Cardio-Oncology in Brazil: The Dimensions of a New Era in the Care of Patients.

Occupying nearly one-half of South America’s landmass, Brazil is the largest country of the continent. The country has a diverse range of tropical and subtropical regions, with wetlands, grassy plains (known as savannahs), and low mountainous landscapes. That diversity also extends to the presence of many regional and social inequalities, including severe income inequality. In 1988, the Brazilian Constitution defined health as a universal right, and in 1990, a Unified Health System (Sistema Único de Saúde) was created to deliver access to health care for a substantial proportion of the population (1,2). However, in the last 10 years, there have been significant changes in mortality and morbidity primarily related to demographic and epidemiological transitions, including aging of the Brazilian population and inequities in income and housing. The majority of the population lives in impoverished conditions with scarce access to health care resources, imposing significant challenges to a health care system organized to provide predominantly acute care.

Diseases of the cardiovascular (CV) system became the leading cause of death in Brazil, followed by cancer and external causes, such as homicides and traffic accidents (1,2). Therefore, an urgent transformation in health care was needed. In this context, cardio-oncology in Brazil was developed as a specialty in 2010, when the Brazilian Societies of Cardiology and Oncology convened a group of 40 specialists to discuss what had become a Brazilian reality, acknowledging the increased prevalence of common risk factors for cardiovascular disease (CVD) and cancer and the critical goal of improving health care for these patients. We developed the “Brazilian Guidelines of Cardio-Oncology” to enable and guide physicians and other health care professionals to prioritize the prevention, diagnosis, and management of CVD in cancer patients (3). The formation of the International Cardio-Oncology Society in 2009 further stimulated growth of this relatively new medical discipline in Brazil. Since then, we have initiated a productive international collaboration with countries such as the United States of America, Canada, and the United Kingdom, promoting international annual meetings in Brazil in the field of cardio-oncology. Cardio-oncology topics were included in the scientific program of the Brazilian medical meeting of Cardiology and of the Brazilian medical meeting of Oncology, events that brought together approximately 20,000 participants. Knowledge of cardio-oncology as an important medical discipline was furthered by the introduction of preceptorships, trainings, and courses.

The University of São Paulo, with the integration of the Cancer Institute and of the Heart Institute (with 1,000 beds in total), implemented a Program of Cardio-Oncology to comprehensively assess the CV health of cancer patients before treatment, to optimize the management of pre-existing cardiac diseases, and ultimately, to decrease CV complications during and after cancer therapy. An integrated and comprehensive care model involving a multidisciplinary team of providers was understood as necessary to achieve better outcomes for these patients. Many specialties are an essential component of such patients’ care, including oncology, hematology, cardiology, oncologic surgery, cardiac surgery, interventional cardiology, radiology, palliative care, hospital pharmacy, psychology, social work, genetics, intensive care, pharmacy, and rehabilitation (4).

In 2017, we created the first fellowship program on cardio-oncology. The objective of this fellowship is to enable cardiologists to specialize in the CV care of cancer patients, including training in clinics, acute care, biomarkers, CV imaging, oncology, and hematology. Currently, 16 physicians have completed the fellowship, and the majority are now leaders of cardio-oncology programs in all 5 regions of Brazil (North, Northeast, Center-West, Southeast, and South). In 2019, we had the privilege of hosting the Global Cardio-Oncology Summit in São Paulo, Brazil, which is an interdisciplinary international meeting aimed at enhancing knowledge regarding the potential CV complications that may develop in cancer patients. The meeting had 587 participants, the highest number of attendees to date, including cardiologists, oncologists, hematologists, physiotherapists, nurses, pharmacists, researchers, and students. During the meeting, specific topics were comprehensively discussed. Such topics included precision medicine; basic and translational mechanisms of cardiotoxicity; prevention, early diagnosis, and treatment of CV complications during cancer therapy; the need for implementing evidence-based research and treatment to improve outcomes; biomarkers and imaging in clinical practice; and the generation and dissemination of knowledge to our multidisciplinary community (5).

The recognition of cardio-oncology as a crucial medical discipline by Brazilian health care professionals was further demonstrated by the release of the first issue of JACC: CardioOncology in September 2019 (6). One of the authors (L.A.H.) was honored to be invited to serve as an International Advisor for this prestigious journal. Since then, regular journals clubs have been established in São Paulo to discuss the research and review articles from JACC: CardioOncology, aiming to educate students and health care professionals and to advance the development of this growing field. The ongoing goal is to enhance the quality of care due to obtaining and applying robust scientific evidence via patient-centered medicine both with a collaborative multidisciplinary team and patient and community engagement.

For several months now, the world has been facing the coronavirus disease 2019 (COVID-19) pandemic. Brazil is now experiencing one of the most challenging times in its history since 1918, when millions of people died from what was called “Spanish flu.” Our Unified Health System is under significant stress, with more than 90% of hospital beds occupied, approximately 162,000 people known to be infected with the virus, and about 11,000 deaths due to COVID-19 (7). Patients with cancer and CVD are particularly vulnerable. Depressed immunity in patients with cancer and poor physiological reserve combined with direct cardiotoxicity in patients with CVD increase the risk of severe disease and adverse outcomes (8). In addition, in recent days, reports from New York have described increasing rates of mortality due to CVD (6 times higher when compared with the previous year) (9). Many patients may have been reluctant to seek medical care due to fears of contracting the virus; may have had their follow-up visits postponed or routine cancer screenings rescheduled; may have themselves postponed chemotherapy or other necessary cancer treatments; and may have had elective surgeries postponed (where, unfortunately, some cancer surgeries as well as cardiac interventional procedures may be considered “elective”). Further, many patients may have been wary of going to potentially crowded hospitals or other medical facilities even if they developed serious symptoms possibly associated with the virus or had other medical emergencies secondary to their cancer, CVD, and/or other comorbidities. All of these factors have contributed to a higher risk of worse outcomes in cancer patients with CVD. Brazil has just started a national registry to identify and better characterize drug cardiotoxicity in the context of COVID-19. In addition, a specialized plan of care has been established in Brazil to safely care for cancer patients regarding CV risk and monitoring, with the goal of improving outcomes without risk (10).

After 10 years of clinical practice in cardio-oncology, the Brazilian Societies of Cardiology and Oncology define cardio-oncology as an evolving field of medicine, with the clear objectives of delivering the best care to cancer patients and preventing and managing CV complications based on the best available scientific evidence. In the near future, we hope to further deepen knowledge in cardio-oncology, applying the concepts of patient-centered care, and improving both oncology and CV outcomes for these patients.