Cardiovascular impacts of combination cancer therapies in Africa: challenges and solutions

Abstract

Background

In Africa, deaths from non-infectious causes, including cancer, have been rising. In 2022, over a million new cancer cases were reported, and projections indicate that this number could double by 2040 without significant interventions. To improve cancer management, combination treatments often including systemic therapies, radiotherapy, and surgery are employed, however, they pose the risk of cardiotoxicity. Given the growing burden of cancer and the associated cardiovascular complications, it is essential to evaluate the cardiovascular outcomes of combination cancer therapies in African populations, identify challenges faced by healthcare systems, and propose strategies to mitigate these risks.

Main body

Several anti-cancer agents, including anthracyclines, HER2 inhibitors, immune checkpoint inhibitor myocarditis, VEGF inhibitors, 5-fluorouracil, etc., have been linked to cardiovascular complications. These include left ventricular dysfunction, immune myocarditis, coronary spasms, and oxidative stress-induced cardiomyocyte death amongst others. The field of cardio-oncology has emerged to address these risks and improve patient outcomes. African health systems face unique challenges in managing cardiovascular risks associated with cancer therapies. These include delayed diagnosis and limited screening, resource constraints, underrepresentation in clinical trials, comorbidities, and socioeconomic barriers. These factors hinder early detection and management of cardiovascular complications, exacerbating the burden of treatment-related morbidity and mortality.

Conclusion

As the burden of cancer continues to rise in Africa, addressing cardiovascular complications associated with cancer therapies is critical. Strengthening cardio-oncology programs, improving early screening, and increasing access to cardiovascular care within oncology settings are essential steps toward better patient outcomes. By addressing existing gaps and resource limitations, African healthcare systems can enhance cancer treatment while minimizing the attending cardiovascular risks.

Background

Recent measures in the African health sectors such as widespread vaccination have significantly reduced deaths from infectious diseases [1]. Sustained health interventions between 2000 and 2017 led to dramatic declines in mortality from major infectious diseases in several African countries, surpassing 50% in some cases [2]. However, deaths from non-infectious causes are on the rise, particularly cancer [1]. The International Agency for Research on Cancer (IARC) in 2022, estimated 1,185,216 new cases of cancer in Africa, where the age-standardized incidence rate for both sexes was 132.3 per 100,000 population, and the number of cancer deaths in 2022 alone was 763,843 [3]. If unaddressed, cancer cases in Sub-Saharan Africa are projected to double by 2040 [4].

Monotherapy, which is the use of only one therapeutic agent can be effective in certain contexts, but it’s efficacy is often limited compared to combination therapy, as prolonged use can induce cancer cells to develop resistance by recruiting alternative salvage pathways [5]. Hence, current cancer treatment often combines surgery, radiation, chemotherapy, and targeted therapies [6]. Exact combinations may vary by cancer type, cancer stage, or aim of care which may include curing, reducing recurrence, or managing advanced cases to alleviate symptoms and prolong life [6].

Combination therapy has improved cancer outcomes but has also been implicated in causing cardiovascular toxicity (Fig. 1) [7]. This challenge is even more pronounced in Africa, where limited access to newer and less cardiotoxic cancer therapies intensifies the risk [8]. Many patients are left with the harsh choice of delaying treatment or relying on older, more affordable drugs known to cause cardiovascular damage. These constraints not only reduce the effectiveness of cancer care but also heighten the incidence of therapy-related heart complications across the continent [8].

Fig. 1.

Mechanisms of Cardiovascular Toxicity from Combination Cancer Therapies [5, 7].. Abbreviations: ADCs, Antibody–Drug Conjugates; ICIs, Immune Checkpoint Inhibitors; VEGF, Vascular Endothelial Growth Factor; HER2, Human Epidermal Growth Factor Receptor 2

The commonly implicated cardiotoxic drugs include anthracyclines such as doxorubicin, which induces cardiotoxicity primarily through mitochondrial dysfunction, oxidative stress, and ferroptosis [7]. It forms oxygen radicals that damage the DNA of mitochondria, disrupt its dynamics, impair ATP production, disturb Ca[²]⁺ homeostasis, and trigger cardiomyocyte death by topoisomerase 2β interaction [7].

