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Cardio-oncology rehabilitation for patients with cancer and survivors


(From Gilchrist SC, Barac A, Ades PA et al. Cardio-oncology rehabilitation to manage cardiovascular outcomes in patients with cancer and survivors: a scientific statement from the American Heart Association. Circulation . 2019;139(21):139 e997–e1012.)

KEY POINTS

  • Patients with cancer experience an increased risk of developing cardiovascular diseases owing, in part, to the direct effects of cancer treatments (cardiotoxicity), a high prevalence of standard cardiovascular risk factors, and deconditioning associated with a decrease in cardiorespiratory fitness.

  • Cardiorespiratory fitness, which is inversely related to cardiovascular risk, is approximately 30% lower in patients with cancer than in healthy persons.

  • In breast cancer survivors, a strong, graded relationship between the amount of habitual physical activity and the incidence of coronary artery disease and heart failure has been established. Patients in the top tertile of physical activity experience an approximately 35% reduction in cardiovascular endpoints.

  • Exercise training guidelines have been published for patients with cancer but are achieved by less than one third of patients. Exercise training in patients with cancer results in reduction in symptoms and improvement in quality of life and cardiorespiratory fitness.

  • A 2019 American Heart Association scientific statement, endorsed by the American Cancer Society, recommends partnering with existing multidimensional, interdisciplinary cardiac rehabilitation programs to provide cardio-oncology rehabilitation (CORE).

  • CORE will include standard cardiac rehabilitation components and interventions, as follows, with cancer-specific features: patient assessment; nutrition counseling; management of weight, blood pressure, blood lipids, and diabetes; tobacco cessation; psychosocial management; physical activity counseling; and exercise training.

  • CORE is a novel concept in the care of patients with cancer. Widespread implementation will require development of a robust evidence base and a strategy for reimbursement.

Interrelationship of cancer and cardiovascular diseases

There are approximately 17 million survivors of cancer in the United States. Many of these patients are at increased risk of noncancer maladies, primarily cardiovascular diseases, such as coronary artery disease and chronic heart failure. Persons who survive at least 5 years beyond a cancer diagnosis experience a 1.3- to 3.6-fold increase in cardiovascular mortality and a 1.7- to 18.5-fold risk of developing cardiovascular diseases. , With current treatments, improvements in cancer-specific mortality have resulted in cardiovascular diseases becoming more problematic for cancer survivors. Some of the heightened cardiovascular risk is owing to age-related pathology, direct effects of cancer treatments (cardiotoxicity), and indirect effects of cancer treatment, such as deconditioning and an increase in body fat stores.

Cancer and cardiovascular disease are interrelated and share common risk factors, such as cigarette smoking, a diet rich in animal fat, dyslipidemia, obesity, chronic inflammation, sedentary lifestyle, and diabetes mellitus. , Preexisting cardiovascular disease is present in approximately 20% to 30% of patients with cancer. Compared with healthy controls, those with cancer report reduced health-related quality of life with persistent fatigue as a common feature. Cancer-related fatigue is general in nature, not relieved by rest or sleep, and may persist for months to years after remission.

Cardiovascular risk factors that are present before a cancer diagnosis are strong predictors of chemotherapy and radiation-related cardiovascular diseases. In addition, cancer survivors are more likely than healthy controls to have hypertension and diabetes. For 2-year survivors of adult-onset cancer, survivors with at least two cardiovascular risk factors had a higher risk of cardiovascular diseases (incidence rate ratio 1.8 to 2.6) compared with healthy controls. There was a 3.8-fold increased risk of all-cause mortality in cancer survivors who developed cardiovascular diseases compared with survivors without cardiovascular diseases.

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