The advancement of oncologic treatments has radically transformed the prognosis of millions of patients worldwide. Today, more people live longer after a cancer diagnosis, and in many cases, the disease is no longer immediately fatal but instead becomes a treatable or even controllable condition in the long term. However, this progress has brought with it a new clinical challenge that is becoming increasingly relevant: the cardiovascular impact of cancer therapies.
In this context, in an article published in Canadian Family Physician, a fundamental but often underestimated topic in clinical practice is addressed: the cardiotoxicity associated with cancer treatments. Far from being an isolated side effect, cardiovascular involvement currently represents one of the leading causes of morbidity and mortality in cancer patients, even doubling the risk of cardiovascular disease compared to the general population.
This translates into the fact that cancer treatment can no longer be understood solely from a tumor-centered perspective. Each therapeutic intervention must also be evaluated for its systemic impact, particularly on the cardiovascular system, which is highly susceptible to multiple forms of injury induced by therapies such as chemotherapy, radiotherapy, targeted therapies, and immunotherapy. This integrative vision has led to the development of an emerging field known as cardio-oncology, whose goal is precisely to balance oncologic efficacy with cardiovascular safety.
One of the most relevant aspects highlighted in the article is that the risk of cardiotoxicity does not depend solely on the treatment itself, but also on the patient’s baseline condition. Factors such as hypertension, diabetes, obesity, smoking, or a sedentary lifestyle not only influence general cardiovascular risk but can also significantly amplify the adverse effects of cancer therapies. This implies that the management of cancer patients should begin even before the initiation of treatment, through a comprehensive evaluation of cardiovascular risk and the optimization of these modifiable factors.
At this point, the role of the primary care physician becomes critically important. Beyond specialized treatment, these professionals are the ones who best understand the patient’s clinical history and who can identify early signs of risk or decompensation. Their involvement is not only key in prevention but also in long-term follow-up, as some cardiovascular complications may appear even years after the completion of cancer treatment.
From a mechanistic perspective, cardiotoxicity can manifest in multiple ways depending on the type of therapy used. In the case of chemotherapy, especially with agents such as anthracyclines (for example, doxorubicin or epirubicin), damage may present as myocardial dysfunction (when the heart muscle loses its ability to pump effectively) or heart failure (when the heart cannot deliver sufficient blood to the body), due to direct effects on cardiac muscle cells, mainly through the generation of reactive oxygen species (oxidative stress) that damage mitochondria and cellular structures.
On the other hand, radiotherapy, particularly when administered to the chest, can induce acute inflammation such as pericarditis (inflammation of the membrane surrounding the heart), as well as late effects including coronary artery disease (damage to the arteries of the heart), valvular abnormalities (problems in the heart valves that regulate blood flow), and cardiac fibrosis (hardening or scarring of heart tissue), largely due to progressive damage to blood vessels and connective tissue exposed to radiation.
More modern therapies are not exempt from this issue. Targeted therapies, such as HER2 inhibitors (for example, trastuzumab) or antiangiogenic agents (such as bevacizumab or sunitinib), can alter vascular function and increase the risk of hypertension, thrombotic events (formation of clots that can obstruct vessels), or ventricular dysfunction (impairment in the heart’s pumping ability), due to their effects on signaling pathways that also play a role in maintaining normal vascular function.
Figure 1. Cancer therapies can affect the heart through different mechanisms that converge on cardiovascular injury. These effects may appear during or after treatment, highlighting the importance of anticipating and monitoring potential cardiac complications.
Similarly, immunotherapy, particularly immune checkpoint inhibitors (such as nivolumab or pembrolizumab), has been associated with events such as myocarditis (inflammation of the heart muscle), a rare but potentially serious complication that occurs when the activated immune system attacks not only the tumor but also healthy tissues such as the heart. Even more recent therapies, such as CAR-T cells, can trigger cardiac dysfunction in certain clinical contexts, partly related to intense inflammatory responses in the body.
This landscape highlights that the success of cancer treatment cannot be measured solely in terms of tumor control, but also in the ability to preserve the patient’s overall health. In this sense, cardiovascular monitoring becomes an essential tool. Baseline evaluations, periodic follow-up, and the use of tests such as electrocardiograms, biomarkers, or imaging studies allow for the early detection of potential complications and intervention before they become irreversible.
A particularly relevant aspect is that many of these complications are not immediate. Cardiovascular damage can develop silently and manifest years later, making long-term follow-up a fundamental component of oncologic care.
Each therapeutic advance brings new challenges, and cardiotoxicity is one of the most relevant today. Integrating cardiovascular prevention, continuous monitoring, and interdisciplinary collaboration not only improves patients’ quality of life but also redefines what we understand as successful treatment.
Because today, more than ever, the goal is not only to live longer… but to live better.
Main reference:
Shuel S. L. (2024). Cardiotoxicity of cancer treatment. Canadian family physician Medecin de famille canadien, 70(10), 629–631. https://doi.org/10.46747/cfp.7010629
Other references:
Stoltzfus, K. C., Zhang, Y., Sturgeon, K., Sinoway, L. I., Trifiletti, D. M., Chinchilli, V. M., & Zaorsky, N. G. (2020). Fatal heart disease among cancer patients. Nature communications, 11(1), 2011. https://doi.org/10.1038/s41467-020-15639-5
Gilchrist, S. C., Barac, A., Ades, P. A., Alfano, C. M., Franklin, B. A., Jones, L. W., La Gerche, A., Ligibel, J. A., Lopez, G., Madan, K., Oeffinger, K. C., Salamone, J., Scott, J. M., Squires, R. W., Thomas, R. J., Treat-Jacobson, D. J., Wright, J. S., & American Heart Association Exercise, Cardiac Rehabilitation, and Secondary Prevention Committee of the Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; and Council on Peripheral Vascular Disease (2019). Cardio-Oncology Rehabilitation to Manage Cardiovascular Outcomes in Cancer Patients and Survivors: A Scientific Statement From the American Heart Association. Circulation, 139(21), e997–e1012. https://doi.org/10.1161/CIR.0000000000000679
Martín García, A., Mitroi, C., Mazón Ramos, P., García Sanz, R., Virizuela, J. A., Arenas, M., Egocheaga Cabello, I., Albert, D., Anguita Sánchez, M., Arrarte Esteban, V. I., Ayala de la Peña, F., Bonanand Lozano, C., Castro, A., Castro Fernández, A., Córdoba, R., Cosín-Sales, J., Chaparro-Muñoz, M., Dalmau, R., Drak Hernández, Y., Deiros Bronte, L., … López Fernández, T. (2021). Stratification and management of cardiovascular risk in cancer patients. A consensus document of the SEC, FEC, SEOM, SEOR, SEHH, SEMG, AEEMT, AEEC, and AECC. Revista espanola de cardiologia (English ed.), 74(5), 438–448. https://doi.org/10.1016/j.rec.2020.11.020
