Preventing, detecting and managing cancer therapy-related cardiovascular toxicity (CTR-CVT) is a clear objective during cancer treatment. An expert panel report published in JACC: CardioOncology provides practical recommendations during cancer therapy supported by high-quality evidence that can be applied across diverse settings, and highlights the significant gaps in knowledge in cardio-oncology.

The panel, chaired by Darryl P. Leong, MBBS, MPH, PhD, focus on cardioprotective strategies, CTR-CVT surveillance during treatment and permissive CTR-CVT, and outline recommendations and discuss gaps in knowledge in each area. They also address the management of severe cardiovascular disease.

Among cardioprotective strategies for combatting CTR-CVT in patients being treated with anthracyclines or human epidermal growth factor receptor 2 (HER2)-targeted therapies are the use of ACE inhibitors/ARBs and beta-blockers to prevent decline in left ventricular ejection fraction and the use of statins in patients treated with anthracyclines. Limiting cardiac exposure to radiation is imperative during radiotherapy and reduction strategies and advancing planning techniques are reviewed.

Surveillance is also recommended when toxicity can be reasonably detected during treatment, the specific CTR-CVT is common or potentially serious and is actionable, and the cost of surveillance is acceptable. Based on these principles, they discuss surveillance across major classes of cancer therapy, noting that evidence is limited in most settings. Of note, special attention should be paid to treatment with immune checkpoint inhibitors (ICI), and most patients with suspected ICI-associated myocarditis should be hospitalized.

In terms of permissive cardiotoxicity, they write it should be individualized based on the type of cancer, the specific cancer therapy and patient preferences. They note that the balance of risks and benefits have not been adequately studied for all cancer therapies. Special consideration should be given to newer immunotherapies and potential drug-drug interactions for a range of drug types and they provide a table to support this work.

“The identification, prevention, and management of CTR-CVT should be driven by outcomes-based data,” the panel writes. Potential research areas are outlined by the panel. They add that, “In areas in which such data are lacking, management should be tailored to the individual needs of each patient.”

This report is the second part of a three-part Expert Panel series, with the final report in the series focused on cardiotoxicity post-cancer therapy and slated for January. Read the first paper addressing cardiotoxicity before cancer therapy here.

Clinical Topics: Cardio-Oncology

Keywords: Cardio-oncology, Cardiotoxicity, Risk Assessment