Cardio-Oncology in Italy

Doxorubicyn is an anthracycline drug which was firstly discovered in Italy. At the end of the sixties it was found to have a significant cardiac toxicity, thus representing the first example of a cardio-oncology problem.

In the same period, also radiation therapy was found to produce severe cardiovascular complications, including vascular, pericardial and valve heart disease.  

An Italian group described probably for the first time the radiotherapy induced coronary involvement in 1993 (1).

Italian researchers were involved in Cardio-Oncology from those years and  contributed to the development of Cardio-Oncology in clinical practice, also producing  a huge scientific number of scientific papers.

Progressively many oncology but also large university or community hospitals began to organize Cardio-Oncology services, sometimes beginning on specific interest of some volunteers, and more recently structured and organized from the beginning in the planning of the different services of the hospital.

In the more recent years, both ANMCO (Hospital Italian Cardiology Association) and SIC (University Italian Cardiology Society) constituted working groups of Cardio-Oncology. They assembled different cardiac competence, with the cooperation of oncologists and haematologists. Both these working groups organized and are still planning research and educational activities.

The SIC working group wrote a large amount of expert consensus documents on the diagnosis and the management of several cardiovascular complications of different kinds of anti-cancer drugs. This working group recommended also the need of improving preclinical models for the study of chemotherapy induced cardiotoxicity (2).

Also the Italian Society of Cardiovascular Imaging (SIECVI) is participating in this process, pointing out the role of cardiac imaging and in particular of echocardiography in detecting early (subclinical) and overt cardiotoxicity of anti-cancer drugs and radiotherapy  in oncologic patients.   

In 2017 ANMCO finalized an analysis on the status of Cardio-Oncology among different hospitals in Italy. A short questionnaire was administered to cardiology divisions asking for  existence and inner organization of Cardio-Oncology services, workload, presence of multidisciplinary team and intra/inter-hospital connections. One hundred and twenty divisions completed succesfully the questionnaire. This survey drew a nationwide map of Cardio-Oncology centres (3).

About half of the responders (52% ) declared the existence of a Cardio-Oncology service inside their hospital, while  48% planned to begin this kind of activity.

7% didn’t answer the question. 81% of the Cardio-Oncology services stated the existence of a multidisciplinary team with clearly defined cardio-oncology pathways within their department. By this survey, it appears that great part of the workload involves ECGs and echocardiograms. 13% are little centres taking care of symptomatic patients on a daily base upon request of the oncology service of the hospital.  28% consists of large or university hospitals specialized oncology centres endowed of advanced imaging and specialized cardiologists  playing  a central role in the care of high complexity oncology patients having well-defined path  and being reference for other centres (with an hub and spoke organization).

About half of these high specialization Centres are so called IRCCS (Institute of Research and Cure at Scientific Character). Many of them are very renowned also at international level.

In this survey, it appears clear that no single cardio-oncology model can be applied to all hospitals. Each service could choose the model best fitting its internal organization. Multidisciplinary and networking should play a pivotal role.  

At the present time, several factors limit the existence and the impact of Cardio-oncology services in Italy. They include the lack of financial and human resources, the difficult geographic localization of some of these services, the absence of dedicated educational activities of medical and nurse staff, the difficult interaction between small and larger centres at greater complexity.     

In conclusion, the perception on cardio-oncology speciality and cardio-oncology services is quickly increasing in Italy. Future perspectives correspond to the need of creating services able to promptly diagnose and manage oncologic patients with any kind of cardiovascular complications related to both cancer therapy and radiotherapy, and also of forming a network among the different Cardio-Oncology services.  

Authors

Prof. Maurizio Galderisi MD FESC

Full Professor of Internal Medicine - Head, Interdepartmental Laboratory of Cardiac Imaging -  Program of Cardiovascular Emergencies and Onco-Haematological Complications - Federico II University Hospital -  Naples, Italy

Dr. Iris Parrini MD

Past chair of the Working Group of Cardio-Oncology of the ANMCO (Italian Medical Association Hospital Cardiology) – Cardiology Division – Mauriziano Hospital – Turin, Italy

Dr. Riccardo Asteggiano MD FESC

Chair of the Council of Cardio-Oncology of the ESC – LARC Turin, Italy