Reducing Cardiovascular Risks in Patients with Cancer

Presently, oncology stands as the second leading cause of mortality globally, following cardiovascular diseases. Substantial strides have been achieved in managing various oncological conditions, largely attributed to the advancements in targeted therapy for cancer. However, a noteworthy concern arises as the cardiovascular risk escalates significantly in cancer patients undergoing chemotherapy or targeted therapy, surpassing that of the general population. This heightened risk stems from increased survival rates among cancer patients and the adverse effects associated with chemotherapy and targeted treatments.

Along with the increased survival of patients with different types of oncology, special attention has recently been paid to cardiovascular complications due to the prevalence of cardiovascular diseases in the general population and the toxicity profile of targeted drugs.

Current data confirm the increased cardiovascular risk in the specific types of cancers population compared to the general population, which necessitates the widespread introduction of cardiovascular prevention strategies in such groups of patients.

Patients with cancer face a dual challenge in terms of cardiovascular health. On one hand, they can have common cardiovascular risk factors with the general population, encompassing modifiable factors such as weight, smoking status, increased sugar level, increased cholesterol level, and increased blood pressure, as well as non-modifiable factors like gender, age, and genetics. On the other hand, the complexity arises from the fact that many drugs employed in cancer treatment exhibit cardiotoxicity. This dual burden underscores the importance of comprehensive cardiovascular monitoring and management in the oncology setting.

Cardiotoxicity is heart damage that arises from certain cancer treatments or drugs. It can develop years after cancer treatment, especially in adults who received cancer treatment during childhood. Certain types of cancer treatments have a higher risk for cardiotoxicity.

Cardiotoxicity differed depending on the type of drug.

Anthracyclines (Doxorubicin, Daunorubicin, Epirubicin)  are potent chemotherapy drugs commonly used for various cancers, including breast cancer and lymphomas. They are associated with dose-dependent cardiotoxicity, leading to conditions such as cardiomyopathy and congestive heart failure.

Trastuzumab is a targeted therapy used for HER2-positive breast cancer. While highly effective in treating cancer, it can lead to cardiotoxicity, particularly when used in combination with anthracyclines.

Tyrosine Kinase Inhibitors (TKIs - Dasatinib, Nilotinib, Ponatinib) can cause hypertension, heart failure, accelerated atherosclerosis and other cardiovascular complications.

VEGF Inhibitors (Bevacizumab, Sunitinib, Sorafenib) associated with hypertension, proteinuria, and an increased risk of cardiovascular events.

Proteasome Inhibitors (Bortezomib, Carfilzomib) are used in the treatment of multiple myeloma. They can lead to cardiac toxicities, including heart failure and arrhythmias.

Immune Checkpoint Inhibitors (Nivolumab, Pembrolizumab) have been associated with immune-related myocarditis, which can lead to serious cardiac complications.

Mitotic Inhibitors (Paclitaxel, Docetaxel) may cause arrhythmias and myocardial ischemia.

In the general population, well-established strategies for mitigating and managing cardiovascular risk, rooted in evidence-based medicine, are widely disseminated and implemented across various tiers of healthcare, spanning from family physicians to specialized institutions offering highly targeted medical care.

However, the landscape becomes more challenging when addressing the reduction of cardiovascular risks in patients with cancer. One significant hurdle is the limited accessibility to consultations with cardio-oncologists. Often, patients only seek the expertise of a cardio-oncologist when severe complications have already manifested. For instance, a patient with chronic myeloid leukemia taking the tyrosine kinase inhibitor nilotinib might present with advanced atherosclerosis, leading to lower limb amputation. In such cases, the focus shifts from primary prevention, which aims to avert cardiovascular events, to secondary prevention, aimed at managing and preventing further complications after an event has occurred.

Additionally, the drug-drug interactions pose a substantial concern. Many medications utilized in cancer treatment have the potential to interact, altering each other's pharmacokinetics and potentially intensifying toxic effects. This aspect is especially critical in the treatment of comorbid patients with cardiological pathology and cancer, where a comprehensive understanding of potential interactions is imperative.

The field of cardio-oncology is rapidly evolving globally, witnessing the emergence of specialized advisory centers and dedicated departments. Recently, collaborative efforts between cardiology and oncology societies have culminated in the development of joint clinical guidelines. These guidelines underscore the paramount importance of cardiac monitoring in cancer patients. By emphasizing proactive monitoring and the management of cardiovascular health, these guidelines aim to bridge the gap between oncology and cardiology, ensuring a more holistic and integrated approach to the care of patients facing both cancer and cardiovascular challenges.

The strategy for reducing cardiovascular risk in patients with cancer should be based on the individual patient risk assessment, general population recommendations, and cardiotoxic features of the drug used for cancer treatment. All cancer patients should be recommended a two-stage approach for reducing cardiovascular risk. The first stage is risk assessment and the choice of appropriate cancer treatment based on cardiovascular risk assessment before starting cancer therapy. The second stage is monitoring and treatment during cancer therapy with further prevention of cardiovascular complications.

In certain instances, conventional clinical guidelines may fail to address the myriad questions that surface in routine clinical practice. Recognizing this gap, our research group endeavored to address the challenges by publishing the article titled "A New Paradigm of Cardio-Hematological Monitoring in Chronic Myeloid Leukemia Patients Treated With Tyrosine Kinase Inhibitors" in 2022 (Lopina N, Dmytrenko I, Hamov D, Lopin D, Dyagil I. Cureus. 2022 Jun 8;14(6):e25766. doi: 10.7759/cureus.25766. PMID: 35812557; PMCID: PMC9270100. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9270100/). This research aims to reduce cardiovascular risk in patients with Chronic Myeloid Leukemia (CML), offering potential enhancements to the prognosis within this specific population grappling with blood cancer.

When clinical recommendations prove insufficient in navigating the complexities of routine clinical cases, healthcare providers often rely on their experience, standard treatment, and prevention algorithms for the general population. Additionally, aligning an individual patient's risk profile with the cardiotoxicity attributes of specific drugs becomes crucial. This confirms the necessity of the development of personalized strategies encompassing prevention, monitoring, and treatment for cancer patients, thereby mitigating cardiovascular risk and ultimately enhancing prognosis.

Our research group in Ukraine is actively engaged in advocating for increased awareness of the toxicity associated with cancer therapy, overcoming different types of cancer drug toxicity, and the concurrent increase of treatment tolerance. This involves active participation in national and international conferences, and conducting lectures for healthcare professionals from various specialties, including patient involvement in educational initiatives. Also, we are actively involved in developing written algorithms for delivering medical assistance to the blood cancer patient’s population and are currently testing interprofessional protocols for providing medical care to cancer patients.

In collaboration with the Charitable Foundation "Kraplya Krovi" (Drop of Blood), dedicated to safeguarding the rights of patients with various forms of cancer, we have supported the implementation of the first strategies for cardiac and vascular prevention in Ukraine, particularly among patients with blood cancer. Despite the challenging circumstances posed by the ongoing war in Ukraine, our commitment to caring for patients and ensuring their access to adequate medical care remains unwavering.

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