Chemotherapeutic drugs that are also toxic to the cardiovascular system include HER 2 inhibitors such as trastuzumab which can cause left ventricular dysfunction, Immune checkpoint inhibitors such as ipilimumab which can cause myocarditis and other cardiovascular issues, VEGF Inhibitors such as bevacizumab, and Multi-Targeted Kinase Inhibitors such as sorafenib which can cause left ventricular dysfunction, increased blood pressure and toxicity to blood vessels [7]. Also 5-fluorouracil which is the third most commonly used chemotherapeutic agent for solid malignancies has also been shown to cause coronary vasospasm [7].

While specific incidence data on cardiovascular toxicity from combination cancer therapy as a whole is limited, the individual agents that typically constitute these regimens have well-documented cardiotoxic effects. For instance, a meta-analysis of 72 randomized controlled trials involving 30,013 patients found that VEGF receptor tyrosine kinase inhibitors (VEGFR-TKIs) were associated with Common Terminology Criteria for Adverse Events (CTCAE) grade ≥ 3 hypertensive events in 23.0% of cases, and with all-grade hypertensive events in 4.4% of cases [7, 9].

Similarly, fluorouracil-induced cardiotoxicity, including angina, ischemic electrocardiographic abnormalities, and myocardial infarction, was reported in approximately 10% of patients [7]. Additionally, proteasome inhibitors such as bortezomib had an overall cardiotoxicity incidence of 3.8% (95% CI: 2.6%−5.6%), with high-grade cardiotoxicity (CTCAE grade ≥ 3) occurring in 2.3% of cases (95% CI: 1.6%−3.5%) [7, 9]. Given that these agents are frequently co-administered in combination therapy, their cumulative cardiovascular impact warrants close monitoring and proactive management.

Despite this growing burden, cardio-oncology research and management capabilities remain underdeveloped across Africa [10]. There is a significant information gap in the region, with most of the available data and treatment strategies derived from high-income countries [10].

This review aims to examine the cardiovascular outcomes associated with cancer treatments in African populations, highlighting the unique challenges and insights derived from clinical data. By exploring these issues, the review seeks to propose actionable strategies to mitigate cardiovascular risks, particularly in resource-limited settings.

Challenges of managing cardiovascular risks in african cancer patients

Risk stratification and management of comorbidities are critical first steps in minimizing treatment-related cardiovascular complications in African cancer patients. Poverty, lack of health insurance, and other socioeconomic barriers significantly limit treatment access and adherence for managing cardiovascular risks in African cancer patients [11]. These factors exacerbate health inequities, particularly given the high prevalence of comorbidities like hypertension, diabetes, and obesity [11]. The issue of limited access to healthcare further worsens the matter, as it contributes to the increasing prevalence of non-communicable diseases (NCDs) in Africa [11]. For example, hypertension has a prevalence of about 30–40% among adults in sub-Saharan Africa [12]. The International Diabetes Federation (IDF) has also estimated that 24 million adults in Africa live with diabetes, while the prevalence of obesity ranges from 20–35%, mainly affecting urban populations, women's gender, and increasingly affecting children [13, 14].

Limited access to cardioprotective drugs and advanced cardiac monitoring tools in African cancer patients presents a significant challenge, as these individuals are at heightened risk of cardiovascular complications due to cancer itself and the cardiotoxic effects of cancer therapies [15]. This gap contributes to increased morbidity and mortality due to a lack of access to cardioprotective drugs and an overburdened healthcare sector [11, 16]. These could lead to delayed diagnosis, progression of disease, and untimely interventions as there is limited access to expert knowledge as well as advanced cardiac monitoring tools such as Holter monitors, echocardiograms, or biomarker measurement such as troponin tests [11, 16].

Economic implications such as financial loss, a grievous psychological, and social impact could also arise [16]. Due to the high likelihood of late cancer presentation and diagnosis, often there will be reduced chance of cure, higher treatment costs, loss of income due to prolonged illness, and an overall greater financial burden on families [11, 16]. Additionally, it contributes to increased psychological distress, social isolation, and stigma, particularly among individuals in resource-limited settings [7, 16]. For example women with cervical cancer from rural areas are nearly three times more likely to present at advanced stages due to limited healthcare access, reducing opportunities for timely cancer treatment and increasing the burden of in-care cardiotoxicity which normally is already as high as 10% [16].

