Cardiovascular Health during and after Cancer Therapy

Artificial intelligence-assisted evaluation of cardiac function by oncology staff in chemotherapy patients

Aims

Left ventricular ejection fraction (LVEF) calculation by echocardiography is pivotal in evaluating cancer patients' cardiac function. Artificial intelligence (AI) can facilitate the acquisition of optimal images and automated LVEF (autoEF) calculation. We sought to evaluate the feasibility and accuracy of LVEF calculation by oncology staff using an AI-enabled handheld ultrasound device (HUD).

Methods and results

We studied 115 patients referred for echocardiographic LVEF estimation. All patients were scanned by a cardiologist using standard echocardiography (SE), and biplane Simpson's LVEF was the reference standard. Hands-on training using the Kosmos HUD was provided to the oncology staff before the study. Each patient was scanned by a cardiologist, a senior oncologist, an oncology resident, and a nurse using the TRIO AI and KOSMOS EF deep learning algorithms to obtain autoEF. The correlation between autoEF and SE-ejection fraction (EF) was excellent for the cardiologist (r = 0.90), the junior oncologist (r = 0.82), and the nurse (r = 0.84), and good for the senior oncologist (r = 0.79). The Bland-Altman analysis showed a small underestimation by autoEF compared with SE-EF. Detection of impaired LVEF < 50% was feasible with a sensitivity of 95% and specificity of 94% for the cardiologist; sensitivity of 86% and specificity of 93% for the senior oncologist; sensitivity of 95% and specificity of 91% for the junior oncologist; and sensitivity of 94% and specificity of 87% for the nurse.

Conclusion

Automated LVEF calculation by oncology staff was feasible using AI-enabled HUD in a selected patient population. Detection of LVEF < 50% was possible with good accuracy. These findings show the potential to expedite the clinical workflow of cancer patients and speed up a referral when necessary.

Risk profiles and incidence of cardiovascular events across different cancer types

BACKGROUND

Cancer survivors are at increased risk for cardiovascular (CV) disease, although additional data are needed to better understand the incidence of CV events across different malignancies. This study sought to characterize the incidence of major adverse CV events [myocardial infarction, stroke, unstable angina (MACE), or heart failure (HF)] across multiple cancer types after cancer diagnosis.

PATIENTS AND METHODS

Patients were identified from a USA-based administrative claims database who had index cancer diagnoses of breast, lung, prostate, melanoma, myeloma, kidney, colorectal, leukemia, or lymphoma between 2011 and 2019, with continuous enrollment for ≥12 months before diagnosis. Baseline CV risk factors and incidence rates of CV events post-index were identified for each cancer. Multivariable Cox hazards models assessed the cumulative incidence of MACE, accounting for baseline risk factors.

RESULTS

Among 839 934 patients across nine cancer types, CV risk factors were prevalent. The cumulative incidence of MACE was highest in lung cancer and myeloma, and lowest in breast cancer, prostate cancer, and melanoma. MACE cumulative incidence for lung cancer was 26% by 4 years (2.7-fold higher relative to breast cancer). The incidence of stroke was especially pronounced in lung cancer, while HF was highest in myeloma and lung cancer.

CONCLUSIONS

CV events were especially increased following certain cancer diagnoses, even after accounting for baseline risk factors. Understanding the variable patient characteristics and associated CV events across different cancers can help target appropriate CV risk factor modification and develop strategies to minimize adverse CV events and improve patient outcomes.

Time to consider the potential role of alternative resistance training methods in cancer management?

Exercise has emerged as fundamental therapeutic medicine in the management of cancer. Exercise improves health-related outcomes, including quality of life, neuromuscular strength, physical function, and body composition, and it is associated with a lower risk of disease recurrence and increased survival. Moreover, exercise during or post cancer treatments is safe, can ameliorate treatment-related side effects, and may enhance the effectiveness of chemotherapy and radiation therapy. To date, traditional resistance training (RT) is the most used RT modality in exercise oncology. However, alternative training modes, such as eccentric, cluster set, and blood flow restriction are gaining increased attention. These training modalities have been extensively investigated in both athletic and clinical populations (e.g., age-related frailty, cardiovascular disease, type 2 diabetes), showing considerable benefits in terms of neuromuscular strength, hypertrophy, body composition, and physical function. However, these training modes have only been partially or not at all investigated in cancer populations. Thus, this study outlines the benefits of these alternative RT methods in patients with cancer. Where evidence in cancer populations is sparse, we provide a robust rationale for the possible implementation of certain RT methods that have shown positive results in other clinical populations. Finally, we provide clinical insights for research that may guide future RT investigations in patients with cancer and suggest clear practical applications for targeted cancer populations and related benefits.

