br should be referred to
should be referred to a cardiologist . After 10 years, stress testing should be performed even in asymptomatic cancer survivors (echocar-diography, MRI, scintigraphy) .
9. Conclusions and perspective
Due to better tolerability and precision of modern cancer therapies, more patients with cardiovascular risk factors undergo potentially cardiotoxic cancer treatments. Moreover, survival rates of cancer pa-tients have generally improved, and the introduction of modern thera-pies directed against specific molecular targets and of immune checkpoint inhibitors has provided long-term disease control even in advanced or metastatic cancer populations. Hence, prevention, moni-toring and early treatment in particular of late toxicities associated with cancer therapy are of growing importance. The characterization of cardiotoxicity from many specific cancer treatments is incomplete. This is particularly true for the plethora of novel cancer agents that were clinically introduced during the past decade. Adequate detection of early and subclinical effects requires attention to clinical signs and symptoms along with biomarkers and imaging. Specific treatments of cardiovascular complications in oncology are not yet established.
General physicians and cardiologists are confronted with an increas-ing number of patients surviving cancer treatment or receiving long-term cancer therapy. A broad Cyclophosphamide of their symptoms and diseases, ranging from acute coronary events to chronic heart failure, is encoun-tered. Careful examination of these patients is best realized in close co-operation between cardiologist and oncologist, and by dedicated cardio-oncology teams that are established in comprehensive cancer centers [58,78,112,115,124]. Cardio-oncology units provide diagnosis and treatment of acute and chronic cardiotoxicity for cancer patients. As clinical presentation and underlying heart disease in cardio-oncology patients may differ from those in canonical cohorts specific curricula must be developed for cardio-oncologists. Interaction must be established between the cardio-oncology unit and the local imaging center, the emergency department, and the intensive care unit. Given the paucity of data for long-term cancer survivors and specific treat-ment options, appropriate pathways of patient management must be elaborated and established. Preventive, diagnostic and therapeutic algo-rithms must be continuously re-evaluated in interdisciplinary cardio-oncology boards. Ultimately, the cardio-oncology team must balance between effective cancer therapy and cardiotoxicity. Of note, direct and indirect complications from cancer per se, including venous throm-boembolism, pericardial effusion and tamponade, superior vena cava syndrome, constrictive pericarditis and valvular heart disease are be-yond the scope of the present review but can often not be distinguished from cardiotoxic effects of cancer therapy.
Cancer survivorship programs continuously monitor patients for morbidity and mortality and aim to characterize the long-term success in relation to the quality of life. Ideally, these programs assess cardiovas-cular complications on a patient- and physician-reported basis . Current deficiencies in such programs include inconsistent structures, lack of evaluation, missing risk factor and outcome data, and socioeco-nomic costs . A better mechanistic understanding of the molecular and cellular targets of classical chemotherapy and novel cancer thera-pies is needed to develop more specific prevention and treat.
Schuler (all not related to this manuscript):
• Consultant (compensated)
– AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Novartis, Roche
• Honoraries for CME presentations
– Abbvie, Alexion, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Lilly, MSD, Novartis, Pierre Fabre
• Research funding to institution
– Boehringer Ingelheim, Bristol Myers-Squibb, Novartis
– Universität Duisburg-Essen (Patents)
The support of Matz Dietrich, Sebastian Korste and Dr. Raluca Mincu in the preparation of this manuscript is acknowledged.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
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