The underrepresentation of Africans in clinical trials is a significant issue that has far-reaching consequences for patient care and health equity [17]. This lack of inclusion leads to generalized treatment protocols that may not account for population-specific responses to therapy, especially regarding cardiotoxicity risk. As a result, cardiovascular complications in African cancer patients may go unrecognized or be mismanaged due to unidentified genetic, pharmacogenomic, or comorbidity-related risk profiles [11]. This underrepresentation also hampers the development of tailored CV monitoring strategies and cardioprotective interventions, ultimately limiting the efficacy of managing cardiovascular disease in this population [17]. Also, the lack of multidisciplinary teams (MDTs) comprising oncologists, cardiologists, and other specialists also significantly hampers the quality of care for African cancer patients experiencing cardiotoxicity from cancer treatments [11]. This gap affects both short-term treatment outcomes and long-term survivorship.

Across the African continent, specialized cardio-oncology care remains severely lacking. Most cases are still managed in general hospitals or the few available cardiology and oncology centers [10]. Until 2018, there was no dedicated cardio-oncology unit in Africa [10]. That year, Dr. Y.T. Trishun Singh established the Netcare Umhlanga Cardio-Oncology Unit in Durban, South Africa as the first in Africa to be accredited by the International Cardio-Oncology Society (IC-OS) [10]. Yet, such facilities remain rare, leaving many patients without access to the specialized care needed to prevent or manage treatment-related cardiovascular complications.

Also, access to essential cancer medicines in Africa is marked by significant disparities, both in terms of availability and affordability (Table 1). Across the continent, countries in the African region tend to pay more for a standard package of essential cancer medicines than their counterparts in Latin America [24]. Moreover, the inclusion of anti-cancer medicines on national essential medicines lists (NEMLs) remains relatively low in many African countries, suggesting gaps in prioritization and procurement frameworks [24].

Table 1.

Access to Cancer Drugs in Africa: A Regional Snapshot

Region	Country	Key Highlights	References
North Africa	Morocco	- First in North Africa to implement a national cancer control plan - Pembrolizumab course costs about 8 × the average monthly income	[18]
Southern Africa	Botswana	- 80.5% alignment with WHO EML in 2015 - Yet, at least 40% of essential drugs were out of stock for a median of 30 days	[19]
West Africa	Ghana	- LPG availability: 46% (public), 22% (private hospitals), 74% (private pharmacies) - Colorectal cancer treatment may cost 2554 day's wages	[20]
East Africa	Rwanda	- 45% availability of anti-cancer drugs in public hospitals (2019–2021), offered at no cost - 80% of drugs in private hospitals were unaffordable	[21]
East Africa	Tanzania	- Inadequate availability in public hospitals - Patients often purchase costly, uninsured medicines from private pharmacies	[22]
East Africa	Ethiopia	- LPG availability: 34.8% (public), 9.9% (private) - Breast cancer medication costs up to 249 days of wages in the public sector	[23]

WHO EML World Health Organization Essential Medicines List, LPG Low-Price Generics

Insights from current data and clinical practice

Cardiotoxicity brought on by cancer treatments is caused by common signalling pathways that are necessary for both cancer growth and heart cell defense [25]. Maintaining the efficacy of cancer treatment and protecting heart function while focusing on detrimental pathways are necessary for optimal management. Research shows that cardiotoxicity occurs in as many as 10% of anthracycline-treated patients [25]. Age, diabetes, heart disease, high blood pressure, excessive dosages, and concurrent cardiotoxic treatments such as VEGF inhibitors, paclitaxel, trastuzumab, or radiation therapy are risk factors [25].

Cardiovascular diseases have been linked to several cancer treatments. For instance, a Nigerian study that discussed three cases of heart failure (HF) in patients undergoing treatment for breast cancer reported an association with cytotoxic drugs such as 5-fluorouracil, cyclophosphamide, and anthracyclines [26]. These cases not only demonstrate the cardiotoxic potential of these drugs but also reflect common challenges in African cardio-oncology practice, such as delayed presentation, limitations in diagnostic imaging, and lack of access to specialized cardio-oncology care. In the study, the aforementioned cytotoxic drugs were implicated in causing reduction of heart contractility by altering iron metabolism, increasing oxidative stress, and causing DNA damage, mitochondrial dysfunction, and ATP depletion [27, 28]. Patients were reported to have heart failure with either preserved or reduced ejection fraction during both the diastolic and systolic phases [26]. While data in Africa are still scarce, the prevalence of asymptomatic cardiac dysfunction years after anthracycline chemotherapy may reach up to 57% in cancer patients in Western nations, raising concerns over the need to improve cardio-oncology services in Africa to ensure routine cardiac monitoring and develop strategies to mitigate risks among vulnerable patients [10].

