The side effects patients fear most about cancer treatment are fatigue, weakness, psychological issues, digestive dysfunction, pain, and change in appearance (such as hair loss), according to a 2020 study published in Cancer Research and Treatment. However, the potential cardiac side effects of cancer therapies also pose substantial long-term risk of morbidity and mortality. Primary care providers and other caregivers must actively work to educate their patients about their risk and recognize and reduce the effects of cardiotoxic agents.
“It is incumbent that we shift our mindset to take a macro-evaluation of patients,” said Kathy Albert, DNP, FNP-BC, AOCNP, an advanced practice provider for oncology and hematology at Rocky Mountain Cancer Centers (RMCC). “Across the cancer-diagnosis continuum – from diagnosis to treatment and afterward, we should identify risk factors and monitor for cardiovascular complications.”
Today, cardio-oncology bridges the gap between cardiology and cancer care. Cardio-oncology is a subspecialty of cardiology that not only emphasizes cardiac issues in cancer patients; it bridges the gap between cardiology and cancer care.
Identifying Obstacles to Recognizing Cardiotoxicity Risk
While earning her DNP, Kathy was particularly interested in identifying post-cancer treatment monitoring of patients who receive anthracyclines. During her study, she determined specific obstacles (limitations) could reduce the likelihood of clinicians fully evaluating their patients for cardiovascular risk.
Those obstacles include:
- Difficulty accessing specialists. Cardio-oncologists are not easy to access in all areas of the United States. For many, cardiologists are also difficult to access. This makes it harder for these patient populations to receive testing for (screening or symptoms that could be a consequence of) cancer treatment-induced heart disease.
- Insurance coverage. Following oncological care, insurance companies do not always cover echocardiography. An echocardiogram costs approximately $1,500 out of pocket, which many patients cannot afford, so they skip the screening test. Determining insurance coverage for the test at the beginning of a patient’s cancer journey would provide patients the time needed to research options that make cardiac testing more affordable.
- Lack of awareness. Multiple agencies, such as the American Society of Clinical Oncology, Comprehensive Cancer Network, and other organizations provide guidelines for post-therapeutic cardiac monitoring, but some providers are unaware of them.
Along with these obstacles, ethnicity and financial means seem to play a role. The Journal of the American Heart Association reports disparities in cardiotoxicity morbidity and mortality among Black breast cancer survivors, females who undergo anthracyclines or radiation, and younger cancer survivors with a low socioeconomic status.
Regardless of socioeconomic status or ethnicity, the burden to recognize a patient’s likelihood of cardiotoxicity does not rest solely on the shoulders of a single member of the patient’s care team.
“It’s impossible to look at every facet of every patient’s health at every visit,” Kathy said. “It takes a village – primary care, oncology, other specialists, and the patient – all must work together to detect and manage cardiac risk. If we work as a community to care for patients on the cancer survivorship continuum, we can offer heightened screening and therefore minimize cardiovascular risk in this setting.”
Offering Patients Education and Opportunity
For optimal outcomes, Kathy encourages patients to be accountable for their cardiovascular health. Impressing this responsibility on patients increases the likelihood that those at higher risk for cardiac side effects of cancer treatment will receive the care they need.
Members of the patient’s care team should emphasize the importance of screening and monitoring for cardiovascular issues. Teach patients their specific risk of cardiotoxicity, which medications increase the risk, and ways to minimize that risk with post-chemotherapy and -radiation treatments. For further cancer education, direct patients toward patient-friendly resources from the ACC and other organizations.
Beyond education, reaching positive outcomes for at-risk patients also requires them to receive appropriate specialty care in a timely manner.
“The most basic adherence to cardio-oncology guidelines involves identifying and stratifying patients at high risk for cardiotoxicity,” Kathy said. “Once identified, these patients should have an opportunity to consult with cardiology.”
In some settings, a cardio-oncologist is available for consultation. In settings where specialists are unavailable, referring to a general cardiologist can be effective, though “it may take weeks to see a cardiologist,” Kathy said.
The experts at RMCC have relationships with multiple cardiologists across the Colorado Front Range. Patients undergoing treatment for lymphoma, breast cancer, and sarcomas are often prescribed anthracycline agents, which are known to cause cardiomyopathy. Research suggests anti-hypertensives as beta blockers can decrease the development of such complications. A cardiologist can recommend for or against these medications and increase the safety and effectiveness of therapy, while improving the patient experience.
Maintaining strong relationships with cardiologists is also of benefit, especially when a quick consultation does not meet the patient’s needs. When a patient is at high risk for cardiotoxicity or a cardiac side effect from cancer treatment is suspected, an RMCC team member can get the patient in to see the cardiologist quickly. This early identification can minimize complications.
Care Recommendations for Referring Providers
Though a cardio-oncologist or cardiologist specializes in detecting and preventing heart disease and the cardiac side effects of cancer treatment, referring physicians can also play a substantial role in their patients’ care. Clinicians should act when patients who have undergone cancer therapy in the past are experiencing the following:
- Congestive heart failure symptoms
- Nuanced high blood pressure
With these symptoms, a head-to-toe assessment to determine the patient’s clinical picture can help detect and decipher any changes taking place in the body and verify the risk for and/or help reduce the risk of heart problems.
Clinicians should also be willing to contact the patient’s oncology provider to ensure the patient undergoes appropriate screening, even if an extensive amount of time has passed following the completion of cancer therapy.
“Patients exposed to chemotherapy should be monitored throughout their survivorship journey,” Kathy said. “There is some research showing patients of a certain age who are exposed to anthracyclines can develop cardiomyopathy 20 years after exposure; this is especially noted if these patients have certain comorbidities.”
Should a patient develop cardiomyopathy, which is a type of heart disease that makes it difficult to pump blood or develops issues with the blood vessels, heart valves, or heart muscle following treatment, providing that information to RMCC is helpful. Kathy encourages referring physicians to “be liberal with calling if you have any concerns.”
In the event a patient requires follow-up care due to recurring cancer, past cardiac side effects of cancer treatment may modify future treatment planning. Accumulating this data also helps grow our understanding of various cancer agents’ cardiotoxicity. It is readily accepted that all chemotherapies carry some level of cardiotoxicity risk; however, the risk profiles of some are less so than others. Reporting the cardiac side effects of cancer therapy provides the opportunity to produce stronger profiles for all currently available chemotherapy agents.
“There is a robust pool of data regarding how to minimize the risk of cardiotoxicity, but so far the guidelines haven’t caught up with this data,” Kathy said. “In the meantime, we will continue expanding our data pool and using that information to better understand how to screen for and reduce those risks.”
At Rocky Mountain Cancer Centers, we work with referring physicians and specialists to manage cardiotoxicity risks and care for the whole patient throughout the cancer journey. If you desire compassionate, leading-edge multidisciplinary care for your patients, refer a new patient.