The Nordic Cardio-Oncology Society: mission and future goals

Based on a common wish to unite oncologists/haematologists and cardiologists and improve collaboration, the Nordic Cardio-Oncology Society (NCOS) is an encouragement for shared medical knowledge and performance of high-quality research with high clinical impact.

The Nordic Cardio-Oncology Society for collaboration and networking

The Nordic countries comprise Denmark, Finland, Iceland, Norway, and Sweden. By themselves the countries are small, but together they have a population of >27 million¹ (Figure 1), by number comparable to the population of Australia. The average age-standardized incidence rate for all cancers in the Nordic countries in 2020 was 300.7 per 100 000.¹ The leading cause of death is cardiovascular disease closely followed by cancer in all the Nordic countries, except for Denmark and Norway, where mortality due to cancer precedes cardiovascular mortality (Figure 1). With an increase from 7 to 597 hits of the word ‘cardio-oncology’ on PubMed in the year 2012 to the year 2022, cardio-oncology has proven a growing field of interest and research. In the 2022 European Society of Cardiology (ESC) cardio-oncology guidelines, 118 of the 156 class I recommendations were based on expert opinion (level of evidence C) and five were based on randomized data (level of evidence A).⁴ This should serve as a strong incentive to initiate clinical studies to fill in the gaps of knowledge.

Figure 1

The population, cancer incidence per 100 000, cancer mortality, and cardiovascular mortality for the Nordic countries in 2020^1–3

The health care systems in the Nordic countries are quite similar. At a large extent, they are publicly financed, giving the citizens an accessible and high-quality health care system. By initiating the NCOS, united forces among these countries allow sharing clinical experiences and collaboration in research, producing high clinical impact studies as has been inspired by other initiatives in the Nordic countries.^5,6 The NCOS was formally established in 2019,⁷ and the third meeting takes place in 2024.

Future research/collaboration goals

Across Scandinavia, an increasing number of multidisciplinary teams are managing cancer patients with acute and long-term cardiovascular damage after cancer treatment. There are many shared risk factors for cardiovascular disease and cancer including old age, obesity, and smoking, and these factors are very frequent in the general population. In addition, more and more diverse cancer therapies enter standard therapy. Most of these treatments were tested in highly selected patients with no or limited comorbidities, thus not reflecting the many cancer patients suffering from frailty, comorbidities, and multipharmacy in real life. Added to this picture, most clinicians only see few patients with severe cardio-oncological conditions, so the risk of not identifying the patients at risk of cardiovascular disease in the daily busy clinic is likely high.

The 2022 ESC cardio-oncology guidelines were very welcomed and helpful. It is now pivotal that the guidelines are implemented and followed, and that adherence to the guidelines is documented. The NCOS offers a society to stimulate the broadening and knowledge of the international guidelines by holding meetings and discussing adaption to fit the Nordic health system. There is high focus on having physical meetings as old fashion mingling facilitates clinicians and researchers to meet and start to collaborate, and these can then be followed by virtual meetings for further discussions and plans. The NCOS is an important platform to facilitate increased focus and knowledge on cardio-oncology aspects by structured education and faculty development.

Several important research questions lie just ahead and should be investigated. Firstly, the NCOS strongly encourages a prospective evaluation and harmonization of the ESC cardiovascular risk stratification tool in the Nordic collaboration. Secondly, Nordic countries are known for their high-quality registries; thus, a Nordic cardio-oncology initiative could be a way forward for documenting incidence and management of cardiovascular complications. For this to happen, the NCOS calls for definition to diagnose and code reflecting cardio-oncologic disease panorama. Lastly, acknowledging the complexity of cancer therapies and cardiovascular diseases, the NCOS would work diligently to encourage initiation of several phase IV studies investigating the cardiovascular risks when new treatments are approved and introduced as standard therapy. Much cancer treatment is highly complex, for example when combining new systemic therapies with each other or with radiation therapy. It is thought-provoking how little is known about the combination of the newer systemic therapies used for breast cancer when the patient also has radiation therapy. From another perspective, it could also be of high interest to identify cancer patients who are at high cardiovascular risk already before starting cancer therapy. An example of that is investigating the cardiovascular risk from irradiating lung cancer patients who have high levels of coronary calcifications.⁸ Surely, the ultimate goal is a Nordic collaboration on prospective clinical trials investigating cardio-oncological clinical questions of broad interest.

Future cancer therapy is not only targeted towards specific cellular and immunological signalling pathways but even personalized down to the molecular level. Consequently, cardio-oncological risk assessment and management during treatment and follow-up also need to embrace this perspective.

Conclusions

‘Talent wins games, but teamwork and intelligence win championships’. These words from Michael Jordan summarize the importance of collaboration in cardio-oncology across the Nordic boarders. By focusing on the same problems, we can do better clinical work and produce high-quality research.

Declarations

Disclosure of Interest

G.G.: President of the Nordic Cardio-Oncology Society.