Cardiotoxicity in Cancer Treatment

Mar 20, 2023 - 5 min. read time

Remarkable progress has been made in the diagnosis and management of many types of cancer. Nowadays, patients have access to advanced diagnostic tools and increasingly more targeted treatment options, resulting in improved disability-free life expectancy. Consequently, we are also starting to understand the importance of managing cardiovascular damage that can be caused by many established and novel cancer treatments. In fact, this has led to the new subspeciality of cardio-oncology.

Benjamin Vandendriessche
CMO at Byteflies & Adjunct prof at WRCU

Cardiotoxicity in Cancer Treatment

Mar 20, 2023 - 5 min.

Remarkable progress has been made in the diagnosis and management of many types of cancer. Nowadays, patients have access to advanced diagnostic tools and increasingly more targeted treatment options, resulting in improved disability-free life expectancy. Consequently, we are also starting to understand the importance of managing cardiovascular damage that can be caused by many established and novel cancer treatments. In fact, this has led to the new subspeciality of cardio-oncology.

Reach out to our experts

Arno Bossaert and Benjamin Vandendriessche authored this article. It is a quick primer on cardiotoxicity in cancer treatment programs, and how remote cardiac monitoring solutions could improve the standard of care and drug development in oncology. It is in no way intended to provide an exhaustive overview of the field.

Remarkable progress has been made in the diagnosis and management of many types of cancer. Nowadays, patients have access to advanced diagnostic tools and increasingly more targeted treatment options, resulting in improved disability-free life expectancy. Consequently, we are also starting to understand the importance of managing cardiovascular damage that can be caused by many established and novel cancer treatments. In fact, this has led to the new subspeciality of cardio-oncology.

What is Cardiotoxicity?

Cardiotoxicity is cardiovascular damage caused by certain cancer treatments. It can develop days, weeks, or even years after treatment (ref). Several cardiac problems such as cardiac ischemia (reduced blood flow to the heart leading to heart muscle damage), heart failure, arrhythmias (abnormalities in electrical conduction in the heart), pericarditis (inflammation around the heart), coronary artery disease (reduced blood flow in the vessels that supply the heart muscle with blood), and embolisms (blood cloths) are all potential manifestations or causes of cardiotoxicity. In many cases, cardiotoxicity presents as cardiomyopathy, a catch-all term for conditions that make it harder for your heart to pump blood. Certain types of cancer drugs and treatments are associated with a higher cardiotoxicity risk. Some important but non-exhaustive examples are (ref, ref, ref):

  • Anthracyclines: Chemotherapy that is often used to treat leukemia, lymphoma, breast cancer, sarcoma, or multiple myeloma.
  • Trastuzumab: Targeted therapy drug commonly used to treat breast, stomach, and esophageal cancer.
  • Radiation therapy, especially when targeted at the chest: Often used to treat breast cancer or certain leukemias.
  • Fluoropyrimidines: Often used in the treatment of colorectal, breast, and aerodigestive tract cancers.
  • Immune Checkpoint Inhibitors (ICIs): Immunotherapy used for melanoma skin cancer and lung cancer.

Telemonitoring Tools to Reduce Cardiotoxicity Risks

Cardiotoxicity risk is a dynamic variable, and the risk changes throughout the care pathway, depending on factors such as age, cancer history, pre-existing cardiovascular disease, and cardiotoxic events. The risk of cardiotoxicity is important to understand and balance against the benefit of the cancer treatment, before, during and after treatment. The risk can be reduced by several mitigation strategies, including (ref):

  • Primary prevention: Cardioprotective treatment strategies focused on preventing cardiovascular damage from occurring, evaluated on a patient-by-patient basis.
  • Secondary prevention: Similar to primary prevention but focused on those with a history of cardiovascular disease and/or prior cardiotoxic events.
  • Cardiovascular surveillance: Careful and frequent clinical evaluation during cancer treatment to detect early signs and symptoms.
  • Early cardioprotection: If surveillance identifies (sub)clinical cardiotoxicity, cardioprotective treatment should be started promptly.

Figure adapted from the 2022 ESC guidelines on cardio-oncology. It depicts how: 1) at baseline (pre-cancer treatment), primary and secondary prevention strategies can reduce the occurrence or effect of cardiotoxicity (BLUE arrow); and 2) during treatment early cardioprotection should be initiated as soon as possible (GREEN arrow) to bring the increased risk for severe cardiotoxicity back down (DASHED line), based on results from surveillance activities. It also shows how long-term surveillance after completion of cancer treatment is recommended to minimize chronic cardiovascular events (ORANGE arrow).

Patient surveillance with remote patient monitoring (telemonitoring) tools is a potentially powerful method to keep a close eye on patients in these care trajectories without generating much additional hassle such as repeated physician visits.

