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Semin Thromb Hemost 2021; 47(08): 907-913
DOI: 10.1055/s-0041-1726297
Review Article

Cardiovascular Oncology: The Need for a Multidisciplinary Approach

Rodrigo Ortega Pérez
1   Department of Cardiology, University Hospital Ramón y Cajal, Madrid, Spain
,
Ana Pardo Sanz
1   Department of Cardiology, University Hospital Ramón y Cajal, Madrid, Spain
,
Valentín García Gutiérrez
2   Department of hematology, University Hospital Ramóny Cajal, Madrid, Spain
,
José Luis Zamorano Gómez
1   Department of Cardiology, University Hospital Ramón y Cajal, Madrid, Spain
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Abstract

Improved cancer survivorship has led to an increase in cardiovascular (CV) complications in the oncologic population, mainly associated with therapeutic regimens. Hence, cardio-oncology has grown toward unifying the cancer care process in which the best prevention, early detection, treatment, and CV surveillance are offered to patients. This multidisciplinary approach allows us to optimize and agree upon clinical decisions to enhance clinical outcomes. Atrial fibrillation is one of the hot topics in the field because it is still challenging in cancer patients. The optimal antithrombotic therapy remains unclear. Nevertheless, evidence supports that specific recommendations are needed due to a hemorrhagic/thrombotic disbalance present within this subgroup of patients and a low rate of anticoagulation treatments compared with the general population. Further, cardiotoxicity management is currently transforming. Increasingly, early detection of subclinical alterations is raising awareness. When medical therapy is initiated early, fewer patients progress to ventricular dysfunction and the rate of patients completing cancer therapy gradually increases. New approaches are demonstrating better outcomes and these strategies will expectedly be established in clinical practice. Cardio-oncology enables us to find the best balance between cancer treatment and CV health protection. Nowadays, more and more physicians are being instructed in this discipline, which gradually exhibits a greater presence in conferences and scientific journals. However, given the need for physicians thoroughly trained in cardio-oncology, this subspecialty must be promoted further.

Keywords

Cardio-oncology - multidisciplinary approach - cardiotoxicity - atrial fibrillation


Publication History

Article published online:
21 June 2021

© 2021. Thieme. All rights reserved.

