An increasing number of patients with cancer and cancer survivors are living with cardiovascular disease. Pre-existing cardiac condition or risk factors may limit available therapeutic options for cancer treatment, while cancer therapies, or cancer itself, may lead to development of cardiovascular complications thus impacting patients’ outcomes. With the development and widespread use of novel, molecularly-targeted cancer therapies there has been an increased recognition of their cardiovascular adverse effects, spanning from hypertension, asymptomatic left ventricular dysfunction and QT prolongation to clinical heart failure, arrhythmia and vasculopathy.

Cardio-Oncology or Onco-Cardiology Programs

With growing clinical demand a number of dedicated cardio-oncology programs have recently emerged, most often on the grounds of and in strong collaborative effort with comprehensive cancer centers. Cardiologists at oncology-dedicated institutions such as MD Anderson and Memorial Sloan Kettering Center in the United States or Istituto Europeo di Oncologia in Milan, Italy—to name a few—have led the way over the years and have set critical groundwork in the field. Individual differences in cardio-oncology programs reflect wide variations in patient population, specific oncological disease focus and prevention, areas of research excellence as well as in institutional structures that facilitate cross-disciplinary work. Most commonly the members of the team include cardiovascular specialist(s) with expertise in cardiac disease in patients with cancer, nurses, nurse practitioners and professional staff that are familiar with and/or work within cancer center(s) so that seamless and continued communication with all members of the oncology team can be assured.

Areas of Need and Cardio-Oncology Focus

1. Providing risk assessment and comprehensive cardiac care for patients who develop or may be at risk for cardiovascular complications while undergoing treatment for cancer. Patients with pre-existing cardiac conditions also fall into this category. Cardio-oncology programs assure cancer-treatment-specific cardiac evaluation, anticipation, early recognition and ongoing treatment of cardiovascular morbidities in close collaboration with treating oncology teams.
2. Providing care for cancer survivors who have developed cardiac complications as a result of chemo- or radiation- therapy.
3. Development of new strategies for early recognition and treatment of known side effects of cancer therapies such as hypertension, asymptomatic LV dysfunction. This includes development and implementation of latest technology in cardiac imaging, for example, echocardiographic strain (often one of the first signs of therapy-induced LV dysfunction) and 3D-imaging, as well as cardiovascular biomarkers into cancer-treatment-specific cardiac protocols.
4. Development and implementation of cardiac monitoring protocols in the setting of Phase I-III clinical trials with the goal of early recognition of potentially unexpected cardiac effects. With the incredible growth of cancer-therapeutics and increased awareness of their—frequently unexpected—cardiovascular complications there has been an expansion of research investigating cardiovascular effects of targeted therapies.¹ Cardio-oncology programs will have an important role in furthering the knowledge in this area and implementing it in clinical practice.

Resources: Cardio-Oncology Networks, Research, Training and Education

In the Spring of 2013, the National Heart, Lung, and Blood Institute (NHLBI) and National Cancer Institute (NCI) organized a leadership meeting to discuss cancer treatment-related cardiotoxicity thus recognizing the need for a joint effort of multiple disciplines within cardiology and oncology. This conference focused on important scientific knowledge gaps, spanning basic and clinical science, and summarized a number of research activities and priorities, thus creating a valuable resource for scientists and clinicians in this area.² Meetings and events organized by the International CardiOncology Society³ or cancer centers, such as MD Anderson’s conference on cancer and heart,⁴ represent opportunities for presentation of ongoing clinical and research activities and exchange of ideas and initiatives.

Cardiovascular and oncology societies are increasingly taking note and important documents are being been published that facilitate clinical translation and implementation of research growth in this area. Examples include expert consensus on evaluation of cardiovascular complications of radiotherapy from cardiovascular Imaging societies,⁵ and practice guidelines on cardiac effects of cancer therapies,⁶ and clinical review of cardiac care of cancer survivors from oncological societies.⁷

Ongoing Need and Initiatives

With the increased growth of clinical cardio-oncology programs there is an increasing need for development of metrics and standardization of different components of the programs. Development of curriculum content for cardiology trainees is critically needed to expose cardiology fellows to this area as well as to set the basis for further training in cardio-oncology.

On a broader perspective, there is a need for a cross-disciplinary interaction, education, and collaboration among cardiology and oncology societies and their members that would result in faster development of novel educational modules, as well as clinical and research activities.

As a dynamic and growing field, cardio-oncology is of particular interest for the early career professionals and fellows in training. Importantly, many areas within cardio-oncology overlap with established cardiology sub-specialties such as cardiovascular imaging, heart failure and pediatric cardiology, and much of the recent growth in research and knowledge in cardio-oncology has come from a number of experts in these areas.

Next Steps and the Future

With active work and communications among members of the College there has been a rapidly growing interest in the development of a Cardio-Oncology Working Group. This recently formed group—currently housed within the Early Career Professionals Section—is working diligently on identifying priorities and task-items in diverse areas of need, including clinical practice approaches, educational programs and curriculum, as well as research development and interdisciplinary collaborations. The goal of the group that consists of early career members, senior cardiologists and advisors, as well as fellows-in-training representatives, is to create a foundation that will allow for the development of a full and feature-rich set of cardio-oncology offerings within the College.

Interested in being a part?  E-mail: ana.barac@medstar.net

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References

1. Ky B, Vejpongsa P, Yeh ET, Force T, Moslehi JJ. Emerging paradigms in cardiomyopathies associated with cancer therapies. Circ Res 2013;113:754–64.
2. Cancer Treatment-Related Cardiotoxicity: Understanding the Current State of Knowledge and Developing Future Research Priorities, http://epi.grants.cancer.gov/workshops/cardiotoxicity/.
3. International CardiOncology Society, www.cardioncology.com.  
4. MD Anderson Practices in Onco-Cardiology, http://www.mdanderson.org/education-and-research/departments-programs-and-labs/departments-and-divisions/cardiology/cancer-and-the-heart/index.html.  
5. Lancellotti P, Nkomo VT, Badano LP et al. Expert consensus for multi-modality imaging evaluation of cardiovascular complications of radiotherapy in adults: a report from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. J Am Soc Echocardiogr 2013;26:1013–32.
6. Curigliano G, Cardinale D, Suter T et al. Cardiovascular toxicity induced by chemotherapy, targeted agents and radiotherapy: ESMO Clinical Practice Guidelines. Ann Oncol 2012;23 Suppl 7:vii155–66.
7. Carver JR, Shapiro CL, Ng A et al. American Society of Clinical Oncology clinical evidence review on the ongoing care of adult cancer survivors: cardiac and pulmonary late effects. J Clin Oncol 2007;25:3991–4008.

Keywords: Arrhythmias, Cardiac, Heart Failure, Hypertension, Medical Oncology, Cardiotoxicity

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