Another problem is the wide genetic variation in African populations [29]. This affects the metabolism and efficacy of cancer drugs while impacting their risk of cardiotoxicity [30]. For example, variants of NQO1, SOD2, and GSTP1 enhance oxidative stress and heart damage by lowering antioxidant defense [31]. Also, RYR2 and CACNA1C upset calcium balance, increasing the risk of cardiomyopathy, while HER2/ERBB2 and TP53 affect cell survival [31]. Others include ABCB1, SLCO1B1, and the CYP450 which control drug clearance and impact toxicity risk as well as TGF-β1 which promotes cardiac fibrosis, raising the risk of heart failure [31].

However, in Africa, the capacity to harness this genetic variation through pharmacogenetics for personalized medicine is hampered by a lack of infrastructure, financing, and awareness, necessitating focused research and solutions for successful clinical integration [29]. Certain races or ethnicities have been the target of prescribing guidelines, and inter-individual variations in pharmacokinetic parameters have been connected to race, ethnicity, and ancestry [32].

The European Society of Cardiology (ESC) Cardio-oncology Guidelines for 2022 provide a strong emphasis on early risk assessment, ongoing cardiovascular monitoring, and customized treatment of cancer patients' cardiotoxicity [33]. For the best possible patient management, the 2023 ESC Cardiomyopathy Guidelines emphasize accurate categorization, early identification, and interdisciplinary cooperation [34]. To enhance outcomes, the 2023 American Heart Association (AHA) Update emphasizes early toxicity detection, timely antidote administration, and toxin-specific Advanced Cardiac Life Support (ACLS) improvements [35]. Sub-Saharan Africa is underrepresented in cardiovascular trials, according to a report published in ESC guidelines [36]. This highlights the critical need for inclusive research to guarantee internationally viable treatment solutions, especially in low- and middle-income nations.

Strategies for mitigating cardiovascular risk

The field of Cardio-Oncology is experiencing a paradigm shift in focus from merely treating cardiotoxicities to early detection of complications and integrating preventive cardiology into the care of patients with cancer [37]. Hence, attention is being focused on early risk assessment and cardiovascular monitoring in the treatment of patients with cancer, especially those needing medications and therapies with known or predictable cardiotoxicity. In the African continent, efforts at achieving this and synergy of purpose must be reinforced (Fig. 2) [37].

Fig. 2.

Strategies to Mitigate Cardiovascular Risk in African Cancer Patients [38–41]. Abbreviations: ECG, electrocardiogram; ECHO, echocardiogram

At the clinical level, data suggests there has to be an intentional incorporation of pre-treatment cardiac assessments into cancer care protocols at all cancer treatment centers in Africa, utilizing the evaluation cost-effectiveness tools of Electrocardiography (ECG), Echocardiography (ECHO) and Cardiac biomarkers for initial assessment, monitoring, and prognosis [38]. An example is the inclusion of modern techniques like strain analysis on ECHO to detect subclinical stages [38]. Nuclear and multimodality imaging approaches which are being favoured in higher income settings because of their superiority in characterizing underlying pathophysiology should also be made available for use in African cancer centers [38].

In Africa, a lot more studies need to be conducted on the effects of oncological care on the cardiovascular system of African patients with cancer [42]. There is a need to also differentiate cardiotoxicity from new-onset cardiovascular disease [42]. Studying both from an African standpoint would be valuable in addressing the whole spectrum of Cardio-oncology. Surveillance, prevention, and intervention strategies must be used in an integrated approach [37, 43]. There is a need to establish societies in Africa as are in Europe and America (American Society of Clinical Oncology, European Society for Medical Oncology, etc.) saddled with the task of training cardio-oncologists in Africa, releasing position papers, guideline recommendations, and expert opinion; and governing councils [39].

There is a need for Cardio-oncology to be formally recognized in Africa as a very important subset of preventive cardiology and not a one-off practice. The determination of cardiac function, reserve and integrity of the patient, and the level of cardiotoxic risk of the therapies to be instituted should be balanced with the patient’s decision and capacity for alternative management solutions including palliative care [39]. Establishing cardio-oncology programs at all cancer treatment centers is an important long-term goal for Africa, however, immediate efforts should focus on bringing services closer to patients through practical, scalable approaches. These include informal collaborations that allow cardio-oncology care to be managed by available oncologists and general cardiologists, while general practitioners handle cases in rural areas [10]. To maximize the effectiveness of this approach, Africa would have to implement training and mentorship on cardio-oncology expertise while leveraging on digital tools to ensure patients from both urban and underserved settings are not excluded from potentially lifesaving therapies despite the shortage of specialized care [39–41].

