During the 2020 Association of Community Cancer Centers Virtual National Oncology Conference, a cardio-oncologist and nurse navigator explained the importance of identifying cardiotoxicities in patients with cancer and how to implement a program to help these patients have improved care coordination and experience through employing a nurse navigator
Multiple cancer treatments, such as regimens that include anthracyclines and molecular targeted therapies, can cause cardiotoxicities. Patients who are at high risk for these dangerous adverse events (AEs) need to be identified and managed appropriately by educating everyone involved in the patient’s care and establishing collaboration between medical oncologists and cardiologists.
During the 2020 Association of Community Cancer Centers (ACCC) Virtual National Oncology Conference, a cardio-oncologist and nurse navigator explained the importance of identifying cardiotoxicities in patients with cancer and how to implement a program to help these patients have improved care coordination and experience through employing a nurse navigator.1
“We have a population that’s surviving their initial insult, whether that be cancer or heart disease, but then may subsequently develop, over the course of the next 10 to 15 years, the other comorbidity,” Vijay U. Rao, MD, PhD, director of the Franciscan Health Cardio-Oncology Clinic and codirector of the Heart Failure Program and Anticoagulation Clinic at Franciscan Health, said in his presentation.
Both patients with breast cancer and patients with hematologic cancers, among a few others, are exposed to anthracycline chemotherapy. Patients who survive their cancer can experience the AEs that come with this type of therapy even years later. In some, there have been cases of irreversible heart dysfunction and heart failure, and for the worst-case scenarios, patients could not be managed medically and required heart transplantation, according to Rao.
Additionally, anti-angiogenic agents, such as VEGF-targeting regimens, can cause cardiotoxicity such as acute coronary syndrome, hypertension, heart failure, and left ventricle systolic dysfunction. Signal transduction inhibitors that target the HER family can cause QT prolongation, as well as heart failure and left ventricle systolic dysfunction.
To identify these cardiotoxicities in patients, physicians need the patient’s history and physical exam, as well as an ECG and imaging including a multigated acquisition scan, echocardiogram, and cardiac MRI, “which is the gold standard for assessment of left ventricular function,” according to Rao. Biomarkers also need to be looked at such as troponin and b-type natriuretic peptide.
Predictors of cardiotoxicity include female gender; being under the age of 15 or over the age of 65; pre-existing cardiovascular disease; hypertension; receiving mediastinal radiation; and the type, rate, and dose of anthracycline administration.2,3 Rao said that the radiation predictor is important because radiation is given to patients who also receive anthracyclines for multiple malignancies including breast cancer and certain lymphomas.
To treat patients that experience cardiotoxicity, there are therapies such as ace-inhibitors, beta-blockers like carvedilol (Coreg) and nebivolol (Bystolic), statins—which lower cholesterol—and dexrazoxane (Zinecard). The sooner patients at high risk for cardiotoxicities are identified, the sooner they can receive the proper monitoring and treatment they need to lessen or avoid cardiotoxicity altogether.
A cardio-oncology program was initiated at Franciscan Health to identify and patients these patients who were at risk for cardiotoxicities. A main goal of the program was to be proactive through the early recognition and treatment of cardiotoxicities by cardiovascular risk assessment and prevention. The program would identify those at risk, triage cardiovascular complications, and set up survivorship plans for the patients.
After the Franciscan Health Cardio-Oncology Program was started, Rao realized it was important to explain to oncologists that the goal of the program was to continue therapy safely and be able to have better patient outcomes overall, not to stop chemotherapy altogether. To do that in the most efficient way, Rao’s program developed workflows that benefitted inter-departmental collaboration, so that they did not slow the process down for patients. They were able to get patients tested and seen for consultation within their target time of 7 days.
Through developing this process, the Franciscan Health Cardio-Oncology Program saw that they “needed someone that was living in the oncology world who could bridge the gap between cardiology and oncology to identify those patients, to relate to those patients, to have the ear of the oncologist,” and tell them the patient needs to be seen by the cardio-oncologist for help, Rao said.
A nurse navigator was suggested to bridge the gap and provide cardio-oncology surveillance as an ongoing task. Through testing and chart reviews of patients, subsequent identification of patients who are at risk with the cardiac risk assessment tools, and referrals of those patients to the cardio-oncologist based on their results, the nurse navigators can successfully help patients reduce their cardiotoxicity risk and minimize interruption of oncology treatment.
