INCORPORATING CARDIAC CARE
Despite efforts by professional bodies, however, implementation of cardio-oncology programs varies widely between centers.6,12 A 2015 national survey found that formal training in cardio-oncology services are inadequate, with 70% of respondents reporting that the cardiovascular implications of cancer treatment is an important consideration but only about a third of centers surveyed offered cardio-oncology services as part of preoperative patient consultations.12 Only 27% had established, specialized cardio-oncology services. Twelve percent had no cardio-oncology services but were in the process of establishing them.12
Although cardio-oncology programs vary, they should all involve risk stratification or screening of cancer patients for cardiovascular disease prior to cancer-directed therapy, coordinated care for patients undergoing concurrent cardiovascular disease-directed and cancer-directed care, prevention, rehabilitation and supportive care, and survivorship planning for patients whose cancer treatment likely increases their risk of late cardiovascular side-effects.3,6 For example, baseline screening for dyslipidemia and diabetes mellitus, and baseline and surveillance electrocardiography (ECG) should be considered, and other imaging, including cardiac MRI or radionuclide ventriculography for left ventricular function, and possibly serum biomarker surveillance with high-sensitivity troponin, should be considered.3,6
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Cardio-oncology programs involve timely consultations and diagnostic testing to avoid interruptions in cancer care. Urgent cardio-oncology procedures that should be undertaken in less than 2 weeks, include new referral assessments for patients with pending or active cancer therapy, patients with symptoms of progressive heart failure, or new or worsening chest pain (angina), or uncontrolled hypertension or arrhythmia.5,6
When cardiac dysfunction is detected, cardioprotection should be considered, including ACE inhibitors or beta-adrenergic receptor antagonists (beta-blockers).2
CONCLUSION
Because of latency periods for late cardiovascular effects following cancer treatment, long-term cardiovascular surveillance should be planned for survivors of childhood cancer who have undergone cardiotoxic cancer therapies.2 Breast cancer survivors frequently experience radiotherapy or other cancer treatment-related heart failure, cardiomyopathy, coronary ischemia, thromboembolism, heart arrhythmia, or valve or pericardial heart disease.1,5,14 Preexisting hypertension or left-ventricular dysfunction increases the risk of such late cardiotoxicities.1 Prevention efforts such as exercise and dietary considerations, and scheduled cardiovascular disease surveillance should be included in these patients’ cancer survivorship care plans.1,3
Cardio-oncology is a new and rapidly expanding field faced with a limited evidence base. Oncology nurses will face increasingly complex management challenges in the concurrent management of cancer and cardiovascular disease, and preventing cancer therapy-associated cardiotoxicities.
References
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11. Armenian SH, Lacchetti C, Barac A, et al. Prevention and monitoring of cardiac dysfunction in survivors of adult cancers: American Society of Clinical Oncology clinical practice guideline. J Clin Oncol. 2017;35(8):893-911.
12. Cardio-oncology services may improve patient care if more widely available: American College of Cardiology aims to fill gaps in cardiovascular care for cancer patients. Washington, DC: American College of Cardiology; June 22, 2015. http://www.acc.org/about-acc/press-releases/2015/06/22/14/18/cardio-oncology-services-may-improve-patient-care-if-more-widely-available. Accessed December 12, 2017.
13. Iliescu CA, Grines CL, Herrmann J, et al. SCAI expert consensus statement: evaluation, management, and special considerations of cardio-oncology patients in the cardiac catheterization laboratory (endorsed by the cardiological society of india, and sociedad Latino Americana de Cardiologia intervencionista). Catheter Cardiovasc Interv. 2016;87(5):E202-E223.
14. Harrison JM, Pressler SJ, Friese CR. Cardiotoxic heart failure in breast cancer survivors: a concept analysis. J Adv Nursing. 2016;72(7):1518-1528.
