After ten years of activity the IEO Cardioncology Unit, the first of its kind to be established in Italy, can be proud of a very positive trend: not one patient has died from cardiovascular disease among the almost four thousand treated since the Unit was set up.
A new review led by dr. Curigliano and dr. Cardinale from IEO, recently published on CA A Cancer Journal for Clinicians, focuses on the common cardiovascular issues that may arise during or after cancer therapy, the detection and monitoring of cardiovascular injury, and the best management principles to protect against or minimize cardiotoxicity during the spectrum of cancer treatment strategies.
Cancer and heart disease are the leading causes of morbidity and mortality in the industrialized world.
As written in the review, lead by IEO physicians dr. Curigliano and dr. Cardinale, "Mortality rates from cancer have declined over the past 30 years largely because of early detection strategies, improved surgical approaches, as well as advances in cancer therapeutics. Improvement in survivorship, however, can be associated with other organ injuries, including impact on cardiovascular health". Patients may experience adverse cardiovascular events related to their cancer treatment or as a result of an exacerbation of underlying cardiovascular disease.
With longer periods of survival late effects of cancer treatment may become clinically evident years or decades after completion of therapy. Current cancer therapies incorporate multiple agents whose deleterious cardiac effects may be additive or synergistic. Cardiac dysfunction can depend on agents that can result in myocyte destruction -such as with anthracycline use- or from agents that appear to transiently affect left ventricular contractility. In addition, cancer treatment may be associated with other cardiac events, such as severe treatment-induced hypertension and vasospastic and thromboembolic ischemia, as well as rhythm disturbances, including QTc prolongation.
Moreover early and late effects of chest radiation can lead to radiation-induced heart disease including pericardial disease, myocardial fibrosis, cardiomyopathy, coronary artery disease, valvular disease, arrhythmias in the setting of myocardial fibrosis.
The discipline of cardio-oncology has developed over the years in response to the combined decision making necessary to optimize the care of cancer patients, whether they are receiving active treatment or are long-term survivors. Strategies to prevent or mitigate cardiovascular damage from cancer treatment are needed to provide the best cancer care.
Nowadays one of the big challenges the oncologists has to overcome is to treat patients with the best cancer therapies available without adversely impacting CV health. Oncologic guidelines recommend regular cardiac function assessment (generally by echocardiography or MUGA scan) to detect CT- induced cardiac damage in an early phase. In order to increase the predictive value of this kind of evaluation IEO Cardioncology Unit has developed a protocol of specific procedures based on the use of Troponin I – a marker of myocardial damageI, and BNP – a hemodynamic marker; in particular, the increase of Troponin I soon after CT is a strong predictor of left ventricular dysfunction and poor cardiologic outcome.
Two different therapeutic strategies could be implemented by using these biomarkers in order to reduce the clinical impact of cardiotoxicity: 1) the use of specific cardiologic treatments given to cancer patients during CT in the attempt of preventing or blunting the rise of these markers; 2) the use of cardiologic treatments given only to those selected cancer patients showing an increase in these markers after CT. This with the aim to interfere with the natural evolution of cardiac toxicity, and prevent the occurrence of left ventricular dysfunction and cardiac adverse events.