Training for healthcare workers in Africa on cardiotoxicity management should begin at medical school and other affiliate schools and institutions of learning using curricula designed to increase knowledge and awareness [39]. African postgraduate training institutions should use their curricula to fill the vacuum that exists in standard practice and training guidelines, which should be regularly updated [39]. An independent form of certification and accreditation of trainee’s competency is important as well as those obtained from programs [39].

Artificial intelligence algorithm models should be embraced in Africa particularly machine learning, which has shown great potential in screening, diagnosis, monitoring, and management of cancer-induced and cancer therapy-related cardiovascular complications [40]. Telemedicine and other digital health tools should also be incorporated into African health systems given their potential to provide remote cardiac monitoring hence improving access to equitable, consistent, and personalized care [41]. Mobile/wearable digital devices for example improve adherence to cardiac care protocols and are useful in monitoring patient’s parameters/vitals, and arrhythmia detection [44].

Future directions and recommendations

Improving cardio-oncology outcomes in Africa requires the implementation of targeted strategies across clinical, research, and policy levels (Table 2). While substantial research on cardiotoxicity has been conducted globally, there is a scarcity of studies focused on cardiovascular outcomes in African cancer patients. Promoting local research is very crucial to understanding the distinct risk factors and cardiotoxicity symptoms within African populations [10]. Generally, African patients most often present with higher cardiovascular risk factors which can worsen the cardiotoxic effects of cancer treatment. By identifying these risks, thorough assessments can be conducted before, during, and after cancer treatment [33].

Table 2.

Strategic Recommendations for African Cardio-Oncology

Focus Area	Recommendation	Goal	References
Local Research	Promote region-specific studies on cardiotoxicity in African cancer patients	Understand unique risk factors and symptom patterns to inform tailored care	[10]
Risk Assessment	Conduct cardiovascular assessments pre-, during, and post-treatment	Identify and manage exacerbating cardiovascular risks	[33]
Global Collaboration	Partner with AORTIC, IC-OS, ESC, and similar bodies	Leverage expertise and support for guideline development	[45]
Policy Integration	Include cardiac care in national cancer treatment plans	Ensure holistic treatment that addresses cardiac risks	[45]
Funding and Training	Increase investment in cardio-oncology and train more specialists	Build healthcare capacity and expertise across African countries	[45]
Data and Registry Development	Establish more national/regional cardio-oncology registries	Increase availability of high-quality data for research and clinical improvement	[45, 46]
Interdisciplinary Teams	Form teams combining oncology, cardiology, and other allied health professionals	Ensure comprehensive, coordinated care for patients	[46, 47]

AORTIC African Organisation for Research and Training in Cancer, IC-OS International Cardio-Oncology Society, ESC European Society of Cardiology

To effectively create guidelines specific to African cardio-oncology care, the following strategies should be considered. First, collaboration with global health organizations such as; the African Organisation for Research and Training in Cancer (AORTIC), Global Oncology Network, European Society of Cardiology (ESC), International Cardio-Oncology Society (IC-OS), etc. should be fostered [45]. These global organizations assist in developing guidelines for cardio-oncology care, by providing insights and facilitating partnerships that will improve the development of cardio-oncology guidelines, tailored to African populations [45].

Integrating cardiac care into cancer treatment plans requires policy changes to address the challenges faced by healthcare systems. Increased funding for cardio-oncology programs and research, proper training for cardio-oncology specialists, and establishment of national or regional registries in several African countries can also help with the strategic improvement of cardiovascular outcomes in cancer patients [45, 46]. Establishing interdisciplinary teams that can work together to guarantee thorough treatment of cardiac and oncological care while having access to high-quality data from the established cancer registries is also essential [46, 47]. Effective cardio-oncology multidisciplinary teams (CO-MDTs) typically include not only cardiologists and oncologists but also pharmacists, nurses, and allied health professionals. Pharmacists provide medication reconciliation and manage drug–drug interactions, while nurses support early risk assessment, patient education, and follow-up [47]. Evidence from models such as the Team Intervention in Ardio-oncology (TITAN) trial shows that structured multidisciplinary teams enable earlier detection of cardiovascular risk and timely intervention, reducing complications and improving treatment continuity [47].

