Cardio-Oncology in France

Cardio-oncology exists in France for a number of years ¹. It has for a long time mainly concerned with cardiac complications such as heart failure or reduction of left ventricular ejection under anthracyclines and prolongation of QT after chemotherapy. These issues were well  known by both oncologists and cardiologists. It’s how cardio-oncology was born. But more recently, since the 2000’s, with the develpoment of targeted therapies, new toxicities, such as atrial fibrillation, pulmonary arterial hypertension or myocarditis, have arisen. They could occur even with oral therapies, which are given for years sometimes. Thus, their screening and management remains challenging. In 2017 ², a survey  conducted with 303 French oncologists confirmed this observation. Eighty-three percent of them worked in collaboration with a cardiologist in the same structure of care. All oncologists were aware of the risks of cardiac complications of anthracyclines or traztuzumab. The majority of them, 93%, used echocardiography to assess the cardiac function of their patients under anthracyclines. But on the other hand,  at that time, only 35% of oncologists said they followed the recommandations of Scientific Societies in Oncology regarding the management of cardiac toxicities of the other cancer treatments. None were aware of the recommendations published by the Scientific Societies of Cardiology in this field. Only 38% of them were aware of the existence of screening methods for left ventricular dysfunction, such as global strain deformation. The interest of biomarkers was only known by 32% of them. Only 42% of them proposed a pre-therapy assessment before vascular endothelium growth factor pathway antibodies and only 28% on per therapeutic time.

Finally, 34% of oncologists surveyed thought that the working relationship with the cardiologists with whom they worked could be improved. 88% supported the idea of ​​cardiologists specialising in oncology collaborating with them for treatment of cardiovascular complications of chemotherapy. The main obstacle to the creation or extension of these cardio-oncology programmes within their institution was financial in origin for 61% of oncologists; insufficient infrastructure for 22% of oncologists. Thus, the need for cardio oncology programme is clear.

In recent years, several cardio-oncology structures have tried been set up. In 2018, there were only two structures really labeled Cardio-Oncology, one in a university hospital in Marseille the Mediterranean University Cardio-Oncology center (MEDI-CO center) who was created in 2015,  and the other in a university hospital in Paris. Over the past 5 years, interest has grown significantly and in January 2018, the French Society of Cardiology decided to create a Council of Cardio-Oncology. This Council is creating a website, to include also practical sheets in the field of heart failure, toxic cardiomyopathy, induced-hypertension, venus thrombo-embolism disease or rythmology. For the past four years, cardiogists of the Council have organised an annual Heart and Cancer Congress. The Council has also created this year an Inter-University  Diploma of Cardio-Oncology which has a great success. Lastly, many clinic and fundamental research projects have been established in order to better understand the pathophysiological mechanisms of these new complications.

In practice, there is no specific recommendation of the French Society of Cardiology regarding cardio-oncology and the experts propose to adhere to the International position paper. Thus, regarding the cardiotoxicity of anthracyclines, the use of echocardiography is quite similar to the recommendations proposed by the learned societies. On the other hand, the place of biomarkers is much more limited and troponin is only use for anthracyclins. Finally, the preventive use of treatments such as ACE inhibitors, betablockers or dexrazoxane remains low. The traztuzumab possible cardiac complications have stimulated the knowledge and interest of oncologists in the cardiac complications of chemotherapy. Recently, the risk of fulminant myocarditis under immunotherapy has continued to strengthen the links between oncologists and cardiologists. In fact, several public or private hospital care facilities, whether academic or not, are considering developing these cardio-oncology structures. However, there are still many financial and architectural obstacles to the generalization of a cardio-oncology unit. But there is a very strong dynamic attested by 1) the audience at the Cardiology congresses when the theme of CardioOncology is present. 2) the waiting lists for registration for the Interuniversity Diploma in Cardiology; 3) the number of registrations at the Council of Cardiology.

Authors

Cohen-Solal A

Cardiology Department, Paris Diderot University and UMR-S 942 Research Unit « BioCanvas », Lariboisiere Hospital, Paris, France.

Cautela J

Aix-Marseille University, Assistance Publique–Hôpitaux de Marseille (AP-HM), Mediterranean University Cardio-Oncology center(MEDI-CO center), Department of Cardiology, Hôpital Nord, France