Reducing Cancer Therapy’s Toll on the Heart

September 8, 2023

Evolent is leveraging our expertise in two key specialties to reduce cardiovascular damage related to cancer drugs.

Cancer patients often face a cruel reality: To treat one disease, they risk developing another one. Cardiotoxicity — the direct damage to the heart by anti-cancer agents—is a significant risk in many cases. For example, up to 1 in 10 patients who receive an anthracycline, such as doxorubicin, experience a weakening of the heart's ability to pump blood one year after the start of treatment.1

In some cases, cardiotoxicity can be monitored and managed without interrupting anticancer therapy — for instance, through the early initiation of heart failure medications. In others, it may prompt a switch to other treatments that may be less effective, or discontinuation of therapy. Its most serious and long-lasting outcomes include heart failure. Cardiovascular comorbidities are a leading cause of death in cancer survivors 10 years after their diagnosis.2

Given the serious impacts of cardiotoxicity and published studies suggesting there is much room for improvement, Evolent is taking steps to identify and address gaps in cardio-oncology. 

Adherence to Heart Monitoring Guidelines

Routine monitoring of heart function is a key step for detecting damage to the heart, managing it and preventing further damage. While numerous medical societies in recent years have issued guidelines outlining which patients should receive this monitoring, and how often, large portions of patients still don't receive them. For example:

  • 21-27% of patients did not receive the guideline-recommended baseline cardiac monitoring four months before the start of trastuzumab-based therapy.3, 4
  • 53-64% of patients did not receive guideline-directed cardiac monitoring every three to four months while being treated with trastuzumab.3, 4, 5

Monitoring at appropriate intervals is important because the impacts of some anti-cancer agents, such as anthracyclines, are cumulative. Each dose can result in further injury to the heart.

A Health Equity Component

Cardiotoxicity does not affect all patient populations equally. Underserved groups tend to have higher incidence of cardiovascular damage from their cancer therapy, as well as greater risk of death related to it. For example, the percentage of Black women who developed cardiotoxicity one year after the start of adjuvant HER2-targeted therapy was more than three times that of white women (24% vs. 7%).6 The percentage of Black patients who did not complete their therapy was more than 4.5 times higher than white women in the same study.

Evolent Improvement Efforts

Evolent is launching a pilot program that seeks to prevent cardiotoxicity through adherence to monitoring guidelines across all patient groups. Starting with one health plan partner, we are:

  • Leveraging baseline data to measure the frequency of appropriate cardiac monitoring for patients receiving cardiotoxic therapies.
  • Identifying subgroups of patients who are less likely to receive recommended cardiac monitoring before, during or after anticancer therapy.
  • Conducting outreach to oncologists to show them their baseline data, help them understand any gaps and educate them on the importance of this initiative. After this education, we will feed back quarterly performance data to these providers.
  • Working with providers to ensure that all eligible patients on cardiotoxic therapy receive  cardiac studies per guidelines. Interventions include automated reminders in our decision support system, as well as peer-to-peer conversations.
  • Expediting appropriate cardiac studies by auto-approving them through our clinical decision support system.

We hope that comprehensive cardiac monitoring before cancer treatment, with early referrals to cardio-oncology specialists for subsequent studies, will improve clinical outcomes among high-risk and underserved populations while delivering cost-savings for our partners.

Risk Factors for Cancer Therapy- Related Cardiomyopathy Include:
  • Female gender
  • Black race
  • Coronary artery disease
  • Hypertension
  • Diabetes
  • Preexisting heart failure and cardiomyopathy
  • Previous exposure to anthracyclines
  • Genetic polymorphism
  • Previous chest radiation
  • Prior elevated troponin
  • Elevated N- terminal pro-brain natriuretic peptide 

Sources: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure and J Clin Oncol. 2007; 25:3991–4008. doi: 10.1200/JCO.2007.10.9777

1  JCO Oncology Practice 17, no. 5 (May 01, 2021) 228-236. doi: 10.1200/OP.20.00924.
 Cancers (Basel). 2020 Dec 11;12(12):3737. doi: 10.3390/cancers12123737.
3  JACC: Cardiovascular Imaging, Volume 11, Issue 8, 2018, Pages 1084-1093,
4  J Clin Oncol. 2015 Jul 1;33(19):2176-83. doi: 10.1200/JCO.2014.58.9465.
 J Am Coll Cardiol CardioOnc. 2020 Jun, 2 (2) 166–175.
6  Cancer. 2018 May 1;124(9):1904-1911. doi: 10.1002/cncr.31260.

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