Recently, we invited a professor from oncology hospital and a professor from cardiovascular department to have a unique dialogue between oncologists and cardiovascular doctors.
How can oncology and cardiovascular departments work together to overcome the difficulties?
Professor of oncology:
With the rapid development of tumor treatment, patients’ survival period is getting longer and longer. On the one hand, anti-tumor drugs bring cardiovascular problems while prolonging patients’ survival period; on the other hand, as patients’ survival period is prolonged, they inevitably face cardiovascular problems as ordinary people do.
Tumor patients are also a high-risk group for cardiovascular disease and should be vigilant. The concept of co-management of tumor and cardiovascular disease among medical workers should be improved, without shifting the blame and sharing the burden, and at the same time, the popularization of science should be done.
Professor of cardiovascular medicine:
Oncology cardiology, in English, is Cardio-Oncology, directly translated as cardiac oncology, in order to avoid the narrow understanding of heart long tumor, finally it will be defined as oncology cardiology, i.e. cardiac events in the field of tumor, which includes four aspects.
First, the cardiovascular toxicity and cardiac damage caused by drugs in the course of antitumor therapy, how to detect and warn early and how to intervene in the treatment.
Secondly, how to establish a high-quality and most suitable treatment plan for patients with tumor combined with cardiovascular disease, instead of pressing the gourd to start the dipper.
Third, the two diseases have many common risk factors, such as smoking, obesity, sedentary, hypertension, diabetes, etc., how to target the relevant mechanism research, effective intervention of their common risk factors, very necessary.
Fourth, cardiovascular auto-tumors, such as cardiovascular mucinous tumors, sarcoma rhabdomyosarcoma, or metastatic tumors, although the incidence is low, but cannot be ignored.
At present, the main concern is how to protect cardiovascular and avoid cardiovascular drug toxicity during antitumor therapy.
Atherosclerotic cardiovascular disease requires aggressive lipid intervention, is this necessary for patients with combined tumors?
Professor of Oncology:
A domestic baseline study on breast cancer found that 40% of breast cancer patients have dyslipidemia before undergoing treatment, and 20%-30% of normal patients develop dyslipidemia after anti-cancer treatment, and when the two are added together, up to 2/3 of breast cancer patients will develop dyslipidemia.
Strikingly, less than 1 in 20 patients are seen for interventions for dyslipidemia, far fewer than patients with normal hyperlipidemia.
Studies have found that statins do not lead to an increased incidence of tumors and also do not affect tumor outcomes. For breast cancer patients with the same cardiovascular abnormalities and dyslipidemia, the ultimate survival was longer with statin intervention compared to those who did not. Therefore, tumor patients with dyslipidemia can be treated with statins as well as other patients.
Professor of Cardiovascular Medicine:
A recently published cohort study of 100,000 people with a 16-year follow-up by our team examined the association of lipid levels with cardiovascular disease and oncology in men. The results showed that lower LDL levels were associated with lower cardiovascular incidence, however the curve of tumor incidence was not consistent with cardiovascular and was separated. Tumor incidence was relatively high when lipids were below normal and the tumor incidence curve hovered at a low frequency when lipids were within the normal range.
The lower the lipids, the lower the cardiovascular risk, but there is not enough evidence-based medical evidence on how it affects the risk of other diseases such as tumors.
On the other hand, statins have a protective effect on the myocardium itself due to their anti-inflammatory and antioxidant effects, beyond the benefit provided by lipid lowering itself.
Some oncology drugs have the potential for myocardial injury, is cardiovascular safety testing required before oncology drugs are marketed?
Professor of Cardiovascular:
Almost all drugs, internationally, will be evaluated for safety, including cardiovascular corresponding indexes, before marketing. However, in the field of oncology, due to the special nature of the disease, patients do not have a long survival period, and in the research and development, as long as the overall survival of patients is prolonged, that is, to be quickly marketed, thus missing the study of their adverse reactions. In the process of developing antineoplastic drugs, how to reasonably conduct cardiovascular safety assessment is an important issue. Available data indicate that different classes of antineoplastic drugs have different cardiovascular toxicity profiles, for example, anthracyclines have a greater impact on cardiac function and arsenic agents can affect the electrocardiogram QT interval. Therefore, evaluation protocols need to be developed according to different drugs. There is a certain lack of work in this area in China, and we advocate the measurement of corresponding cardiovascular safety indicators for oncology drugs before marketing.
