Editor's Note: With the continuous advancement of cancer treatment technologies, the survival rate of cancer patients has significantly improved, but the issue of cardiac safety during antitumor therapy has increasingly become a clinical focus. In this context, cardio-oncology has emerged as an important interdisciplinary field. At the "2024 CACA Integrated Breast Cancer Conference," during the breast cancer integration and rehabilitation session, Dr. Fengqi Fang from The First Affiliated Hospital of Dalian Medical University shared her insights on "Cardiac Safety Management in Antitumor Therapy for Breast Cancer." After the session, "Oncology Frontier" interviewed Professor Fang on the latest research and future directions in cardio-oncology.

01

Oncology Frontier: You shared on “Cardiac Safety Management in Antitumor Therapy for Breast Cancer” at the conference. Could you discuss the current research hotspots and challenges in cardio-oncology?

Dr. Fengqi Fang: Thank you for your interest in cardio-oncology. Cardiovascular diseases and cancer are major global health threats. Increasing evidence shows that cancer and cardiovascular diseases influence each other. For instance, heart failure patients have a higher risk of developing cancer, which promotes tumor growth. Cancer can cause systemic metabolic, inflammatory, and microbial changes, leading to cardiac dysfunction. Besides common pathophysiological mechanisms, antitumor therapies (chemotherapy, immunotherapy, targeted therapy, radiotherapy) can also cause cardiovascular toxicity.

Research hotspots in cardio-oncology include the unclear common pathophysiological mechanisms between cardiovascular diseases and cancer. Multidisciplinary collaboration is essential to explore these mechanisms. Cardiologists and oncologists need to work together to translate research advances into patient care measures, exploring the common pathogenesis of cardiovascular diseases and cancer through basic, translational, and clinical research to address the growing health issues at the intersection of these fields.

A current challenge is identifying high-risk groups for cardio-oncology. The “2022 ESC Guidelines on Cardio-Oncology” proposed the HFA-ICOS score: a cardiovascular baseline risk assessment for seven antitumor drugs. Each score is complex, making it difficult for clinicians to master and apply in clinical settings. Our center developed a “Cardio-Oncology Assessment and Screening Model” (CO-GPT) to facilitate clinical application and promote the development of cardio-oncology.

02

Oncology Frontier: How can clinicians better identify and monitor cardiac toxicity reactions in cancer patients?

Dr. Fengqi Fang: The best time to prevent cardiovascular diseases in cancer patients is at the time of cancer diagnosis and before starting treatment. It is recommended to conduct baseline cardiovascular risk assessments for all patients undergoing potentially cardiotoxic antitumor therapies.

Current baseline cardiovascular toxicity assessment includes evaluating based on the type of antitumor drug. The “2022 ESC Guidelines on Cardio-Oncology” recommend the HFA-ICOS scoring system for assessing baseline cardiovascular disease risk for seven types of antitumor drugs (e.g., anthracyclines, HER2 inhibitors, VEGF inhibitors, BCR-ABL inhibitors/proteasome inhibitors and immunomodulatory drugs, RAF and MEK inhibitors, GnRH & ADT).

Another approach is evaluating specific cardiovascular disease risks, such as the Systematic Coronary Risk Estimation 2 (SCORE2, ages 40-69) and the Elderly SCORE2 (SCORE2-OP, ages 70-89). The “2022 ESC Guidelines on Cardio-Oncology” recommend using SCORE2 and SCORE2-OP to predict the 10-year risk of cardiovascular disease in breast cancer patients requiring endocrine therapy. Before starting treatment, patients undergoing antitumor therapy should be classified into low, medium, high, and very high cardiovascular risk categories to help clinicians consider cardiovascular risk when devising cancer treatment plans and improving treatment methods. The HFA-ICOS risk assessment tool and monitoring algorithm need validation in clinical practice. The European SCORE system is not suitable for the Chinese population. Models based on Western populations do not meet the cardiovascular disease risk assessment needs in China. Therefore, developing a cardiovascular disease scoring system suitable for the Chinese population and cancer patients is a future focus.

03

Oncology Frontier: How can we balance antitumor efficacy with cardiac safety management in cancer patients? Are there specific strategies or methods?

Dr. Fengqi Fang: Managing cardio-oncology patients requires maximizing cancer treatment efficacy and minimizing cardiovascular toxicity risks. The significant advances in cancer treatment in recent years have remarkably improved the long-term prognosis of cancer patients. We are excited about the survival benefits brought by new antitumor drugs, although we may not yet fully understand the cardiovascular toxicity of each drug. For cancer patients with cardiovascular risk factors or existing cardiovascular diseases, continuous cardiovascular monitoring throughout the treatment provides an opportunity for early identification and management of potential cardiovascular complications.

