Cardio-Oncology in Peru

Cardiovascular disease and cancer are the first and second leading causes of death in Peru, respectively, as is the case in many countries in the region. In Peru, approximately 33,098 cancer deaths were reported in 2019, and 66,627 new cancer cases were detected, with 60% of such cases in women. Alarmingly, Peru’s cancer rate has increased by 40% in the last 20 years, from 156 to 229 per 100,000 live births, which represents a public health crisis that demands greater attention. The most frequent cancer in men is prostate cancer (7,598 new cases and 2,721 deaths), followed by stomach cancer (5,731 new cases and 4,606 deaths), whereas in women, breast cancer is the most frequent (6,985 new cases and 1,858 deaths), followed by cervical cancer (4,103 new cases and 1,836 deaths) (1,2). The increasing cancer prevalence and the epidemiologic overlap between cardiovascular disease and cancer have resulted in a growing interest in the field of cardio-oncology.

Long before cardio-oncology developed as a field in Peru, the country’s fight against cancer began. On May 11, 1939, law number 8892 established the National Cancer Institute, and on December 4, 1939, the National Cancer Institute was officially inaugurated. The legislation’s main goal was to improve cancer prevention efforts and provide specialized medical assistance, as well as to promote education and research in oncology. In 1952, because it was the only specialized cancer center in the country and due to high patient demand, it was renamed the Instituto Nacional de Enfermedades Neoplásicas (INEN) (the National Institute of Neoplastic Diseases). The process of decentralizing cancer control services and treatment began in 2007, with the aim of improving geographic and economic access for Peruvians in the most remote regions in the country, with the opening of 2 hospital centers, 1 located in the north (Trujillo) and the other in the south (Arequipa).

The INEN initiated the Budgetary Program for Cancer Prevention and Control with the mission of providing timely, comprehensive cancer care coverage to all Peruvians, including the most vulnerable populations, by enhancing cancer prevention, early detection, and treatment in the public sector (3). In 2012, with the financial support of Peru’s health insurance system, the National Plan for Comprehensive Cancer Care and Improvement of Access to Oncology Services, called Plan Esperanza (The Hope Plan), was initiated. The Hope Plan made it possible to declare cancer care to be a national interest and improved access to oncology services throughout the country (4). The INEN treats approximately 12,500 new cancer cases per year, with 10,309 hospitalizations, 6,345 cancer surgeries, 44,893 chemotherapy treatments for 63,000 patients, and approximately 81,337 radiation therapy sessions for 4,295 patients. However, delayed health care access may still have contributed to the death of 63% of patients within the first year of their cancer diagnosis in metropolitan Lima, Peru’s capital and largest city.

Early diagnosis of most cancer types usually enables earlier and more effective treatments, thereby reducing mortality rates. However, to detect cancer at early stages, it is necessary to successfully promote health education to raise cancer awareness. Just as importantly, health services must be available to all geographic and economic populations, increasing access to medical staff and equipment to enable accurate and timely diagnoses and effective treatments. In Peru, health resources are limited, because very little is invested in the care of the population. Only 4 countries (the United States, Canada, Costa Rica, and Uruguay) invest 6% or more of their gross domestic product in health care and services, which is the minimum amount recommended by the World Health Organization. Countries that invest 4% to 6% include Honduras, El Salvador, Paraguay, Ecuador, Bolivia, Nicaragua, Colombia, and Panama. Furthermore, the following countries invest between 2% and 4%: Guatemala, Argentina, Mexico, Brazil, Peru, and Chile. Haiti and Venezuela invest <2% (5).

In recent years, Peru has had significantly improved macroeconomic performance compared to other Latin American countries, ranking sixth according to gross domestic product (+2; 16%) (6), after Brazil, Mexico, Argentina, Colombia, and Chile. Despite Peru’s positive economic growth (private consumption: +3.0%; public consumption: +2.7%; private investment: +4.2%; employment: +2.0%), its health budget has been at only 3%. It is estimated that 420,024 healthy life years, or disability-free life expectancy, are lost each year because of cancer in Peru. Of these, 27,929 are due to breast cancer and 44,924 are due to cervical cancer (7,8). In 2012 in Peru, there were 21 cancer health facilities in 9 regions of the country, and in 2016, there were 43 cancer health facilities in 18 regions. This increase reflects the growing need for diagnostic and treatment programs that also address the widening health gap between rural, indigenous, and low-income areas as compared with urban, developed, high-income areas.