Existing frameworks such as the Cardio-Onco-Rehabilitation and Exercise (CORE) model and the Cardio-Onco-Hematology (COH) framework offer scalable approaches that could be adapted for Africa [48, 49]. The CORE model builds on decades of cardiac rehabilitation experience, combining exercise training, cardiovascular risk factor management, nutrition counselling, and psychosocial support across the cancer care continuum [48]. It emphasizes structured referral pathways, safety checklists, and home or hospital-based program flexibility which make it particularly useful in resource-limited settings where centralised care may not be feasible [48]. Similarly, the COH framework highlights the integration of hematology, oncology, and cardiology services to provide coordinated risk assessment, cardiotoxicity monitoring, and timely intervention [49]. Together, these frameworks provide a practical roadmap that can be locally adapted by prioritizing high-risk patients, focusing on feasible interventions (e.g. exercise and risk factor control), and leveraging telehealth or regional collaborations to extend reach.

Conclusion

Cardiovascular risks in African cancer patients present a complex challenge, shaped by pre-existing conditions, treatment-related toxicities, and healthcare system limitations. The interplay between cancer therapies and cardiovascular disease exacerbates patient outcomes, necessitating a comprehensive approach to care. Limited access to early screening, specialized care, and context-specific research further complicates the management of these dual health burdens. Addressing these challenges requires a shift toward integrated, multidisciplinary care models that prioritize both oncologic and cardiovascular health. Additionally, there is a need for locally driven research to generate data that reflect the unique epidemiological and genetic profiles of African populations, ensuring more precise risk stratification and tailored interventions for better health outcomes.

Also, collaboration among healthcare providers, researchers, and policymakers is essential. Strengthening healthcare infrastructure, enhancing training in cardio-oncology, and implementing cost-effective interventions should be prioritized. Sustainable solutions, such as regionally adapted clinical guidelines and frameworks, as well as increased investment in research, will be key to reducing the burden of cardiovascular disease in African cancer patients.

Abbreviations

IARC

International Agency for Research on Cancer

HER2

Human Epidermal Growth Factor Receptor 2

VEGF

Vascular Endothelial Growth Factor

CVDs

Cardiovascular Diseases

ADCs

Antibody-Drug Conjugates

CTCAE

Common Terminology Criteria for Adverse Events

MDTs

Multidisciplinary Teams

IC-OS

International Cardio-Oncology Society

EML

Essential Medicines List

LPGs

Low-Price Generics

NCDs

Non-Communicable Diseases

IDF

International Diabetes Federation

ROS

Reactive Oxygen Species

MAPK

Mitogen-Activated Protein Kinase

ERK

Extracellular Signal-Regulated Kinase

BRAF

B-Raf Proto-Oncogene

MEK

Mitogen-Activated Protein Kinase Kinase

NQO1

NAD(P)H Quinone Oxidoreductase 1

SOD2

Superoxide Dismutase 2

GSTP1

Glutathione S-Transferase Pi 1

RYR2

Ryanodine Receptor 2

CACNA1C

Calcium Voltage-Gated Channel Subunit Alpha1 C

ERBB2

Erb-B2 Receptor Tyrosine Kinase 2

TP53

Tumor Protein p53

ABCB1

ATP-Binding Cassette Sub-Family B Member 1

SLCO1B1

Solute Carrier Organic Anion Transporter Family Member 1B1

CYP450

Cytochrome P450

TGF-β1

Transforming Growth Factor Beta 1

ESC

European Society of Cardiology

AHA

American Heart Association

ACLS

Advanced Cardiac Life Support

ECG

Electrocardiography

ECHO

Echocardiography

AORTIC

African Organisation for Research and Training in Cancer

TITAN

Team Intervention in Ardio-oncology

CORE

Cardio-Onco-Rehabilitation and Exercise Model

COH

Cardio-Onco-Hematology Framework

Author’s contribution

B.S.F. was responsible for conceptualization, project administration, creation of figures, creation of tables, and preparation of the first and final draft. P.M.O., O.L.B., C.U.O., C.J.E., and I.C.C. were responsible for data collection and initial manuscript writing. T.J.O. was responsible for the review and preparation of the final draft.

Funding

Not applicable.

Data availability

Not applicable.

Declarations

Ethical approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.