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  • References

  • 1 Chang HM, Moudgil R, Scarabelli T, Okwuosa TM, Yeh ETH. Cardiovascular complications of cancer therapy: best practices in diagnosis, prevention, and management: part 1. J Am Coll Cardiol 2017; 70 (20) 2536-2551
    CrossrefPubMedGoogle Scholar
  • 2 Chang HM, Okwuosa TM, Scarabelli T, Moudgil R, Yeh ETH. Cardiovascular complications of cancer therapy: best practices in diagnosis, prevention, and management: part 2. J Am Coll Cardiol 2017; 70 (20) 2552-2565
    CrossrefPubMedGoogle Scholar
  • 3 Koene RJ, Prizment AE, Blaes A, Konety SH. Shared risk factors in cardiovascular disease and cancer. Circulation 2016; 133 (11) 1104-1114
    CrossrefPubMedGoogle Scholar
  • 4 Tan C, Tasaka H, Yu K-P, Murphy ML, Karnofsky DA. Daunomycin, an antitumor antibiotic, in the treatment of neoplastic disease. Clinical evaluation with special reference to childhood leukemia. Cancer 1967; 20 (03) 333-353
    CrossrefPubMedGoogle Scholar
  • 5 Zamorano JL, Lancellotti P, Rodriguez Muñoz D. et al; ESC Scientific Document Group. 2016 ESC position paper on cancer treatments and cardiovascular toxicity developed under the auspices of the ESC Committee for Practice Guidelines: the task force for cancer treatments and cardiovascular toxicity of the European Society of Cardiology (ESC). Eur Heart J 2016; 37 (36) 2768-2801
    CrossrefPubMedGoogle Scholar
  • 6 Ratosa I, Ivanetic Pantar M. Cardiotoxicity of mediastinal radiotherapy. Rep Pract Oncol Radiother 2019; 24 (06) 629-643
    CrossrefPubMedGoogle Scholar
  • 7 Casavecchia G, Galderisi M, Novo G. et al. Early diagnosis, clinical management, and follow-up of cardiovascular events with ponatinib. Heart Fail Rev 2020; 25 (03) 447-456
    CrossrefPubMedGoogle Scholar
  • 8 Ganatra S, Parikh R, Neilan TG. Cardiotoxicity of immune therapy. Cardiol Clin 2019; 37 (04) 385-397
    CrossrefPubMedGoogle Scholar
  • 9 Abdel-Qadir H, Austin PC, Lee DS. et al. A population-based study of cardiovascular mortality following early-stage breast cancer. JAMA Cardiol 2017; 2 (01) 88-93
    CrossrefPubMedGoogle Scholar
  • 10 Miller KD, Nogueira L, Mariotto AB. et al. Cancer treatment and survivorship statistics, 2019. CA Cancer J Clin 2019; 69 (05) 363-385
    CrossrefPubMedGoogle Scholar
  • 11 Albini A, Pennesi G, Donatelli F, Cammarota R, De Flora S, Noonan DM. Cardiotoxicity of anticancer drugs: the need for cardio-oncology and cardio-oncological prevention. J Natl Cancer Inst 2010; 102 (01) 14-25
    CrossrefPubMedGoogle Scholar
  • 12 Hayek SS, Ganatra S, Lenneman C. et al. Preparing the cardiovascular workforce to care for oncology patients: JACC review topic of the week. J Am Coll Cardiol 2019; 73 (17) 2226-2235
    CrossrefPubMedGoogle Scholar
  • 13 Ganatra S, Sharma A, Levy MS. Re-evaluating the safety of drug-eluting stents in cancer patients. JACC Cardiovasc Interv 2017; 10 (22) 2334-2337
    CrossrefPubMedGoogle Scholar
  • 14 McAlister FA, Stewart S, Ferrua S, McMurray JJJV. Multidisciplinary strategies for the management of heart failure patients at high risk for admission: a systematic review of randomized trials. J Am Coll Cardiol 2004; 44 (04) 810-819
    PubMedGoogle Scholar
  • 15 Ung KA, Campbell BA, Duplan D, Ball D, David S. Impact of the lung oncology multidisciplinary team meetings on the management of patients with cancer. Asia Pac J Clin Oncol 2016; 12 (02) e298-e304
    CrossrefPubMedGoogle Scholar
  • 16 Pareek N, Cevallos J, Moliner P. et al. Activity and outcomes of a cardio-oncology service in the United Kingdom-a five-year experience. Eur J Heart Fail 2018; 20 (12) 1721-1731