Common monitoring methods include electrocardiograms, cardiac biomarkers (troponin I/T, BNP/NT-proBNP), and echocardiography. Oncologists should be familiar with primary prevention methods for cardiovascular toxicity to avoid or reduce the risk of cardiovascular diseases developing into treatment-related cardiovascular toxicity. Secondary prevention should be provided for patients with existing cardiovascular diseases, with multidisciplinary consultations if necessary, to ensure the smooth progression of cancer treatment.

04

Oncology Frontier: What technological or methodological breakthroughs do you foresee in managing cardiac safety in breast cancer antitumor therapy?

Dr. Fengqi Fang: The HFA-ICOS scoring tools for different antitumor drugs are complex, and the individual monitoring processes for different risk stratifications are varied. There is an urgent need for convenient clinical risk stratification and monitoring tools. The rise of artificial intelligence (AI) offers efficient and convenient assessment methods. The emergence of Chat-GPT has brought large language model technology into practical applications. The First Affiliated Hospital of Dalian Medical University, in collaboration with leading domestic chip and supercomputing centers, has established the CO-GPT model for cardio-oncology screening and assessment. CO-GPT can automatically integrate patients’ medical data, extract and store it based on medical needs, assist physicians in optimizing diagnostic and treatment processes, and perform automatic grading according to international guidelines, completing multidisciplinary consultations with CO-GPT’s involvement.

Building a Chinese cardio-oncology research collaboration group to involve national multi-center teams, leveraging multi-center platforms to apply extensive clinical evidence to optimize CO-GPT, aims to achieve large-scale standardized high-quality research data collection and management for cardiovascular health follow-ups in cancer patients. This will help establish clinical guidelines and assessment standards suitable for the Chinese population, translating research outcomes into clinical practice.

In recent years, many national and international cardio-oncology groups have been established to promote the development of the field, providing more professional assessment, monitoring, follow-up, and intervention measures for patients. Most patients are examined in cardiology departments, which may not meet the growing clinical demand. More experts from oncology, hematology, cardiology, and radiotherapy need to be involved. Collaboration among healthcare providers, clinical, and basic researchers is essential to meet future needs. It is crucial to play a significant role in education, awareness, and clinical research in cardio-oncology.

Strengthening research training and clinical education in cardio-oncology, conducting medical training courses, including cardiology, oncology, hematology, and other specialties, will help more interdisciplinary doctors understand and optimize the prevention, diagnosis, treatment, and management of cardiovascular toxicity in antitumor therapy, improving cancer patient care.

A thousand miles begins with a single step. Cardio-oncology still faces significant challenges. In the future, the field will focus more on exploring interdisciplinary areas like artificial intelligence, integrating new technologies to establish a more comprehensive prevention and control system and standardized diagnosis and treatment processes, creating greater social value. Ensuring the cardiovascular health of cancer patients remains a priority.

Dr. Fengqi Fang

• MD, Doctoral Supervisor
• Deputy Director of the Department of Oncology, The First Affiliated Hospital of Dalian Medical University
• Executive Member of the Breast Cancer Rehabilitation Professional Committee, Chinese Anti-Cancer Association (CACA)
• Member of the Cancer Heterogeneity and Personalized Treatment Professional Committee, CACA
• Member of the Integrated Cardio-Oncology Branch, CACA
• Standing Committee Member and Secretary-General of the Cardio-Oncology Expert Committee, Chinese Society of Clinical Oncology (CSCO)
• Member of the New Drug Development Expert Committee, CSCO
• Secretary of the Cardio-Oncology Group, Cardiovascular Disease Branch, Chinese Medical Association (CSC)
• Member of the Young Committee, Breast Cancer Committee, Beijing Cancer Prevention and Treatment Society
• Director of the Breast Cancer Professional Committee, Liaoning Cell Biology Society
• Member of the Oncology Branch, Liaoning Medical Association
• Deputy Chairman of the Oncology Specialist Committee, Dalian Medical Association
• Deputy Secretary-General of the Health Medicine Branch, Dalian Sino-Japanese Economic Cooperation Exchange Association
• Previously studied and exchanged at Kitakyushu Municipal Medical Center in Japan
• Specializes in breast cancer, cardio-oncology, and clinical medical research in tumor artificial intelligence diagnosis