Recent advances in the early detection and treatment of cancer have led to increasing numbers of cancer survivors worldwide. Nonetheless, despite major improvements in the outcome of these patients, long-term side effects of radio- and chemotherapy affect both patient survival and quality of life, independent of the oncological prognosis. This has resulted in the development of the ESC position paper on cancer treatments and cardiovascular toxicity in 2016, aimed to increase awareness of these problems in the cardiac community.
Collaboration between the Departments of Cardiology, Radiology, Hematology and Oncology resulted in a specialized cardio-oncology healthcare pathway, which was launched in the Netherlands several years ago (Teske et al. Neth Heart J 2018). The aim of this initiative is to improve cardiac outcome in oncology patients by (A) identifying patients at high risk of developing cardiac toxicity before chemotherapeutic treatment is initiated, (B) screen and monitor high-risk patients to enable early detection of (subclinical) cardiac dysfunction which (C) facilitates early treatment initiation in order to improve overall cardiovascular outcome. The last 2 years there has been an exponential increase in awareness among cardiologists regarding the cardiovascular complications related to cancer treatment in the Netherlands. This has consequently led to the development of several specialized cardio-oncology care primarily embedded within the current outpatient care throughout the country. Historically, LVEF measurements were monitored by the oncologist/hematologist and performed by multiple-gated acquisition scans with virtually no interference of the cardiologists. All acute cardiovascular problems were handled on the spot with cardiac consultation when these acute problems occurred. The shift towards a multidisciplinary approach for the optimal patient specific cancer treatment has led to a new dynamic with a clear focus to prevent short term cardiovascular harm and promote long term cardiovascular health after the cancer treatment. The Cardio-oncology service in the Netherlands is a close collaboration between the (imaging and/or heart failure) cardiologists, the oncologists, hematologists, radiologists and radiotherapists. Specialized cardio-oncology care is subdivided in short-term and long term cardiovascular care, as described below.
Specific cardio-oncology services
Screening for LV dysfunction and heart failure
Anthracyclines and trastuzumab are among the most widely prescribed agents associated with serious cardiotoxicity. Patients receiving a high cumulative dose of anthracyclines, those with a low cumulative dose and additional cardiovascular risk factors, and patients planned for treatment with trastuzumab are referred for baseline cardiac evaluation and followed up throughout and after the planned treatment with 3D echocardiography including deformation imaging analysis. The aim of this active screening policy is to detect early LV dysfunction in order to adjust the cancer treatment and/or start heart failure treatment in a timely fashion. This screening is currently being performed in an increasing number of hospitals. The aim of our cardio-oncology working group is to initiate a national uniform screening protocol (see below) accommodating the oncology and hematology treatment protocols.
Preventing acute cardiovascular problems and emergency consultation
Several chemotherapeutic agents pose very specific cardiovascular complications such as hypertension, arrhythmias, QT prolongation, pericarditis, pulmonary hypertension, coronary spasms and myocardial infarction. There is currently no specific program to adequately manage these patients form a cardiology point of view. Within all our academic centers, there are specific cardio-oncologists or cardiologists with interest in cardio-oncology involved in improving the identification of high risk patients and optimizing referral and treatment. Secondly, these individuals will be on the front-line of the new developments within the oncology field regarding cardiovascular complications of new drugs (for example myocarditis in immune checkpoint inhibitors). The challenge in the next few years will be to transfer this knowledge onto the broad cardiology community.
Long term screening in childhood cancer survivors
In every pediatric oncology center in the Netherlands there is a separate outpatient clinic for survivors of childhood cancer, the LATER outpatient clinic (Feijen et al. JAHA 2019). These outpatient clinics pay special attention to the late effects of childhood cancer treatment. All patients are invited for this outpatient screening 5 years after their cancer diagnosis (current estimates indicate that there are 12.000 patients in the Netherlands). The focus of this screening is multi factorial, but also includes cardiac ultrasound and ECG when appropriate. The Dutch guideline for this long-term screening has already been published in 2010
Long term screening in adult patients after Hodgkin Lymphoma
The so-called BETER outpatient clinics are intended for Hodgkin lymphoma survivors who are lymphoma-free for at least 5 years, who are 15-60 years old when diagnosed and who are not older than 70 at the time of referral. This is a nationwide initiative where patients are screened for breast-cancer, thyroid dysfunction and cardiovascular disease. A total of 26 hospitals are participating in this initiative (including all academic centers).
Training health care providers
In the past 2 years many regional initiatives, typically organized by cardiologists and oncologists, have been undertaken resulting in cardio-oncology symposia and training. Currently, there is no formal cardio-oncology fellowship yet within the Netherlands. This year, a cardio-oncology working group was established with the specific task to harmonize our national patient care, organize and develop teaching sessions (at national conferences), and to boost research within this field.
LATER for LATER symposium is an annual initiative since 2013. The symposium is intended for survivors of childhood cancer, but also partners, parents and other stakeholders are invited. At this symposium there is an informal section where patients are able to ask personal questions to LATER experts and get in touch with other survivors.
Hematon is the organization for adult patients with a hematological-oncological disorder and people who have undergone a stem cell transplant. Their goal is to support them in all aspects that life after cancer entails. The aim of Hematon is to meet three patient needs: knowing, sharing and meeting. There is an annual patient meeting where there is specific attention for long term cardiovascular complications.
Throughout the country there are several patient meetings organized by local institutions, cardio-oncologists and researchers to inform and educate cancer survivors on the long-term effects of their treatment and to provide a platform to share ongoing innovations and receive valuable patient input on future research projects.
As stated above, there is a spectacular momentum in the Netherlands where cardio-oncology is recognized as an important attribution of the standard cardiovascular care provided by the cardiologist. This has already led to close collaborations of cardiologists and oncologists/hematologists at different hospitals in the Netherlands and the establishment of several dedicated cardio-oncology services in both academic and non-academic centers. The Dutch Cardio-Oncology working group aims to develop a national guideline, facilitating research including the initiation of a large national registry. Furthermore, the working group aims to organize training and education sessions, and promote collaboration between academic centers regarding cardio-oncology research.
- A.J. Teske, MD, PhD, University Medical Center Utrecht
- P vd Meer, MD, PhD, University Medical Center Groningen