The Underutilized Role of ECG Monitoring in Cardiotoxicity

Several cardiology and oncology professional societies have emphasized the effectiveness of an electrocardiogram (ECG) and other non-invasive monitoring solutions in managing cardiotoxicity. The European Society of Cardiology (ESC) suggested that all cancer patients should undergo ECG monitoring before treatment to identify cardiotoxicity risk factors. Nowadays, many user-friendly ECG monitoring tools are available that can remotely follow-up patients for longer periods of time, typically multiple weeks.

The relevance and type of ECG monitoring depends on the specific cancer treatment. For example, in Immune Checkpoint Inhibitors (ICIs), remote ECG monitoring is a recommended strategy (ref, ref). Myocarditis is a rare (up to 1.14% or 2.1%, dependent on the source) ICI adverse event but one with extremely high mortality (up to 46% or 50%), making continuous surveillance to identify early warning signs crucial.

As increasingly advanced cancer therapies are developed, more patients survive. Because of this phenomenal evolution we are now starting to understand acute and especially long-term side effects of these treatments in much more detail, including cardiotoxicity, which is a rapidly evolving field. Fit-for-purpose remote monitoring strategies can improve the standard of care for patients and inform clinicians, researchers, and drug developers about the cardiotoxic effects of new therapies.

Byteflies Remote Patient Monitoring

Byteflies has extensive expertise in developing and deploying remote patient monitoring solutions. Our wearable and medically certified Sensor Dot technology has been used in clinical trials, real-world data studies, and in state-of-the-art telemonitoring applications in clinical practice.

As an example of the latter, Byteflies Cardiology Flows provide a comfortable and integrated cardiac patch solution for continuous ECG monitoring at home up to several weeks, including advanced arrhythmia detection analytics. Our Onco Flow is developing continuous remote monitoring features that are relevant during and after cancer treatment, including for new classes of immunotherapies that can cause cytokine release syndrome (CRS) and neurotoxicity. At the intersection of these two diagnostic fields, we can assist innovators, clinical researchers, and physicians with innovative solutions to tackle new challenges in cardio-oncology!

Byteflies is working towards a future where healthcare is fully personalized and preventive. Our diagnostic solution allows high quality, long-term and synchronized measurement of vital parameters and digital biomarkers with user-friendly patches and powerful data analytics, independent of where you are and optimized for your specific needs.

Interested to Learn More?

At Byteflies, we move mountains to enable wearable health. With our Absence & Focal Flows, we are monitoring seizures to improve the standard of care for people with epilepsy. With our Afib Flow, cryptogenic stroke patients are screened for cardiac risk factors much faster and with a user-friendly tool. Our technology allows pharmaceutical companies to monitor patients easily and objectively in clinical trials.

Interested in working with us to reduce cardiotoxicity due to cancer treatment? Curious to know what we can offer for your patients, project, or clinical trial? Contact us at hello@byteflies.com or via www.byteflies.com. We look forward to hearing from you!

The information contained in this article represents the views and opinions of the writer(s) and does not necessarily represent the views or opinions of other parties referenced or mentioned therein.

The article is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified healthcare professional with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you read in this article.

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Arno Bossaert and Benjamin Vandendriessche authored this article. It is a quick primer on cardiotoxicity in cancer treatment programs, and how remote cardiac monitoring solutions could improve the standard of care and drug development in oncology. It is in no way intended to provide an exhaustive overview of the field.

Remarkable progress has been made in the diagnosis and management of many types of cancer. Nowadays, patients have access to advanced diagnostic tools and increasingly more targeted treatment options, resulting in improved disability-free life expectancy. Consequently, we are also starting to understand the importance of managing cardiovascular damage that can be caused by many established and novel cancer treatments. In fact, this has led to the new subspeciality of cardio-oncology.

What is Cardiotoxicity?

Cardiotoxicity is cardiovascular damage caused by certain cancer treatments. It can develop days, weeks, or even years after treatment (ref). Several cardiac problems such as cardiac ischemia (reduced blood flow to the heart leading to heart muscle damage), heart failure, arrhythmias (abnormalities in electrical conduction in the heart), pericarditis (inflammation around the heart), coronary artery disease (reduced blood flow in the vessels that supply the heart muscle with blood), and embolisms (blood cloths) are all potential manifestations or causes of cardiotoxicity. In many cases, cardiotoxicity presents as cardiomyopathy, a catch-all term for conditions that make it harder for your heart to pump blood. Certain types of cancer drugs and treatments are associated with a higher cardiotoxicity risk. Some important but non-exhaustive examples are (ref, ref, ref):

  • Anthracyclines: Chemotherapy that is often used to treat leukemia, lymphoma, breast cancer, sarcoma, or multiple myeloma.
  • Trastuzumab: Targeted therapy drug commonly used to treat breast, stomach, and esophageal cancer.
  • Radiation therapy, especially when targeted at the chest: Often used to treat breast cancer or certain leukemias.
  • Fluoropyrimidines: Often used in the treatment of colorectal, breast, and aerodigestive tract cancers.
  • Immune Checkpoint Inhibitors (ICIs): Immunotherapy used for melanoma skin cancer and lung cancer.

