JACC: CARDIOONCOLOGY
4, 2020
ª 2020 THE AUTHORS. PUBLISHED BY ELSEVIER ON BEHALF OF THE AMERICAN
COLLEGE OF CARDIOLOGY FOUNDATION. THIS IS AN OPEN ACCESS ARTICLE UNDER
THE CC BY-NC-ND LICENSE (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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Cardio-Oncology in Peru
An Emerging Discipline
Enrique Ruiz-Mori, MD, PHD,a,b,c Leonor E. Ayala-Bustamante, MD,b Edgar Quispe-Silvestre, MD,b
Rowel Rolando Rivas-Flores, MD,b Jorge Burgos-Bustamante, MDa,b
C ardiovascular 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 car-
dio-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 Na-
tional 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
From the aUniversidad de San Martín de Porres, Facultad de Medicina
Humana, Lima, Perú; bInstituto Nacional de Enfermedades Neoplásicas,
c
Unidad de Cardio-Oncología, Lima, Perú; and the Cardiology Service,
Instituto Nacional de Enfermedades Neoplásicas.
The authors attest they are in compliance with human studies
committees and animal welfare regulations of the authors’ institutions
and Food and Drug Administration guidelines, including patient consent
where appropriate. For more information, visit the JACC: CardioOncology
author instructions page.
ISSN 2666-0873
VOL. 2, NO.
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 pro-
cess 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 pre-
vention, 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 in-
terest and improved access to oncology services
throughout the country (4). The INEN treats approx-
imately 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 en-
ables 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
https://doi.org/10.1016/j.jaccao.2020.10.004
672 Ruiz-Mori et al.
Cardio-Oncology in Peru
importantly, health services must be available to all
geographic and economic populations, increasing
access to medical staff and equipment to enable ac-
curate 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 ac-
cording to gross domestic product (þ2; 16%) (6), after
Brazil, Mexico, Argentina, Colombia, and Chile.
Despite Peru’s positive economic growth (private
consumption: þ3.0%; public consumption: þ2.7%;
private investment: þ4.2%; employment: þ2.0%), its
health budget has been at only 3%. It is estimated that
420,024 healthy life years, or disability-free life ex-
pectancy, 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 develop-
ment of new antineoplastic drugs with increased ef-
ficacy 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 suc-
cessfully 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
JACC: CARDIOONCOLOGY, VOL. 2, NO. 4, 2020
NOVEMBER 2020:671–3
inhibitors (e.g., HER2 targeted therapies), chest radi-
ation, 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 cardio-
vascular community, which became fundamental
tools to assess cardiac function in patients who un-
derwent chemotherapy. These tools enabled the first
anthracycline-induced cardiotoxicity diagnosis,
monitoring, and follow-up in Peru. The echocardio-
gram 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-HER2þ agent tras-
tuzumab on ventricular function.
Beginning in 2016, cardio-oncology was actively
promoted in Peru as an increasingly important med-
ical discipline for the enhanced care of cancer pa-
tients through the development of courses at the
INEN and, subsequently, participation in national and
international cardiology congresses. Likewise, medi-
cal 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 Villa-
creces (Ecuador), and Bartolomé Finizola (Venezuela)
collaborating on this project. Peru was represented by
an oncologist, a radiotherapist, an electrophysiolo-
gist, 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, multi-
disciplinary approach by oncologists, hematologists,
radiotherapists, oncology surgeons, cardiologists,
nurses, health care providers, and technical staff as
JACC: CARDIOONCOLOGY, VOL. 2, NO. 4, 2020
NOVEMBER 2020:671–3
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 inter-
rupted by the current coronavirus pandemic. Overall,
this unit seeks to enhance the prevention, diagnosis,
treatment, and follow-up of patients at risk for car-
diotoxicity 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
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AUTHOR DISCLOSURES
The authors have reported that they have no relationships relevant to
the contents of this paper to disclose.
ADDRESS FOR CORRESPONDENCE: Dr. Enrique
Ruiz-Mori, Universidad de San Martín de Porres, Las
Gaviotas 165, Surquillo, Lima 34, Peru. E-mail:
cruizm@usmp.pe.
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