Professor of Oncology:
During the development of oncology drugs, not only cardiovascular safety will be concerned, but also other aspects, such as the fact that some drugs can cause interstitial lung disease, which is also a focus of attention.
However, many patients with advanced tumors, whose survival is limited, and whose treatment is limited, even if the disease has no standard treatment, new drugs become their only lifesavers and have the status of orphan drugs. At this point, if its safety is then given top priority and long-term, large-sample safety validation is conducted, it will make many patients miss the opportunity to save their lives. At this point, it is necessary to fast-track priority review and conditional listing. After fast-track marketing, patients are allowed to live first before post-marketing safety assessments are conducted. For cancer types for which many standard treatments are already available, the more early the drug is used for patients, the more stringent the pre-marketing safety assessment is. For safety assessment, it should be treated differently according to different situations.
How to improve oncologists’ understanding of cardiovascular disease prevention and treatment? How to establish a standardized diagnosis and treatment process for cardiovascular disease in oncology patients?
Clinically, there is indeed a situation that oncologists do not pay enough attention to cardiovascular symptoms. On the one hand, symptoms such as chest tightness and shortness of breath are basic symptoms of lung cancer and other cancers in itself, and doctors first consider that they are caused by tumors; on the other hand, oncologists do not know enough about cardiovascular diseases. I have done epidemiological research on oncology patients with blood lipids before, not because it is more serious than heart failure, but because it has an objective test indicator. If even objective numerical abnormalities cannot draw oncologists’ attention, how can they be asked to pay attention to the future occurrence of heart failure in patients.
Because of the lack of awareness of cardiovascular disease symptoms, oncologists desperately need the help of cardiovascular physicians. So in this case, a process or pathway needs to be established so that oncologists can access the pathway very simply and can detect the signs of cardiovascular disease. Therefore, we have established a Chinese guideline for breast cancer follow-up and concomitant disease management, focusing on its concomitant diseases, focusing on oncology follow-up norms, etc. We hope that not only breast cancer, but all other tumor types will have standardized treatment pathways.
The oncologists should go to seek help from cardiologists after finding out the cardiac abnormalities of patients, and the two departments should cooperate to solve the problems together.
Professor of cardiovascular medicine:
Early screening is very important. Sometimes, when a patient has symptoms of chest tightness and panic, an ultrasound of the heart may reveal that the ejection fraction of the heart has decreased; if an ambulatory electrocardiogram is done, it may reveal arrhythmia; if a myocardial marker test is done, it may reveal that myocardial damage has appeared. Therefore, when managing oncology patients, oncologists should be highly alert to potential cardiovascular disease hazards, think about the cardiovascular risks that may occur during the treatment process, and conduct necessary screening and monitoring to prevent them from happening.
In the oncology cardiology outpatient clinic, oncology and cardiovascular physicians make joint visits with the participation of clinical pharmacists, all working together to improve so that patients can receive timely care and attention and develop comprehensive treatment plans to solve complex problems.
Looking ahead, we expect to strengthen basic and clinical research related to oncology cardiology to provide a better basis for clinical practice; carry out multi-center collaboration, conduct epidemiological surveys, and establish case registration databases; promote the establishment of screening and early warning mechanisms for oncology cardiology patients in hospitals of all types and levels, as well as recommendations for interventions; establish educational and teaching norms for oncology cardiology, as well as the establishment of related specialist physicians We are looking forward to the cooperation of experts from different disciplines and the promotion and dissemination of oncology cardiology knowledge and prevention concepts through various channels such as conferences, internet and media. It is expected that experts from various disciplines will cooperate to promote the prevention and treatment of oncology cardiology in China, further improve the quality of life of oncology patients and improve their prognosis.