmakis’ premise, it is evident that the situation is highly complex and therefore requires a systematic approach for oncology patients developing cardiovascular diseases, based on current knowledge. The management of cardiovascular conditions in oncology patients should start at the time of cancer diagnosis, continue throughout the course of therapies to tempestively address any potential cardiovascular complications, and extend into the patient’s follow-up period to assess for late-onset cardiotoxicity [2].
To facilitate the baseline risk certification process for cardiotoxicity, seven distinct risk scores have been developed to stratify the risk of developing cardiotoxicity among seven different groups of anticancer agents. By utilizing this form, it is possible to calculate the level of risk and determine the appropriate approach moving forward [6].
It is possible to use a mobile application, which can be downloaded for free, to calculate a patient’s risk level of developing cardiovascular complications based on the type of therapy administered. The application stratifies the risk level and provides recommendations on whether to refer the patient for a cardiologist consultation and the intensity of patient monitoring during cancer treatment. The management of cardiotoxicity during and after the active phase of cancer should take into account three important factors: tumor prognosis, treatment considerations, and drug-drug interactions.
An individualized approach to anticoagulation in cancer, known as TBIP, involves considering the risk of thrombosis and bleeding, drug interactions, and patient preferences. These assessments should be conducted periodically.
Lastly, surveillance in asymptomatic cancer survivors is of utmost importance to assess the potential development of late-onset cardiotoxicity.
Conclusion
It is imperative for clinicians to prioritize the enhancement of patient management, the expansion of knowledge and research, the promotion of education and training, and the implementation of specialized training programs in the field of cardio-oncology. In response to these requirements, the ESC Core Curriculum for Cardio-Oncology has been developed. This curriculum aims to provide comprehensive guidance and resources for professionals seeking to advance their expertise in this specialized area, ensuring optimal care for patients at the intersection of cardiovascular and oncological health.
References
- Williams, E., On the notions” Lexically related” and” Head of a word”. Linguistic inquiry, 1981. 12(2): p. 245-274.
- Farmakis, D., Is cardio-oncology a rapidly growing field of precision medicine? Eur J Heart Fail, 2020. 22(12): p. 2310-2313.
- Pilleron, S., et al., Global cancer incidence in older adults, 2012 and 2035: a population‐based study. International journal of cancer, 2019. 144(1): p. 49-58.
- De Moor, J.S., et al., Cancer survivors in the United States: prevalence across the survivorship trajectory and implications for care. Cancer Epidemiology, Biomarkers & Prevention, 2013. 22(4): p. 561-570.
- Ning, Y., et al., Abstract LB-339: Cause of death in cancer survivors. Cancer Research, 2012. 72(8_Supplement): p. LB-339-LB-339.
- Lyon, A.R., et al., 2022 ESC Guidelines on cardio-oncology developed in collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO) and the International Cardio-Oncology Society (IC-OS): Developed by the task force on cardio-oncology of the European Society of Cardiology (ESC). European Heart Journal, 2022. 43(41): p. 4229-4361.
- Lenneman, C.G. and D.B. Sawyer, Cardio-oncology: an update on cardiotoxicity of cancer-related treatment. Circulation research, 2016. 118(6): p. 1008-1020.
- Mukai, M. and T. Oka, Mechanism and management of cancer-associated thrombosis. Journal of Cardiology, 2018. 72(2): p. 89-93.
- Farmakis, D., J. Parissis, and G. Filippatos, Insights into onco-cardiology: atrial fibrillation in cancer. Journal of the American College of Cardiology, 2014. 63(10): p. 945-953.
- Farmakis, D., et al., Anticoagulation for atrial fibrillation in active cancer. Oncology Letters, 2022. 23(4): p. 1-10.