Cardiac Oncology: We Save Patients, but the Heart Remains Unprotected… Prof. Lilia Demirevska Speaks to FAKTI

Cardio-oncology is establishing itself as one of the fastest growing medical fields, but in Bulgaria it still remains underappreciated and underdeveloped. Modern anti-tumor therapies significantly increase the survival rate of cancer patients, but often lead to serious cardiovascular complications. This poses new challenges for doctors and requires close cooperation between cardiologists and oncologists. How are we coping… Prof. Liliya Demirevska speaks to FAKTI – member of the Board of the Society of Cardiologists in Bulgaria, chairman of the working group on cardio-oncology at the Society and part of the team of the Cardiology Clinic of the Military Medical Academy.

- Prof. Demirevska, why and what has forced cardio-oncology to develop so dynamically in recent years?
- Modern anti-tumor therapy has significantly increased the survival rate of cancer patients. At the same time, however, some of these therapies lead to heart damage and can cause practically the entire spectrum of cardiovascular complications - from functional disorders to serious and long-term cardiological problems. This is where cardio-oncology comes in - as an interdisciplinary field that aims to reduce the risk of these complications through active monitoring of patients and the application of modern prophylactic and therapeutic approaches.

- What tumors does the heart develop?
- Tumors of the heart are extremely rare - occur in approximately 1 to 30 cases per 100,000 people. They are divided into primary and metastatic. The most common primary tumor of the heart is myxoma, which is usually benign, but can lead to serious clinical manifestations depending on its localization.

- Where do cardiac and oncological problems intersect when we talk about cardiology?
- Heart and oncological diseases intersect on several levels. First of all, they “share“ common risk factors such as smoking, obesity, diabetes mellitus and others, which means that patients with oncological diseases often have an increased cardiovascular risk from the beginning.
In addition, some antitumor therapies can not only cause direct toxic damage to the heart muscle, but also affect cardiac risk indirectly – for example, by increasing cholesterol levels, blood pressure or by provoking vascular spasms. All this makes the treatment of the oncological patient a complex process that requires close cooperation and coordination within a multidisciplinary team.

- What are the most common cardiotoxic effects of modern antitumor therapies that you observe in practice?
- The most common cardiotoxic effects of modern antitumor therapies that we observe in practice include the development of heart failure, arterial hypertension and various types of arrhythmias, some of which can be life-threatening.
Ischemic heart disease is also common, as well as thromboembolic complications - deep vein thrombosis and pulmonary embolism. In certain cases, myocarditis may also develop.
These complications require active monitoring and timely behavior in order to limit the risk and improve the overall prognosis for the patient.

- To what extent is the Bulgarian healthcare system prepared to detect and control these complications in a timely manner?
- Unfortunately, at present, the Bulgarian healthcare system does not have clearly regulated requirements for monitoring cardiac complications in oncology patients. Effective control in this area requires additional resources - both for studies such as echocardiography, specific imaging methods and biomarkers, and for developing behavioral algorithms tailored to our conditions.
In addition, there is a lack of sufficiently trained specialists in the field of cardio-oncology. For these reasons, at this stage, cardiac monitoring of patients often remains a matter of personal initiative and professional commitment of individual doctors.

- What are the most effective approaches for preventing cardiac damage in oncology patients?
- The most effective approaches include a thorough preliminary assessment of cardiovascular risk factors and existing diseases before or in parallel with the start of antitumor therapy. This allows for early identification of patients at increased risk and individualization of the therapeutic approach. During treatment, patients are monitored according to different protocols, tailored to the type of antitumor therapy applied and their individual risk.

- Do cardiologists and oncologists work closely enough in our country, or is there still a lack of coordination?
- Unfortunately, there are still few hospitals in Bulgaria that work in conditions of real close cooperation between cardiologists and oncologists. The lack of structured cardio-oncology teams leads to a certain fragmentation in patient care. The Military Medical Academy is an example of good practice in this regard - in our country, high-risk patients are discussed individually, and decisions are made in a multidisciplinary team. This determines the most appropriate behavior both in terms of oncological treatment and the patient's cardiovascular condition.

- How are cardio-oncological problems defined in the Health Insurance Fund. Are there such clinical pathways and how are they financed?
- Currently, the Health Insurance Fund lacks a clearly defined vision for cardio-oncological problems, and hence for possible solutions.

- What challenges does cardio-oncological care in Bulgaria face?
Currently, cardio-oncological care in Bulgaria has not yet been established as a standard part of the treatment of these patients. Individual hospitals are making efforts to build such a practice, but this often happens at the expense of the medical institutions themselves. This is also one of the reasons why some of the additional tests necessary for adequate follow-up are not routinely applied.