    CrossrefPubMedGoogle Scholar
  • 17 Parent S, Pituskin E, Paterson DI. The Cardio-oncology Program: a multidisciplinary approach to the care of cancer patients with cardiovascular disease. Can J Cardiol 2016; 32 (07) 847-851
    CrossrefPubMedGoogle Scholar
  • 18 Pituskin E, Mackey JR, Koshman S. et al. Multidisciplinary approach to novel therapies in cardio-oncology research (MANTICORE 101-Breast): a randomized trial for the prevention of trastuzumab-associated cardiotoxicity. J Clin Oncol 2017; 35 (08) 870-877
    CrossrefPubMedGoogle Scholar
  • 19 Cardinale D, Biasillo G, Cipolla CM. Curing cancer, saving the heart: a challenge that cardioncology should not miss. Curr Cardiol Rep 2016; 18 (06) 51
    CrossrefPubMedGoogle Scholar
  • 20 Pituskin E, Haykowsky M, McNeely M, Mackey J, Chua N, Paterson I. Rationale and design of the multidisciplinary team IntervenTion in cArdio-oNcology study (TITAN). BMC Cancer 2016; 16 (01) 733
    CrossrefPubMedGoogle Scholar
  • 21 Trachtenberg BH. Future directions in cardio-oncology. Methodist DeBakey Cardiovasc J 2019; 15 (04) 300-302
    CrossrefPubMedGoogle Scholar
  • 22 Bolli R, Hare JM, Henry TD. et al; Cardiovascular Cell Therapy Research Network (CCTRN). Rationale and design of the SENECA (StEm cell iNjECtion in cAncer survivors) trial. Am Heart J 2018; 201: 54-62
    CrossrefPubMedGoogle Scholar
  • 23 Mehta LS, Watson KE, Barac A. et al; American Heart Association Cardiovascular Disease in Women and Special Populations Committee of the Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; and Council on Quality of Care and Outcomes Research. Cardiovascular disease and breast cancer: where these entities intersect: a scientific statement from the American Heart Association. Circulation 2018; 137 (08) e30-e66
    CrossrefPubMedGoogle Scholar
  • 24 Plana JC, Galderisi M, Barac A. et al. Expert consensus for multimodality imaging evaluation of adult patients during and after cancer therapy: a report from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 2014; 27 (09) 911-939
    CrossrefPubMedGoogle Scholar
  • 25 Virani SA, Dent S, Brezden-Masley C. et al. Canadian Cardiovascular Society guidelines for evaluation and management of cardiovascular complications of cancer therapy. Can J Cardiol 2016; 32 (07) 831-841
    CrossrefPubMedGoogle Scholar
  • 26 Lancellotti P, Suter TM, López-Fernández T. et al. Cardio-oncology services: rationale, organization, and implementation: a report from the ESC Cardio-Oncology council. Eur Heart J 2019; 40 (22) 1756-1763
    CrossrefPubMedGoogle Scholar
  • 27 Staerk L, Sherer JA, Ko D, Benjamin EJ, Helm RH. Atrial fibrillation: epidemiology, pathophysiology, and clinical outcomes. Circ Res 2017; 120 (09) 1501-1517
    CrossrefPubMedGoogle Scholar
  • 28 Siegel RL, Miller KD, Jemal A. Cancer statistics, 2019. CA Cancer J Clin 2019; 69 (01) 7-34
    CrossrefPubMedGoogle Scholar
  • 29 Hu YF, Liu CJ, Chang PMH. et al. Incident thromboembolism and heart failure associated with new-onset atrial fibrillation in cancer patients. Int J Cardiol 2013; 165 (02) 355-357
    CrossrefPubMedGoogle Scholar
  • 30 O'Neal WT, Lakoski SG, Qureshi W. et al. Relation between cancer and atrial fibrillation (from the reasons for geographic and racial differences in stroke study). Am J Cardiol 2015; 115 (08) 1090-1094
    CrossrefPubMedGoogle Scholar
  • 31 Kattelus H, Kesäniemi YA, Huikuri H, Ukkola O. Cancer increases the risk of atrial fibrillation during long-term follow-up (OPERA study). PLoS One 2018; 13 (10) e0205454
    CrossrefPubMedGoogle Scholar
  • 32 Farmakis D, Parissis J, Filippatos G. Insights into onco-cardiology: atrial fibrillation in cancer. J Am Coll Cardiol 2014; 63 (10) 945-953
