Yesterday, Doctor Alexander Lyon (Royal Brompton Hospital - London, UK) and Doctor Teresa López-Fernández (University Hospital La Paz - Madrid, Spain), Chairs of the Guidelines Task Force, unveiled the very first ESC Guidelines on cardio-oncology.1
The new guidelines, 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), provide recommendations to enable healthcare professionals to help patients with cancer maintain the best possible CV health along their treatment journey.
Improved cancer-related survival and the development of new therapies, in addition to the continued use of anthracycline chemotherapy, have resulted in an increasing number of both current and previously treated cancer patients presenting to cardiology services with CVD. Cardiotoxicity may occur early or late after treatment initiation or termination and the extent is highly variable, depending on multiple factors, including the type of malignancy, the anticancer drugs and their combinations, use of radiotherapy, the presence of CV risk factors and the patient’s comorbidities.
The aim is to personalise approaches to minimise cancer therapy-related CV toxicity and improve both cancer and CV outcomes.
The guidelines start by explaining the role of cardio-oncology services and set out a harmonised set of definitions of cancer therapy-related CV toxicity (CTR-CVT), which have been lacking until recently. Then follows a section on CV toxicity risk stratification and baseline risk assessments that should be performed before anticancer treatment begins, with recommendations for patients with and without pre-existing CVD. “The optimal time to consider CVD prevention strategies in patients with cancer is at the time of cancer diagnosis, prior to the initiation of cancer treatment,” says Dr. López-Fernández, continuing, “CV toxicity risk stratification must be performed without delaying cancer treatments and cardio-oncology referral is recommended in high-risk and very high-risk patients before anticancer therapy, unless there is an oncology emergency requiring immediate cancer treatment."
The next section on the prevention and monitoring of CV complications during cancer therapy provides primary and secondary prevention strategies, sets out optimum surveillance methods (including ECG, cardiac serum biomarkers and imaging) and provides new monitoring protocols for specific anticancer therapies, such as anthracyclines, HER-2 targeted therapies, immune checkpoint inhibitors, chimeric antigen receptor T-cell therapy and hormone-related therapies.
The management of acute and subacute CTR-CVT arising in patients receiving anticancer treatment is addressed, related to cardiac dysfunction, coronary artery disease, valvular heart disease, arrhythmias, hypertension (arterial and pulmonary), thrombosis, bleeding complications, peripheral artery disease and pericardial diseases. If cardiac dysfunction is detected, cardiology and oncology teams are strongly recommended to discuss the pros and cons of continuing versus stopping cancer treatment. Dr. Lyon comments, “Multiple factors influence the decision to continue or stop therapy including the magnitude and severity of the heart problem, how early or late in the cancer management plan the problem has developed, how many more treatment doses are proposed, the tumour response to treatment, the options for cardioprotection and their predicted benefit, the range of alternative non-cardiotoxic cancer treatments available, and the patient’s preference and concerns.”
Sections cover ‘end-of-treatment’ assessments in the first year after anticancer treatment and provide recommendations for long-term follow-up in those who require additional monitoring beyond the first 12 months, such as adults who have survived childhood and adolescent cancer and adult cancer survivors who required radiotherapy or haematopoietic stem cell transplantation.
Special populations where CVDs are directly caused by cancer or where specific considerations are required (e.g. pregnant patients with cancer) are addressed and there is a section on information for patients' involvement in their own care. The final part highlights the role of the ESC and the ESC Council of Cardio-Oncology in further developing understanding of cardio-oncology and outlines remaining gaps in evidence.
Read the recommendations in full – now published in the European Heart Journal.