Inequity in care delivery in cardio-oncology: dissecting disparities in underrepresented populations

It is well known that patients with cancer have a significantly higher cardiovascular mortality risk than the general population. Cardio-oncology has emerged to focus on these issues including risk reduction, detection, monitoring, and treatment of cardiovascular disease or complications in patients with cancer. The rapid advances in early detection and drug development in oncology, along with socioeconomic differences, racial inequities, lack of support, and barriers to accessing quality medical care, have created disparities in various marginalized populations. In this review, we will discuss the factors contributing to disparities in cardio-oncologic care in distinct populations, including Hispanic/Latinx, Black, Asian and Pacific Islander, indigenous populations, sex and gender minorities, and immigrants. Some factors that contribute to differences in outcomes in cardio-oncology include the prevalence of cancer screening rates, genetic cardiac/oncologic risk factors, cultural stressors, tobacco exposure rates, and physical inactivity. We will also discuss the barriers to cardio-oncologic care in these communities from the racial and socioeconomic context. Appropriate and timely cardiovascular and cancer care in minority groups is a critical component in addressing these disparities, and there need to be urgent efforts to address this widening gap.

Effect of Trastuzumab Deruxtecan on QT/QTc Interval and Pharmacokinetics in HER2-Positive or HER2-Low Metastatic/Unresectable Breast Cancer

HER2-targeted anticancer therapies may be associated with cardiovascular adverse events. This study evaluated effects of the HER2-targeted antibody-drug conjugate trastuzumab deruxtecan (T-DXd, DS-8201a) on QT/QTc interval and its pharmacokinetics. Patients with heavily pretreated, metastatic HER2-expressing breast cancer were enrolled at seven study sites in Japan. T-DXd was administered intravenously at 6.4 mg/kg on day 1 of each 21-day cycle. Primary end points were baseline-adjusted QTcF interval and pharmacokinetics parameters. Key secondary end points included safety events, serum concentration of T-DXd and DXd at the time of electrocardiographic measurements, and antitumor activity parameters. Among 51 total patients, 47 (92.2%) had HER2-low breast cancer (immunohistochemistry 1+ or 2+ and in situ hybridization-negative/equivocal/missing). Pharmacokinetic parameters after a single dose of T-DXd were consistent with previous studies. After multiple doses, T-DXd showed moderate accumulation (accumulation ratio (cycle 3/cycle 1), 1.35), but DXd showed minimal accumulation (1.09). The upper bound of the 90% confidence interval for mean ΔQTcF interval was < 10 ms at all timepoints, and at mean maximum serum concentration was also < 10 ms. Based on concentration-QT analysis, ΔQTcF increased with increasing concentrations of T-DXd and DXd. No clinically meaningful QTcF prolongation was observed. T-DXd had a manageable safety profile and showed antitumor activity in HER2-low breast cancer. In this study, a T-DXd dose of 6.4 mg/kg, higher than the 5.4-mg/kg dose currently approved for breast cancer, was not associated with clinically relevant QTcF prolongation in heavily pretreated patients with HER2-expressing metastatic breast cancer. This study adds to our understanding of T-DXd for treatment of HER2-low breast cancer.

Cardiovascular risks of chemo-immunotherapy for lung cancer: A population-based cohort study

OBJECTIVES

Despite their proven efficacy for treating lung cancer, the cardiovascular risks associated with programmed cell death protein 1 (PD-1) inhibitors and their combinations with chemotherapy (chemo-immunotherapy) are unclear. This study aimed to investigate these associations.

