When helping hurts: restricting cardiotoxicity of cancer therapeutics with accurate cardiovascular risk assessment works!

This editorial refers to ‘Cardiovascular adverse events and prognosis in patients with hematologic malignancies and breast cancer receiving anticancer agents: Kurume-CREO Registry insights’, by T. Shibata et al., https://doi.org/10.1093/eurjpc/zwad210. Cancer patients are understandably dismayed and disheartened when they develop cardiovascular complications related to cancer therapies because of the double whammy of simultaneously having two potentially life-threatening and life-limiting conditions. Cardio-oncology has emerged as an essential sub-specialization of Cardiology to mitigate the burgeoning complications of cancer therapies, including chemotherapeutic agents, immunotherapy, targeted treatments, radiation therapy, and stem cell therapy.1,2 These complications include myocardial dysfunction, myocarditis, heart failure, arrhythmias, cardiac conduction defects, hypertension, pulmonary hypertension, thrombosis, and myocardial ischaemia. Cardio-Oncologists comprehensively manage cardiovascular health and disease in cancer patients and survivors with the goal of eliminating cardiovascular disease as a barrier to effective cancer treatment. This includes assessment of cardiovascular risk, implementation of preventive measures to minimize anticipated cardiovascular complications of cancer therapy, regular monitoring of overall cardiovascular health and disease throughout their cancer treatment journey, close coordination and communication with the oncology team, promptly addressing cardiovascular issues that may arise during or after cancer therapy and providing patients with guidance and information on how to maintain heart health and manage potential side effects of cancer therapies. To facilitate this process, the International Cardio-Oncology Society (IC-OS) and the Heart Failure Association (HFA) developed a risk assessment tool, the HFA-ICOS risk assessment tool (Figure 1), to aid in the early detection and monitoring of cardiovascular complications during cancer therapy2 and the recently published guidelines in conjunction with the European Society of Cardiology.1 The different risk factors which contribute to baseline cardiovascular (CV) risk in a cancer patient scheduled to receive a cardiotoxic cancer treatment, and a checklist of the clinical history and investigations required at baseline prior to starting a cardiotoxic cancer therapy. *Cardiac biomarkers (troponin and natriuretic peptides) should be measured where available. BNP, brain natriuretic peptide; ECG, electrocardiogram; HbA1c, glycated haemoglobin; NT-proBNP, N-terminal pro-brain natriuretic peptide. Lyon et al.2 In this issue of the European Journal of Preventive Cardiology, researchers from a single centre in Japan evaluated this HFA-ICOS risk assessment tool in 486 patients (397 patients with haematologic malignancies and 89 patients with breast cancer) receiving anticancer therapies. The study's primary endpoint was the occurrence of common terminology criteria for adverse events v4.0 grade ≥2, while secondary endpoints included all-cause and cardiovascular deaths. The findings revealed that during a median follow-up of 716 days, cancer treatment-related cardiovascular toxicity occurred in a substantial proportion of patients, with incidence rates of 24.5% in leukaemia, 15.8% in malignant lymphoma, 38.1% in multiple myeloma, and 18.0% in breast cancer cases. The incidence of cardiovascular events was significantly higher in patients classified as high or very high-risk at baseline using the HFA-ICOS risk assessment tool. These results underscore the importance of considering cardiovascular risk factors throughout cancer therapy, as patients may be susceptible to developing cardiovascular complications that could negatively impact their overall health.3–7 One of the important contributions of this study was its evaluation of the HFA-ICOS risk assessment tool for baseline cardiovascular risk stratification. Patients identified as high or very high-risk by this tool exhibited a significantly higher incidence of cardiovascular events. This finding highlights the utility of the risk assessment tool in identifying patients who are more likely to develop cancer treatment-related cardiovascular toxicity, allowing for timely interventions. By recognizing high-risk individuals early in treatment, healthcare providers can implement appropriate preventive and therapeutic measures and closely monitor their cardiovascular health throughout therapy. An important area of investigation is to continue identifying new risk factors, such as neuregulin, that can help improve prediction models and risk assessment tools.8,9 The study's results also highlight the importance of adopting a proactive approach to managing cardiovascular risks in cancer patients. Integrating regular cardiovascular assessments into the cancer treatment plan will aid in detecting potential adverse events promptly. Additionally, healthcare professionals must monitor and manage cardiovascular risk factors in patients with haematologic malignancies and breast cancer undergoing cancer treatment, as they are at a higher risk of experiencing cancer treatment-related cardiovascular toxicity. Patients at high or very high-risk for cancer treatment-related cardiovascular toxicity should be closely monitored for the development of cardiovascular symptoms. Early detection and intervention can help to prevent serious cardiovascular complications, such as heart failure, stroke, and sudden cardiac death. There are a number of things that can be done to help prevent cancer treatment-related cardiovascular toxicity. These include: (i) identifying patients at high or very high-risk cancer treatment-related cardiovascular toxicity, (ii) prescribing medications to mitigate the cardiotoxic effects of cancer treatments, (3) monitoring patients closely for the development of cardiovascular symptoms, and (4) adjusting cancer treatment plans to minimize the risk of cancer treatment-related cardiovascular toxicity. Furthermore, this study emphasizes the significance of multidisciplinary collaboration between oncologists, cardiologists, and other relevant specialists. A collaborative effort can help provide comprehensive care that addresses cancer treatment and cardiovascular health. Developing personalized treatment strategies considering individual patient risk profiles should improve outcomes and enhance patient safety.10,11 An important frontier for the discipline of Cardio-Oncology will be how to implement the ESC IC-OS guidelines into clinical practice and how to integrate these guidelines into the cancer treatment protocols. In conclusion, it is crucial for healthcare providers to recognize the importance of cardiovascular health during cancer therapy and adopt a comprehensive approach to manage potential risks in a proactive manner. Doing so can ensure safer and more effective cancer therapy and improved overall patient well-being. Collaborative efforts between the cancer team and cardiologists are paramount in providing holistic care and putting a brake or even reversing the burden of cancer treatment-related cardiovascular toxicity.