Cardiooncologist: Cancer must be treated so that the patient does not die from the heart

Katarzyna Pinkos, Wprost: Prostate cancer is the most common cancer in men today. Poland is a country with a high level of multiple diseases, so prostate cancer is often not the only disease of the patient. Is cardiac evaluation important for treatment selection?

prof. Sebastian Smith: Of course, we have a lot of international data supporting the need for such an assessment. In the new recommendations of the European Society of Cardiology of August 2022 on cardio-oncology, a special chapter was devoted to the so-called androgen deprivation. This is a hormonal treatment that affects the cardiovascular system. Both American and European studies confirm that men receiving such treatment are at greater risk of cardiovascular disease, more likely to suffer heart attacks, strokes, and heart failure. They have a higher mortality from cardiovascular disease compared to men of the same age who do not receive such treatment, and compared to men who do not have prostate cancer.

This means that prostate cancer and its treatment are significant cardiovascular risk factors. Therefore, we must provide appropriate cardiac treatment in these patients.

Let’s be clear: what is androgen deprivation and do all prostate cancer patients receive this treatment?

One of the most effective treatments for advanced prostate cancer is hormone therapy, i.e. androgen deprivation (antianrogen treatment), the purpose of which is simply to block the production of testosterone. Such therapy is oncologically effective, but is associated with the appearance of lipid and carbohydrate metabolism disorders; also affects the endothelium of blood vessels, mainly arteries. Therefore, men treated in this way are more likely to have heart attacks, strokes, and heart failure.

When cancer treatment blocks testosterone production, we choose to protect against heart failure, heart attack, stroke. This applies to hormone therapy. first line treatment for prostate cancer. However, we already have other areas of treatment, the so-called modern hormonal therapy.

Does modern hormone therapy also negatively affect the cardiovascular system?

Modern hormonal therapy - abiraterone acetate, enzalutamide - these drugs are more effective against cancer, but, unfortunately, cause more complications, especially arterial ones, as well as the development of hypertension. In the case of abiraterone acetate, there are more cardiac complications that threaten patients. It can also cause heart rhythm disturbances such as atrial fibrillation. In the case of enzalutamide, the risk of cardiac complications is significantly lower, but the common property of both drugs is the induction of arterial hypertension.

As for other drugs from the group of modern hormone therapy, such as apalutamide and darolutamide, they are also burdened with some cardiovascular risk. There is debate about whether this risk is lower. Of course, we must remain cardiologically vigilant, but I believe that we can safely use all these drugs under the condition of cardiological monitoring of patients.

Does cardiac risk make patients unable to receive such treatment?

Cardiooncology should not distract patients from treatment; on the contrary: we must break down the barriers and enable treatment even for those patients who already have cardiovascular diseases.

It is important to optimally treat cardiovascular diseases and control risk factors. This can be done, as shown by the example of the PRONOUNCE study, which compared two types of anti-cancer, anti-androgen treatments: one patient took a GnRH receptor antagonist, the other a GnRH agonist. We knew from previous studies that the GnRH receptor antagonist was the safer drug. However, it turned out that if we implemented proper cardiac monitoring, very strict control of risk factors, we reduced cardiovascular risk to the point where there was no difference between patients taking both drugs. Cardiovascular risk was associated only with comorbid cardiovascular disease and not with anticancer treatment. Results obtained by me and my PhD student, Dr. Michal Wilk, regarding abiraterone acetate. It turns out that when we control comorbid cardiovascular disease very well, patients with hypertension or coronary heart disease may even have a better prognosis than other patients. By controlling cardiovascular risk factors and heart disease, we improve the patient’s prognosis.

Cardiac monitoring is extremely important in cancer treatment in order to recognize a cardiac problem as early as possible and to optimally treat risk factors and cardiovascular diseases.

However, new hormonal drugs are safer than previously used chemotherapy?

In the case of chemotherapy, not only cancer cells are damaged, but also healthy tissues. Damage to the heart muscle or blood vessels is possible, which causes clinical complications.

Hormone therapy has a very specific mechanism of action, some even refer to it as specific targeted therapy; we disturb the hormonal balance by blocking the production of testosterone. Possible complications are more sublime, they arise due to the fact that we interfere in the endocrine economy, which is important from a cardiological point of view. Treatment is possible, but additional cardiac prophylaxis and additional control of all risk factors are needed.

Are all prostate cancer patients receiving hormonal treatment already under the supervision of a cardiologist today?

The European Cardiology Guidelines clearly state that every patient should undergo a cardiac examination at the start of treatment. Each patient should also be assessed once a year for cardiac risk. It is very important to control risk factors such as arterial hypertension, hypercholesterolemia, diabetes, as well as avoid a sedentary lifestyle - we are well aware that active patients respond better to treatment, have less toxicity associated with therapy. It is very important to control all these risk factors, to encourage patients to go in for sports, because this eliminates insulin resistance, reduces obesity, strengthens the immune and cardiovascular systems.

Should the choice of drugs be dictated by cardiovascular risk or can it be minimized by cardiac interventions?

If we have two drugs with comparable anti-cancer activity, the safer one should be chosen. However, very often a drug that is more effective against cancer is more toxic. All the more important is cardiological intervention.

Some cancer patients die not because of cancer, but because of heart disease, often exacerbated by treatment. Until recently, no one was talking about cardio-oncology, is it becoming more and more obvious today?

The word “cardio-oncology” was first used in the medical literature in 1996. The most modern definition of cardio-oncology today means overcoming cardiac barriers in optimal cancer treatment. More and more people are suffering from both cancer and cardiovascular disease. An oncologist and a hematologist are increasingly dealing with patients with cardiac complications. It is very important that this patient can be treated for cancer.

Second, anti-cancer drugs cause a number of cardiovascular diseases; it is important to recognize them as early as possible and provide optimal treatment so that there is no need to prematurely stop anticancer treatment.

Cardiooncology helps in the treatment of all types of cancer. Is prostate cancer different in this regard?

Now there is a lot of talk about prostate cancer, it is a huge epidemiological problem.

It is also important that new effective drugs have appeared: I mean modern hormonal therapy. With them, patients live longer, but it is very important that heart disease is not a signal to stop treatment. Modern medicine is increasingly talking about personalization, about the selection of treatment for the patient.

In the case of prostate cancer, we can choose the right oncological drug and manage the patient in such a way that he does not have to stop treatment due to the toxicity of effective oncological therapy.

Is cooperation between oncologists and cardiologists developing in Poland?

In Poland, probably, there is not a single large oncological center where cardiologists would not work. Until recently, many cardiologists did not hear much about cardio-oncology if they worked in centers where there were few oncological patients. I am glad that young cardiologists have a great interest in oncology. The European Society of Cardiology has a Council for Cardio-Oncology, and I would like all Polish cardiologists to observe its activities. It is good that the group of cardiologists dedicating their work to cancer patients is growing.

doctor hab. MD Sebastian Schmit, prof. CMKP – cardio-oncologist, head of the cardio-oncology department of the Postgraduate Medical Center of the Institute of Hematology and Transfusion Medicine in Warsaw, National Institute of Oncology in Warsaw; the first Polish cardio-oncologist certified by the International Society of Cardio-Oncology, the only Pole invited to co-found the board of the Council of Cardio-Oncology in the European Society of Cardiology.