    CrossrefPubMedGoogle Scholar
  • 33 Lancellotti P, Zamorano JL, Galderisi M. eds. Anticancer Treatments and Cardiotoxicity: Mechanisms, Diagnostic and Therapeutic Interventions. New York, NY: Elsiever; 2016
    Google Scholar
  • 34 Kirchhof P, Benussi S, Kotecha D. et al; ESC Scientific Document Group. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37 (38) 2893-2962
    CrossrefPubMedGoogle Scholar
  • 35 Sharma BK, Flick MJ, Palumbo JS. Cancer-associated thrombosis: a two-way street. Semin Thromb Hemost 2019; 45 (06) 559-568
    Article in Thieme ConnectPubMedGoogle Scholar
  • 36 Sanz AP, Gómez JLZ. AF in cancer patients: a different need for anticoagulation?. Eur Cardiol 2019; 14 (01) 65-67
    CrossrefPubMedGoogle Scholar
  • 37 Lip GYH, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest 2010; 137 (02) 263-272
    CrossrefPubMedGoogle Scholar
  • 38 Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJ, Lip GY. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest 2010; 138 (05) 1093-1100
    CrossrefPubMedGoogle Scholar
  • 39 Chu G, Versteeg HH, Verschoor AJ. et al. Atrial fibrillation and cancer - An unexplored field in cardiovascular oncology. Blood Rev 2019; 35: 59-67
    CrossrefPubMedGoogle Scholar
  • 40 Haddad TC, Greeno EW. Chemotherapy-induced thrombosis. Thromb Res 2006; 118 (05) 555-568
    CrossrefPubMedGoogle Scholar
  • 41 Chen ST, Hellkamp AS, Becker RC. et al. Efficacy and safety of rivaroxaban vs. warfarin in patients with non-valvular atrial fibrillation and a history of cancer: observations from ROCKET AF. Eur Heart J Qual Care Clin Outcomes 2019; 5 (02) 145-152
    CrossrefPubMedGoogle Scholar
  • 42 Melloni C, Dunning A, Granger CB. et al. Efficacy and safety of apixaban versus warfarin in patients with atrial fibrillation and a history of cancer: insights from the ARISTOTLE trial. Am J Med 2017; 130 (12) 1440-1448.e1
    CrossrefPubMedGoogle Scholar
  • 43 Giugliano RP, Ruff CT, Braunwald E. et al; ENGAGE AF-TIMI 48 Investigators. Edoxaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2013; 369 (22) 2093-2104
    CrossrefPubMedGoogle Scholar
  • 44 Connolly SJ, Ezekowitz MD, Yusuf F. et al; RE-LY Steering Committe Investigators. Dabigatran versus Warfarin in patients with atrial fibrillation. N Engl J Med 2009; 361 (12) 1139-1151
    CrossrefPubMedGoogle Scholar
  • 45 Patel MR, Mahaffey KW, Garg J. et al. Rivaroxaban versus Warfarin in nonvalvular atrial fibrillation. N Eng J Med 2011; 365 (10) 883-891
    CrossrefPubMedGoogle Scholar
  • 46 Granger CB, Alexander JH, McMurray JJ. et al. Apixaban versus Warfarin in patients with atrial fibrillation. N Eng J Med 2011; 365 (11) 981-992
    CrossrefPubMedGoogle Scholar
  • 47 Fanola CL, Ruff CT, Murphy SA. et al. Efficacy and safety of edoxaban in patients with active malignancy and atrial fibrillation: analysis of the engage AF-TIMI 48 trial. J Am Heart Assoc 2018; 7 (16) e008987
    CrossrefPubMedGoogle Scholar
  • 48 Vedovati MC, Giustozzi M, Verdecchia P. et al. Patients with cancer and atrial fibrillation treated with doacs: a prospective cohort study. Int J Cardiol 2018; 269: 152-157
    CrossrefPubMedGoogle Scholar
  • 49 Pardo Sanz A, Rincón LM, Guedes Ramallo P. et al; Antithrombotic Management of patients with Breast cancER and Atrial Fibrillation multicenter registry (AMBER-AF) investigators. Current status of anticoagulation in patients with breast cancer and atrial fibrillation. Breast 2019; 46: 163-169
    CrossrefPubMedGoogle Scholar