Research advances have resulted in the development of new antineoplastic drugs with increased efficacy and, in some cases, leading to cures for previously difficult-to-treat cancers. For example, survival for early-stage breast cancer has reached 87% in Brazil, 76% in Colombia, and 83% in Ecuador. In Peru, approximately 150,000 women have been successfully treated for breast cancer. However, cancer treatments may also be associated with adverse events and toxicities. Some of the first reports of the cardiotoxicities associated with the use of the anthracycline daunorubicin were published in 1967. There is now increasing knowledge regarding these potential acute, chronic, and late effects associated with certain cancer treatments, including 5-fluorouracil, monoclonal antibodies, and tyrosine inhibitors (e.g., HER2 targeted therapies), chest radiation, and immune therapies (9,10).

In May 1952, Dr. Ricardo Subiría Carrillo joined the INEN as the institution's first cardiologist, evaluating patients with metastatic cancer to the heart and, less frequently, primary cardiac malignancies. He also conducted pre-surgical evaluations of patients who underwent extensive surgeries. In his 1973 doctoral thesis entitled “Metastatic Neoplasms of the Heart,” he highlighted the significance of cardiac dysfunction developing secondary to cancer therapy. In November 1992, Dr. Enrique Ruiz Mori introduced the traditional electrocardiogram, Holter monitor, blood pressure monitor, and echocardiogram to the cardiovascular community, which became fundamental tools to assess cardiac function in patients who underwent chemotherapy. These tools enabled the first anthracycline-induced cardiotoxicity diagnosis, monitoring, and follow-up in Peru. The echocardiogram also enabled physicians to quantify the results of cardioprotective drugs such as dexrazoxane to help prevent anthracycline-induced cardiotoxicities and, later, the toxic effects of the anti-HER2⁺ agent trastuzumab on ventricular function.

Beginning in 2016, cardio-oncology was actively promoted in Peru as an increasingly important medical discipline for the enhanced care of cancer patients through the development of courses at the INEN and, subsequently, participation in national and international cardiology congresses. Likewise, medical researchers in Peru began to publish on important cardio-oncology topics. In 2018, the first cardio-oncology manual of the South American Society of Cardiology was published (11), with subspecialists Gina Gonzalez (Colombia), Carlos Lax (Argentina), Pamela Rojo (Chile), Ariane Scarlatelli Macedo (Brazil), Horacio Vásquez (Uruguay), Vicente Villacreces (Ecuador), and Bartolomé Finizola (Venezuela) collaborating on this project. Peru was represented by an oncologist, a radiotherapist, an electrophysiologist, and 3 cardiologists from INEN.

On February 19, 2019, 5 cardiologists, 4 nurses, and 4 technicians at the INEN launched the first cardio-oncology unit in the country, with a monthly demand of 750 evaluations, either outpatient, hospitalized, or ICU patients and more than 300 echocardiographic studies. The main goal of the cardio-oncology unit is to consolidate efforts to enhance the safety and efficacy of cancer patient care through a coordinated, multidisciplinary approach by oncologists, hematologists, radiotherapists, oncology surgeons, cardiologists, nurses, health care providers, and technical staff as well as to promote and establish new cardio-oncology units countrywide (12,13). Moreover, in 2020, the first cardio-oncology rotation for cardiology residents was initiated at the INEN, but unfortunately, it was interrupted by the current coronavirus pandemic. Overall, this unit seeks to enhance the prevention, diagnosis, treatment, and follow-up of patients at risk for cardiotoxicity or who have developed cardiotoxicity second to cancer treatment and, under a research framework, to contribute to the awareness, medical education, and development of this new, emerging, and critically important subspecialty. Cardio-oncology has proven to be a true oncological and medical necessity in Peru, throughout South America, and across the world to improve care for our citizens affected by cancer.

Author Disclosures

The authors have reported that they have no relationships relevant to the contents of this paper to disclose.