Telemonitoring Tools to Reduce Cardiotoxicity Risks

Cardiotoxicity risk is a dynamic variable, and the risk changes throughout the care pathway, depending on factors such as age, cancer history, pre-existing cardiovascular disease, and cardiotoxic events. The risk of cardiotoxicity is important to understand and balance against the benefit of the cancer treatment, before, during and after treatment. The risk can be reduced by several mitigation strategies, including (ref):

  • Primary prevention: Cardioprotective treatment strategies focused on preventing cardiovascular damage from occurring, evaluated on a patient-by-patient basis.
  • Secondary prevention: Similar to primary prevention but focused on those with a history of cardiovascular disease and/or prior cardiotoxic events.
  • Cardiovascular surveillance: Careful and frequent clinical evaluation during cancer treatment to detect early signs and symptoms.
  • Early cardioprotection: If surveillance identifies (sub)clinical cardiotoxicity, cardioprotective treatment should be started promptly.

Figure adapted from the 2022 ESC guidelines on cardio-oncology. It depicts how: 1) at baseline (pre-cancer treatment), primary and secondary prevention strategies can reduce the occurrence or effect of cardiotoxicity (BLUE arrow); and 2) during treatment early cardioprotection should be initiated as soon as possible (GREEN arrow) to bring the increased risk for severe cardiotoxicity back down (DASHED line), based on results from surveillance activities. It also shows how long-term surveillance after completion of cancer treatment is recommended to minimize chronic cardiovascular events (ORANGE arrow).

Patient surveillance with remote patient monitoring (telemonitoring) tools is a potentially powerful method to keep a close eye on patients in these care trajectories without generating much additional hassle such as repeated physician visits.

The Underutilized Role of ECG Monitoring in Cardiotoxicity

Several cardiology and oncology professional societies have emphasized the effectiveness of an electrocardiogram (ECG) and other non-invasive monitoring solutions in managing cardiotoxicity. The European Society of Cardiology (ESC) suggested that all cancer patients should undergo ECG monitoring before treatment to identify cardiotoxicity risk factors. Nowadays, many user-friendly ECG monitoring tools are available that can remotely follow-up patients for longer periods of time, typically multiple weeks.

The relevance and type of ECG monitoring depends on the specific cancer treatment. For example, in Immune Checkpoint Inhibitors (ICIs), remote ECG monitoring is a recommended strategy (ref, ref). Myocarditis is a rare (up to 1.14% or 2.1%, dependent on the source) ICI adverse event but one with extremely high mortality (up to 46% or 50%), making continuous surveillance to identify early warning signs crucial.

As increasingly advanced cancer therapies are developed, more patients survive. Because of this phenomenal evolution we are now starting to understand acute and especially long-term side effects of these treatments in much more detail, including cardiotoxicity, which is a rapidly evolving field. Fit-for-purpose remote monitoring strategies can improve the standard of care for patients and inform clinicians, researchers, and drug developers about the cardiotoxic effects of new therapies.

Byteflies Remote Patient Monitoring

Byteflies has extensive expertise in developing and deploying remote patient monitoring solutions. Our wearable and medically certified Sensor Dot technology has been used in clinical trials, real-world data studies, and in state-of-the-art telemonitoring applications in clinical practice.

As an example of the latter, Byteflies Cardiology Flows provide a comfortable and integrated cardiac patch solution for continuous ECG monitoring at home up to several weeks, including advanced arrhythmia detection analytics. Our Onco Flow is developing continuous remote monitoring features that are relevant during and after cancer treatment, including for new classes of immunotherapies that can cause cytokine release syndrome (CRS) and neurotoxicity. At the intersection of these two diagnostic fields, we can assist innovators, clinical researchers, and physicians with innovative solutions to tackle new challenges in cardio-oncology!

Byteflies is working towards a future where healthcare is fully personalized and preventive. Our diagnostic solution allows high quality, long-term and synchronized measurement of vital parameters and digital biomarkers with user-friendly patches and powerful data analytics, independent of where you are and optimized for your specific needs.

Interested to Learn More?

At Byteflies, we move mountains to enable wearable health. With our Absence & Focal Flows, we are monitoring seizures to improve the standard of care for people with epilepsy. With our Afib Flow, cryptogenic stroke patients are screened for cardiac risk factors much faster and with a user-friendly tool. Our technology allows pharmaceutical companies to monitor patients easily and objectively in clinical trials.

Interested in working with us to reduce cardiotoxicity due to cancer treatment? Curious to know what we can offer for your patients, project, or clinical trial? Contact us at hello@byteflies.com or via www.byteflies.com. We look forward to hearing from you!

The information contained in this article represents the views and opinions of the writer(s) and does not necessarily represent the views or opinions of other parties referenced or mentioned therein.

The article is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified healthcare professional with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you read in this article.

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