MATERIALS AND METHODS

This retrospective cohort study included Hong Kong patients with lung cancer receiving PD-1 inhibitors during 2013-2021. Patients with non-concurrent use of PD-1 inhibitors and chemotherapy, any use of tyrosine kinase inhibitors or other immunotherapy agents, and those with prior stroke, heart failure, or myocardial infarction were excluded. PD-1 inhibitors and chemo-immunotherapy were compared for major adverse cardiovascular events (MACE), a composite of cardiovascular mortality, heart failure, stroke, and myocardial infarction. All patients were followed up until the end of 2021. Inverse probability of treatment weighting was used to balance covariates between the two treatment groups.

RESULTS

In total, 713 patients (333 PD-1 inhibitors users and 380 chemo-immunotherapy users) were analysed. Over a mean follow-up of 1.4 ± 1.3 years, 24 had MACE, with an observed incidence of 2.8 [1.6-4.8] events per 100 person-year for patients on PD-1 inhibitors, and 2.1 [1.2-3.8] per 100 person-year for patients on chemo-immunotherapy. No significant between-group difference in MACE incidence was observed (log-rank p = 0.641).

CONCLUSION

The cardiovascular risks associated with PD-1 inhibitors and chemo-immunotherapy may not be significantly different amongst patients with lung cancer. Cardiovascular events associated with either regimen may be uncommon.

Cardio-oncology Clinical Assessment and Screening in Patients Undergoing High Toxicity Chemotherapy: A Retrospective Cohort Study

OBJECTIVE

To describe the clinical characteristics and cardio-oncological assessment in patients undertaking highly toxic chemotherapy and/or chest radiotherapy in a high-complexity hospital.

METHODS

A single-center retrospective cohort study was carried out between January 1st, 2017 and December 31st, 2019. The medical records of patients with solid or hematological neoplasms were reviewed. Descriptive information was obtained on demographic characteristics, chemotherapeutic agents, pre-chemotherapy cardiovascular (CV) evaluation, and CV outcomes. The risk of complications was assessed using the Mayo Clinic risk score.

RESULTS

A total of 499 patients were included, the most common neoplasm was non-Hodgkin's lymphoma (21.6%), followed by breast cancer (19.4%). A very high risk of cardiotoxicity was present in 44.1% and 90% were not evaluated by cardiology. Pre-chemotherapy echocardiography was obtained in 65%, but only 19.4% underwent echocardiographic control after finishing chemotherapy. The most frequent CV outcomes were chemotherapy-related systolic dysfunction (4.4%) and rhythm disturbances (2.8%), with atrial fibrillation and atrial flutter being the most frequent arrhythmias.

CONCLUSION

Despite the recognized CV toxicity of chemotherapeutic drugs, the majority of patients receiving highly toxic regimens at high risk of CV complications are not previously evaluated by a cardiologist and the CV workup was not routinely used in our study. The implementation of cardio-oncology programs will facilitate the identification of high-risk patients, aiming to detect and treat complications early.

Shared Genetic Risk Factors Between Cancer and Cardiovascular Diseases

Cancer and cardiovascular diseases (CVD) account for approximately 27.5 million deaths every year. While they share some common environmental risk factors, their shared genetic risk factors are not yet fully understood. The aim of the present study was to aggregate genetic risk factors associated with the comorbidity of cancer and CVDs. For this purpose, we: (1) created a catalog of genes associated with cancer and CVDs, (2) visualized retrieved data as a gene-disease network, and (3) performed a pathway enrichment analysis. We performed screening of PubMed database for literature reporting genetic risk factors in patients with both cancer and CVD. The gene-disease network was visualized using Cytoscape and the enrichment analysis was conducted using Enrichr software. We manually reviewed the 181 articles fitting the search criteria and included 13 articles in the study. Data visualization revealed a highly interconnected network containing a single subnetwork with 56 nodes and 146 edges. Genes in the network with the highest number of disease interactions were JAK2, TTN, TET2, and ATM. The pathway enrichment analysis revealed that genes included in the study were significantly enriched in DNA damage repair (DDR) pathways, such as homologous recombination. The role of DDR mechanisms in the development of CVDs has been studied in previously published research; however, additional functional studies are required to elucidate their contribution to the pathophysiology to CVDs.

