The first European Society of Cardiology (ESC) Guideline on cardio-oncology has been published online on August 22nd 2022 in European Heart Journal. The document has been developed in collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO), and the International CardioOncology Society (IC-OS).
In the related press release ESC explains that this Guideline provides specific recommendations on management before, during and after administering cancer therapies which have the potential to cause problems with the heart or blood vessels.
In fact almost all cancer therapies have the potential to cause cardiovascular disease. Due to cancer therapy’s success in prolonging survival, growing numbers of people now live with heart disease as a result of their treatment, and previous studies have demontrated that survivors of several solid cancers and lymphoma have a two-fold risk of fatal heart disease compared to their peers.
The first important issue is for oncologists and haematologists to know which therapies could cause heart problems. The second issue is that specific cancer treatments do not create the same level of risk in all patients. Therefore, a baseline cardiovascular assessment is advised to identify patients at high risk; they should be referred to a cardiologist for further cardiac evaluation and optimisation of heart health and risk factors before starting therapy.
Preservation and monitoring of heart health during cancer treatment is a key part of the guideline. Patients should be educated on the potential risks and how to reduce them such as quit smoking, exercise at least 150 minutes per week but not to exhaustion, eat a healthy diet, and limit alcohol to 100 grams weekly. Tight control of high blood pressure, diabetes and high cholesterol is recommended. Some patients are advised to monitor their blood pressure at home when starting a cancer therapy known to raise blood pressure.
ESC also highlights that recommendations in the Guideline are provided for the diagnosis and management of cardiovascular side effects during cancer treatment. One common complication is a weakening of the heart muscle, known as left ventricular dysfunction, which can progress to more severe weakening called heart failure. A typical cause is anthracycline chemotherapies, such as doxorubicin, daunorubicin or epirubicin, which are used for breast cancer, acute leukaemia, lymphoma and sarcoma. If cardiac dysfunction is detected during surveillance with echocardiograms and/or with blood tests for heart injury or strain, then cardiology and oncology teams are strongly recommended to discuss the pros and cons of continuing versus stopping cancer treatment.
Monitoring in the first year after treatment is recommended in certain groups. These include those who developed a cardiac complication during treatment to assess whether the problem resolves or persists after the cancer drug has cleared from the body. For some patients this will lead to a trial of weaning off cardiac medications started during cancer treatment while others will be recommended lifelong cardiac treatment.
Another goal is to detect new heart problems since for some cancer therapies, for example anthracyclines, the majority of cardiovascular side effects are detected in the first 12 months after completing treatment. Patients should continue healthy lifestyle habits, report potential cardiac symptoms, and keep blood pressure, diabetes and high cholesterol under control.
Some patients require long-term surveillance for cardiovascular problems. These include survivors of paediatric and young adult cancers treated with high doses of anthracycline chemotherapy and/or high doses of radiotherapy to the chest, adult cancer patients who developed moderate or severe complications during treatment, survivors of leukaemia, myeloma or lymphoma who required a bone marrow transplantation, and patients on long-term cancer treatments with the potential to cause heart problems after years of treatment.
2022 ESC Guidelines on cardio-oncology developed in collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO) and the International Cardio-Oncology Society (IC-OS). European Heart Journal. 2022.