Kerry Skurka, RN, BSN, a cardio-oncology nurse navigator at Franciscan Health, discussed where they started when creating this program and why a nurse navigator was needed. After starting as a nurse navigator and working with both cardiologists and oncologists, she realized she had to be the connection for them and for the patients.
She described the first step to implementation of such a program as assessing the current practiceand meeting the providers where they are. Then a foundational education of guidelines, clinical literature, and research can be introduced. She recommended options including the American College of Cardiology, the American Society of Clinical Oncology, and the National Comprehensive Cancer Network guidelines. From there, processes and workflows can be established for the identification of patients using existing risk assessment tools.
Skurka also suggested that these programs should start small, because they grow quickly. These programs are highly dependent on a cohesive multidisciplinary team that collaborates and communicates consistently. Establishing a sub-committee of clinical staff who take care of program development as well as establishing a steering committee to inform administration and other key stakeholders of how that development is going is vital.
“You have to look at processes and workflows, and you have to work on both sides of the fence. Both the oncology office and the cardiology office,” Skurka said.
The workflow used at Franciscan Health grouped patients with cancer under 3 categories: before treatment, during treatment, and post-treatment. Each of these patient statuses still required the patient to go through a cardiovascular review of the patient’s history, physical exam, imaging, and testing. Then the risks or complications identified by the assessment told whether that patient needed a cardio-oncology consult.
“The goal of the oncologist is the best treatment [for patients] with the minimal amount of AEs, as close to guideline recommended, so they can get the best outcomes. The goal of our cardiologists was to assist them to meet that goal,” Skurka said.
From a poster by Skurka, Rao, and their colleagues, which was presented at the 68th Scientific Session of the American College of Cardiology,4 there were 259 patients referred to the cardio-oncology clinic between January 2017 and November 2018. There were also 625 patients receiving intravenous therapy at this time under the care of Skurka, including those who were referred, and 300 patients who received oral therapy in 2018 were navigated to the clinic.
The results of this analysis showed that the majority of patients were referred during treatment (84%) versus pre-chemotherapy (12%) and post-treatment (4%). The most common reasons for referral were decreased ejection fraction (25%) and blood pressure issues (24%). Of the common comorbidities and risk factors, the most common were hypertension (17%), hyperlipidemia (16%), and female gender (16%).
Right now, the Franciscan Health Cardio-Oncology Program averages 11 patients a week and has hired a second nurse navigator to focus on patients receiving oral treatments. From May 2018 to May 2020, there was a total of 444 patients who received oral antineoplastic treatment and 18% of referrals to cardio-oncology were from antineoplastic patients.
Some of the accomplishments of the program Skurka highlighted was the acquisition of an ECG machine, a biweekly clinic that will become weekly, and quarterly tumor board presentations. They also started blocking out 2 or 3 office visits for the cardiologist a week since patients need to be seen quickly. She said, “you [have] to know the availability of the cardiologist.”
“Cardio-oncology works best in collaboration. It helps to decrease patients’ cardiovascular outcomes and increase their quality of life and survivorship. Having a program that’s interdepartmental helps increase awareness and education among providers, administrators, and key stakeholders, including payers,” Skurka concluded.
1. Rao V, Skurka K. A nurse navigator led community-based cardio-oncology clinic. Slides presented at: the Association of Community Cancer Centers Virtual National Oncology Conference; September 14-18, 2020; Virtual
2. an Dalen EC, Michiels EMC, Caron HN, Kremer LCM. Different anthracycline derivates for reducing cardiotoxicity in cancer patients. Cochrane Database Syst Rev. 2010;2010(5):CD005006. doi:10.1002/14651858.CD005006.pub4
3. Ewer MS, Ewer SM. Cardiotoxicity of anticancer treatments: what the cardiologist needs to know. Natl Rev Cardiol. 2010;7(10):564-575. doi:10.1038/nrcardio.2010.121
4. Skurka K, Page H, Daly R, et al. Foundational Role of Nurse Navigation in a Community-Based Cardio-Oncology Program: The Franciscan Health Indianapolis Experience. Presented at: 68th Scientific Session of the American College of Cardiology; March 16-18, 2019; New Orleans, LA.