Cardiac Complications: The Understudied Aspect of Cancer Cachexia

The global burden of cancer cachexia is increasing along with drastic increase in cancer patients. Cancer itself leads to cachexia, and cachexia development is associated with events like altered hemodynamics, and reduced functional capacity of the heart among others which lead to failure of the heart and are called cardiovascular complications associated with cancer cachexia. In some patients, the anti-cancer therapy also leads to this cardiovascular complications. So, in this review, an attempt is made to understand the mechanisms, pathophysiology of cardiovascular events in cachectic patients. Important processes which cause cardiovascular complications include alterations in the structure of the heart, loss of cardiac mass and functioning, cardiac fibrosis and cardiac remodeling, apoptosis, cardiac muscle atrophy, and mitochondrial alterations. Previously, the available treatment options were limited to nutraceuticals and physical exercise. Recently, studies with some prospective agents that can improve cardiac health have been reported, but whether their action is effective in cardiovascular complications associated with cancer cachexia is not known or are under trial.

Future steps in cardio-oncology-a national multidisciplinary survey among healthcare professionals in the Netherlands

BACKGROUND

The awareness of cancer therapy-related adverse cardiac effects is fueled by recent literature on cardiotoxicity incidence and detection strategies. Although this influences the sense of urgency, in current practice, cardiotoxicity monitoring and treatment is not structurally performed. With this study, we aimed to evaluate current perspectives on cardio-oncology and to assess needs, ultimately to determine an agenda for improvements in current practice.

MATERIAL AND METHODS

A national multidisciplinary 36-question survey was conducted. The survey was developed by a multidisciplinary team, theoretically based on an implementation checklist and distributed by email, through cardiology and oncology societies as well as social media.

RESULTS

One hundred ninety professionals completed the survey, of which 66 were cardiologists, 66 radiation oncologists, and 58 medical oncologists and hematologists. Many professionals were unaware of their specialisms' cardio-oncology guidelines: 62.1% of cardiologists and 29.3% of the hematologists and medical oncologists respectively. Many cardiologists (N = 46; 69.7%), radiation oncologists (N = 45; 68.2%), and hematologists and medical oncologists (N = 38; 65.5%) expressed that they did not have sufficient knowledge to treat cardio-oncology patients and would either refer a patient or aspire to gain more knowledge on the topic.

CONCLUSION

The field of cardio-oncology is advancing rapidly, with progress in stratification and detection strategies leading to the development of new guidelines and consensus statements. However, the application of these guidelines in current practice appears to be lagging. Professionals express a need for additional training and a practical guideline including risk stratification, monitoring, and treatment strategies. Multidisciplinary discussion and consensus on cardio-oncology care is vital to improve implementation of cardio-oncology guidelines, ultimately to improve cardiac care for oncology patients.

Expert Consensus on Physical Activity Use for Young Adult Cancer Survivors' Biopsychosocial Health: A Modified Delphi Study

Significance: Cancer treatment impacts young adults' (YA) biological and psychosocial health, with over >50% reporting unmet needs. Physical activity (PA) offers symptom mitigation, risk reduction, and critical independence to YA (age 18-39 years) affected by cancer. When tailored to YA, PA guidelines can facilitate PA integration into survivorship care. However, no current expert consensus on PA use in YA exists. Aim: To describe expert consensus and opinions on the application of PA as a biopsychosocial health promotion strategy for YA cancer survivors, guided by the Revised Symptom Management Theory. Methods: A four-round modified Delphi study was conducted with international multidisciplinary experts (round I/II, n = 18; round III, n = 57; round IV, n = 45) in exercise oncology, symptom management, survivorship care, and adolescent-YA cancer care. Qualitative content analysis, descriptive statistics (% agreement, SD, mean), and inter-rater reliability (Kappa) were calculated. Results: Experts reached a consensus on the following: PA should be integrated into YA cancer care as part of supportive oncology to mitigate symptoms of fatigue, cardiometabolic health, muscle mass loss, altered body composition, and anxiety/depression; PA improves functional capacity and wellbeing; at all points on the care continuum YA should be asked if they would like guidance on PA use; PA interventions should be tailored for personal facilitators, barriers, and motivations, to maximize survivorship adaptations. Conclusion/Implication: The results of this study identified areas of expert consensus that warrant PA implementation in YA survivorship care to guide future research and clinical endeavors.