Cardiology and oncology care providers join forces

May 2016   Comments

Patients who undergo cancer treatments may have their quality of life and survival further affected by cardiotoxicity

Because treatments and the management of many cancers have become more successful, the survival rate of patients has improved in the last 25 years. This higher survival rate brings with it more patients presenting with cardiotoxicity as an adverse effect of many radiation and chemotherapy treatments.

As if the diagnosis of aggressive sinus cancer wasn’t frightening enough for Mark Jones,* discovering that the chemotherapy he so urgently needed had to be stopped due to cardiac issues was devastating. During his first infusion, he developed left arm pain and chest heaviness. The infusion was stopped, and he was immediately transferred to a unit with cardiac monitoring capability. Although his coronary angiogram was normal, evidence of heart failure was present. His chemo was put on hold.

Jones was fortunate he was having his infusions at Winnipeg’s Health Sciences Centre (HSC). Darlene Grantham, a clinical nurse specialist in oncology, and Karen Throndson, a clinical nurse specialist in cardiology, consulted with him together and helped support and educate him and his family. As part of the cardio-oncology team, the two made sure his discharge information included what warning signs to watch for and how to manage his cardiac risks so he would be prepared for any future cancer treatments.

These CNSs, who had been sharing an office for several years, found they were following the same patients quite often and realized working together would help patients whose cancer therapy was causing cardiac issues. In 2014, they conducted an audit of admitted oncology patients who developed cardiac complications. The three complications they saw most often in this inpatient population were cardiac ischemia, heart failure and arrhythmias, in part because of the patients’ ages and related comorbidities.

Grantham says the crossover of the oncology and cardiology fields is needed because of the complexity of the situations of these patients. “I think sometimes they are discharged without recognition of the severity of their diagnosis and comorbidities. They definitely need some kind of followup and ongoing support.” Monitoring the cardiac health of patients before, during and after cancer treatment is vital to ensure they can stay on the necessary treatments and have good cardiovascular functioning and health as a cancer survivor.

“Nurses caring for oncology patients play a critical role in the assessment and management of patients with new and pre-existing cardiac disease,” states Grantham. “And observing for cardiac disease in patients with cancer should be on every front-line nurse’s radar.”

Grantham and Throndson formed a nursing consult service at HSC to assist nurses in recognizing risk factors for cardiotoxicity.

They advocate for collaborative interdisciplinary cardiac and oncology team assessments, develop discharge plans that include a cardiology and oncology focus and provide teaching material to patients and families. One of the challenges, Throndson says, is determining just how much information patients and families can take in.

“Patients often feel they’ve traded one deadly disease for another. They discover that their eligibility for cancer treatment is in jeopardy and that their life may be in jeopardy as well,” says

Edith Pituskin, a nurse practitioner and an assistant professor of nursing at the University of Alberta in Edmonton. Her doctoral studies in rehabilitation medicine focused specifically on cardiotoxicity associated with cancer therapies. She is the co-lead of the Edmonton Cardio-Oncology REsearch (ENCORE) program, a clinic for cardio-oncology patients.

“The situation can be demoralizing for them,” Pituskin continues. “My clinics are full of people who are in urgent need of this care. What typically happens is that necessary cancer treatments may be stopped if the providers don’t have access to cardio-oncology expertise. Also, sometimes patients aren’t eligible for the aggressive treatments needed to treat the more aggressive cancers.” There’s a potential of being under treated, having delays in treatment or having the dose decreased.

“It’s almost like the antibiotics analogy, where you need the whole dose for the length of time prescribed,” she explains. “Cancer treatment is thought to be the same — that outcomes are closely associated with the planned dose and planned treatment with the treatment intensity that’s needed.”

Once a patient finishes treatment, responsibility for noticing possible cardiotoxicity falls to community health providers. “There needs to be a safety net that extends outside the cancer clinic and into the communities,” Pituskin says. “With radiation therapy, for example, it takes some years before the effects become evident. The more eyes on the situation, the stronger that safety net is.” She says she believes that all cancer survivors can be considered cardio-oncology patients and that nurses are in a unique position to provide holistic assessments and ongoing surveillance for developing symptoms.

Having postgraduate education in either cardiology or oncology is preferable for those working in this field, Wurtele says. She herself has education and many years of experience in both areas. “Patients and families recognize that I have some background in the situation,” she says, “and they appreciate that I understand their cancer and the types of chemotherapy and treatments they’re going through but can also put that into their cardiac perspective. Overall, patients are very thankful for the care we provide and feel grateful we are looking out for their potential cardiac issues.”

Throndson and Grantham are trying to raise awareness of this patient population and the consult service through newsletters, posters and presentations of case studies to interdisciplinary team members at local and national meetings and conferences. One of their initiatives was a risk assessment card for nurses, listing cardiotoxicity identifiers with the signs and symptoms to monitor for. With patients, their teaching focus is the importance of monitoring heart health and being alert for any shortness of breath, swelling, palpitations and chest pain.

Specialty education in this field is primarily offered to physicians. However, the role of the Canadian Cardiac Oncology Network (CCON), established in 2011, is to facilitate collaboration among physicians, nurses and other health-care professionals who are interested in this emerging field. The network offers conferences aimed at building more understanding of cardiac complications of oncology treatment.

Grantham, a member of the network, has attended a CCON preceptor workshop and presented at one of its conferences. She recommends that interested nurses attend CCON events and join the network to learn more about cardiac issues affecting oncology patients.

*Name has been changed

Susan Pennell-Sebekos

Susan Pennell-Sebekos is a freelance journalist in the Niagara region.

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