Managing Cardiovascular Complications of Oncology Treatment

“We are very conservative. We want patients to get their chemotherapy at all costs. We try not to interfere with that,” Dr Tamarappoo said. “We try to manage patients as much as possible as medical interventions with cardioprotective medications.”

Patients can experience a wide range of cardiovascular side effects from systemic cancer therapies including induction of cardiac dysfunction, myocardial ischemia, arrhythmias, thromboembolism, arterial and pulmonary hypertension, peripheral arterial occlusive disease and pleural effusion.⁸

The European Organization for Research and Treatment of Cancer (EORTC) states that cardiotoxicity following systemic cancer therapy is typically associated with loss of myocardial mass, leading to progressive cardiac remodelling and dysfunction. Patients with cardiotoxicity can develop heart failure years after the initial cancer therapy and often have poor cardiovascular prognosis.¹⁰

“All people need to take care of their hearts. That said, some cancer patients are more at risk for heart disease, such as those on chemo that can affect heart function such as adriamycin, which may cause [left ventricle] dysfunction and heart failure,” Nieca Goldberg, MD, medical director of the Joan H. Tisch Center for Women’s Health at the New York University Langone Medical Center, stated in an email interview. “This has also been reported with herceptin.”

Results from a 2007 study published in the journal Cancer showed that the risk for “serious cardiovascular morbidity” was 20% higher in men with prostate cancer after a year of androgen deprivation therapy (ADT) compared with men who were not treated with ADT.¹¹

Furthermore, the risk for cardiovascular morbidity was significantly greater for men who underwent 12 months of ADT compared with those treated for fewer  than 12 months (hazard ratio [HR]:1.37; 95% CI: 1.29–1.46).¹¹

Establishing Treatment Protocols

In 2014, Aleman et al published findings from the EORTC’s first Cancer Survivorship Summit, evaluating the current state of knowledge regarding cardiotoxicity and establishing goals for future research.¹⁰

The authors noted that there is no universally accepted definition of cardiotoxicity and many clinical trials that have investigated potentially cardiotoxic cancer drugs do not distinguish between Type I cardiotoxicity and Type II cardiac dysfunction.¹⁰ Dr Hamad added that as of now, there are no guidelines for treating cardiotoxicity in patients with cancer and there is not enough research devoted to developing the best clinical practices.

“It’s hard at the beginning to get buy-in from the oncology field,” he said. “The only time they refer a patient to a cardiologist or cardio-oncologist is if they see something abnormal. They don’t tend to send a patient to a cardiologist or cardio-oncologist just [because of] high risk. That’s something we need to educate and collaborate with in order to better establish these practices.”

“Unfortunately, at this time, there are no set guidelines,” Dr Hamad went on to say. “At this point, the cardio-oncology community is still young and there are no big clinical trials to help us guide what the management of these patients is supposed to be.”