  • 50 Deng K, Cheng J, Rao S, Xu H, Li L, Gao Y. Efficacy and safety of direct oral anticoagulants in elderly patients with atrial fibrillation: a network meta-analysis. Front Med (Lausanne) 2020; 7: 107
    CrossrefPubMedGoogle Scholar
  • 51 O'Neal WT, Claxton JS, Sandesara PB. et al. Provider specialty, anticoagulation, and stroke risk in patients with atrial fibrillation and cancer. J Am Coll Cardiol 2018; 72 (16) 1913-1922
    CrossrefPubMedGoogle Scholar
  • 52 Suryanarayan D, Lee AYY, Wu C. Direct oral anticoagulants in cancer patients. Semin Thromb Hemost 2019; 45 (06) 638-647
    Article in Thieme ConnectPubMedGoogle Scholar
  • 53 López-Fernández T, Martín García A, Santaballa Beltrán A. et al. Cardio-onco-hematology in clinical practice. position paper and recommendations. Rev Esp Cardiol (Engl Ed) 2017; 70 (06) 474-486
    CrossrefPubMedGoogle Scholar
  • 54 Pardo Sanz A, Zamorano JL. ‘Cardiotoxicity’: time to define new targets?. Eur Heart J 2020; 41 (18) 1730-1732
    CrossrefPubMedGoogle Scholar
  • 55 Wang L, Tan TC, Halpern EF. et al. Major cardiac events and the value of echocardiographic evaluation in patients receiving anthracycline-based chemotherapy. Am J Cardiol 2015; 116 (03) 442-446
    CrossrefPubMedGoogle Scholar
  • 56 López-Sendón J, Álvarez-Ortega C, Zamora Auñon P. et al. Classification, prevalence, and outcomes of anticancer therapy-induced cardiotoxicity: the CARDIOTOX registry. Eur Heart J 2020; 41 (18) 1720-1729
    CrossrefPubMedGoogle Scholar
  • 57 Cardinale D, Colombo A, Lamantia G. et al; Clinical Relevance and Response to Pharmacologic Therapy. Anthracycline-induced cardiomyopathy: clinical relevance and response to pharmacologic therapy. J Am Coll Cardiol 2010; 55 (03) 213-220
    CrossrefPubMedGoogle Scholar
  • 58 Christenson ES, James T, Agrawal V, Park BH, Author CB. Use of biomarkers for the assessment of chemotherapy-induced cardiac toxicity. Clin Biochem 2015; 48 (4–5): 223-235
    CrossrefPubMedGoogle Scholar
  • 59 Charbonnel C, Convers-Domart R, Rigaudeau S. et al. Assessment of global longitudinal strain at low-dose anthracycline-based chemotherapy, for the prediction of subsequent cardiotoxicity. Eur Heart J Cardiovasc Imaging 2017; 18 (04) 392-401
    PubMedGoogle Scholar
  • 60 Thavendiranathan P, Poulin F, Lim KD, Plana JC, Woo A, Marwick TH. Use of myocardial strain imaging by echocardiography for the early detection of cardiotoxicity in patients during and after cancer chemotherapy: a systematic review. J Am Coll Cardiol 2014; 63 (25 Pt A) 2751-2768
    CrossrefPubMedGoogle Scholar
  • 61 Kaya MG, Ozkan M, Gunebakmaz O. et al. Protective effects of nebivolol against anthracycline-induced cardiomyopathy: a randomized control study. Int J Cardiol 2013; 167 (05) 2306-2310
    CrossrefPubMedGoogle Scholar
  • 62 Cardinale D, Colombo A, Sandri MT. et al. Prevention of high-dose chemotherapy-induced cardiotoxicity in high-risk patients by angiotensin-converting enzyme inhibition. Circulation 2006; 114 (23) 2474-2481
    CrossrefPubMedGoogle Scholar
  • 63 Santoro C, Esposito R, Lembo M. et al. Strain-oriented strategy for guiding cardioprotection initiation of breast cancer patients experiencing cardiac dysfunction. Eur Heart J Cardiovasc Imaging 2019; 20 (12) 1345-1352
    CrossrefPubMedGoogle Scholar
  • 64 Cardinale D, Sandri MT, Colombo A. et al. Prognostic value of troponin I in cardiac risk stratification of cancer patients undergoing high-dose chemotherapy. Circulation 2004; 109 (22) 2749-2754
    CrossrefPubMedGoogle Scholar
  • 65 Yu AF, Yadav NU, Lung BY. et al. Trastuzumab interruption and treatment-induced cardiotoxicity in early HER2-positive breast cancer. Breast Cancer Res Treat 2015; 149 (02) 489-495
    CrossrefPubMedGoogle Scholar