The emergence of cardiovascular diseases in cancer patients and survivors has led to the development of a new field of modern medicine known as cardio-oncology
Royal Brompton Hospital set up the country’s first dedicated specialist cardio-oncology service in 2011. The mission of the service is to improve the cardiovascular health of people before, during and after cancer treatment.
The cardio-oncology service allows cancer patients to benefit from modern cancer treatment safely from a heart perspective and, after treatment, reduce the risk of developing future heart problems.
Dr Alexander Lyon, consultant cardiologist, explains: “In simple terms, we’re trying to prevent the cancer patient of today becoming the cardiac patient of tomorrow.
In the UK and internationally, we’ve seen a significant increase in the number of cancer patients with cardiovascular problems, particularly related to preexisting heart problems becoming destabilised by their cancer treatment.
“We also look after many patients with specific cardiac complications arising from the cancer treatments themselves. This relates to some chemotherapies and many of the modern ‘designer’ cancer treatments targeting specific molecular pathways within the cancer which have proven very effective.”
Who is at risk?
It is not known when an individual may have a heart attack due to blockage of a coronary artery. But it is known exactly when they will receive a chemotherapy infusion or radiotherapy, when their heart is in the radiation field during radiotherapy, or when they will have a tablet prescription for a cancer treatment. This gives an opportunity to implement a strategy with baseline risk assessment, and identify those people at highest risk, before they start their cancer treatment.
“The goal is not to block cancer treatment but to support it by closely monitoring cardiac function to pick up the earliest changes. We provide a personalised plan either to initiate heart protection medicine in people either at highest risk before they start their cancer treatment, or close monitoring of their heart health and treatment when early signs of heart strain are detected and before they develop more serious heart problems.”
Dr Lyon continues: “We offer a personalised approach to risk status and management. It’s certainly not the case of ‘one size fits all’ where everybody should automatically receive cardioprotective medication.”
The Royal Brompton Hospital cardio-oncology team has looked after more than 1,000 cancer patients – and the specialists have observed different patterns emerging. Initially, patients referred tended to be people who were developing problems after receiving treatment.
More recently, a greater proportion of higher-risk patients have been referred by their oncologist or surgeon before cancer treatment has started. This is ideal as it allows the cardio-oncology team to monitor the patient’s heart health and safely support them through their treatment.
Breast cancer patients
The cardio-oncology service looks after many people with abnormalities of heart function picked up on a standard screening for some common treatments and medications.
Unfortunately, many patients across the world who receive these medications have their treatment stopped when their heart function falls below a certain threshold.
The cardio-oncology team at Royal Brompton Hospital has learned that many women can tolerate a minor reduction in heart function without problems while continuing treatment. This is good news since interrupting this critical cancer treatment can have a negative impact on cancer outcomes, with a higher risk of cancer returning if the 12-month course of medication is interrupted.
Through close monitoring, signals of cardiac strain can be picked up earlier – ensuring breast cancer patients can continue their treatment safely.
Prostate cancer patients
Over the past 20 years, advances in prostate cancer treatment have allowed patients to live for many years with their prostate cancer controlled. This is particularly the case with an effective treatment strategy called androgen deprivation therapy (ADT).
However, the main ADT medications – three monthly injections – can accelerate coronary disease and other vascular diseases by increasing the development of diabetes and raising cholesterol.
Childhood and young adult cancer survivors
The cardio-oncology team also cares for adults who had cancer in earlier life – either as children or young adults in their 20s and 30s. Many of these individuals required chemotherapy which is toxic to the heart, or high doses of radiotherapy to their chest which results in their heart receiving the radiation, or both.
Cardio-oncology for the future
Dr Lyon and his team recently published a report on their initial five-year experience setting up and running the cardio-oncology service at Royal Brompton Hospital.
“We have shared our experience with medical colleagues who are planning to start or are currently delivering their own cardio-oncology services. We hope that the specialist model we’ve developed can be rolled out widely across the UK and beyond,” explains Dr Lyon.
Heart failure theme lead
Dr Lyon is an expert in heart failure, cardiovascular diseases and chemotherapy-induced heart failure.