Let's talk about cardio-oncology, in conversation with Dr. Fabio Turazza.

Over the past 40 years, cancer therapies have become increasingly effective and personalized. It has long been known that in some cancer patients, chemotherapy drugs such as anthracyclines (ACs), still among the most widely used and highly effective drugs for numerous types of cancer, from breast cancer to leukemia, could cause the onset of severe cardiomyopathy, often dilated, even years after their administration. It was soon realized that this cardiotoxicity of ACs was dose-dependent (although in some patients it occurred at relatively low doses) and, more importantly, that it was not reversible by discontinuing treatment.
Radiotherapy (RT) with irradiation that also involved the heart, as for example in thoracic lymphomas, could also cause early and, above all, long-term cardiovascular damage with the onset of cardiomyopathy and juvenile ischemic heart disease.
Cardio-oncology was therefore born with the aim of monitoring treated patients, studying the mechanisms of cardiotoxicity from chemotherapy and radiotherapy, in the hope of preventing its onset and carrying out appropriate therapies.

A growing number of cardiologists have dedicated themselves to studying cardiotoxicity related to oncology therapies and to ensuring that even heart patients who are unfortunate enough to develop cancer can benefit from the best available oncology therapies. All of this has been certified by the first cardio-oncology guidelines, published by the European Society of Cardiology in August 2022. (note)

While chemotherapy remains a cornerstone of cancer treatment, innovative drugs are now available that are more selective against certain molecular characteristics of tumors (targeted therapies), making them more sensitive to the action of specific drugs. Other therapies can direct and stimulate the patient's immune system to react and eliminate cancer cells (immunotherapy). All of this, combined with advances in radiotherapy and oncological surgery, allows for the cure of over 50% of cancer patients and the treatment, even with very long survival rates, of patients with advanced cancer.
The number of patients who are considered cured of cancer, or in whom the oncological disease is made “chronic” by the therapies available today, is therefore growing throughout the world.

In many long-term cancer survivors, the onset of treatment-related cardiotoxicity and age-related cardiovascular disease (CVD) requires a personalized assessment of the causative mechanisms in order to prevent potential complications and treat them appropriately.
Today, one of the primary goals of cardio-oncology is to ensure that all cancer patients, even those with pre-existing heart disease or cardiomyopathy, receive the best available oncology treatments. In this case, the cardio-oncologist must work alongside the oncologist from the beginning of the treatment process.

In-depth study of the mechanisms of cardiotoxicity of numerous oncology therapies has yielded many surprises and has led to the understanding that cardiovascular disease and cancer are actually linked by shared risk factors and partially overlapping pathophysiological mechanisms. There is a growing awareness that cancer and cardiovascular disease share common origins, from habits and lifestyles with shared risk factors, the best known of which is cigarette smoke in addition to a sedentary lifestyle, obesity, and alcohol abuse. They may also recognize similar familial genetic transmission patterns, obviously with the involvement of different genes. More rarely, for example, genetic mutations of the RAS system ("rasopathies”) can determine forms of cardiomyopathy, and also different forms of neoplasia.

Perform an accurate cardiac risk assessment of all cancer patients about to start anti-tumor therapies (chemotherapy, radiotherapy, molecularly targeted therapies, or immunotherapies, often in various combinations), in order to identify those at intermediate or high risk, such as patients with pre-existing heart disease or cardiomyopathy.
For all of these, dedicated follow-up strategies and closer monitoring plans will need to be designed, so as to be able to detect any signs of cardiotoxicity early and be able to intervene promptly, with the ultimate goal not to suspend "in time"oncological therapies but to continue them with the possible use of drugs capable of exerting the necessary "cardioprotection"In very high-risk patients, as they are identified and become available, preventive therapies for cardiotoxicity may be used, always keeping in mind the primary objective of ensuring that all cancer patients receive the best available treatments, even when they have a high-risk profile.
It's very important to emphasize that cardiovascular prevention (healthy lifestyle, control of conventional risk factors such as hypertension, diabetes, dyslipidemia, smoking, a sedentary lifestyle, and emerging ones such as obesity and inflammation) is actually also cancer prevention. Naturally, this is even more important for heart patients, with cancer prevention that can be targeted, also based on their family history (e.g., uterus, breast, prostate, colon, skin, etc.).

2022 ESC Guidelines on cardio-oncology developed in collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO) and the International Cardio-Oncology Society (IC-OS): Developed by the task force on cardio-oncology of the European Society of Cardiology (ESC). Alexander R Lyon, et al.

(Note) Cardiovascular disease in adult cancer survivors: a challenge for all cardiologists (and others)
FM Turazza, in press, Italian Journal of Cardiology 2025