Managing Cardiovascular Complications of Oncology Treatment

To that point, the National Cancer Institute (NCI) and the National Heart, Lung, and Blood Institute led a workshop focused on hypertension and heart failure to identify gaps in knowledge, priorities for future research, and resources and collaborations needed to advance the field of cardio-oncology.¹² Workshop participants reached many of the same conclusions as the EORTC would the following year, including the need for standards in the collection of data on patient outcomes and cardiotoxicity and the need for standard terms and procedures to assess heart health at baseline and throughout treatment.¹²

Nonniekaye Shelburne, CRNP, MS, AOCN, has been an oncology nurse for almost 20 years and currently serves a program director in the Epidemiology and Genomics Research Program’s Clinical and Translational Epidemiology Branch at NCI. Dr Hamad, she said, is absolutely right.

“The existing guidelines are very minimal and the ones that do exist are very vague because we don’t have the evidence to support them,” Ms. Shelburne said. “We’re trying to generate the evidence that would support putting clinical practice guidelines out into the community.”

Ms. Shelburne added that NCI supports the National Community Oncology Research Program (NCORE), which has established a cardiotoxicity task force focused on identifying risk and conducting trials in treatment and management. A subgroup on symptom management within the NCI’s Clinical Trials Network has established cardiotoxicity as a priority so researchers will be more aware of the risk cardiotoxicty in study participants. Another subgroup of the Network has focused on cancer-related thrombosis as a research priority.

“People have been working in this area for 3 decades, recognizing that there are some mechanisms of cardiotoxicity we still don’t fully understand” she said. “But we know we have this large population that is suffering from it. We have a huge gap. The science is being done, the evidence is being generated to care for the patients. We’re trying to close that gap.”

Even though there are no established best practices, Dr Tamarappoo said that, in his experience, most patients with chemotherapy-associated cardiotoxicity can be treated like other cardiology patients.

“We’re still treating them with the same cardiac medications. If they come to us in heart failure, we’re still using the same medications,” he said. “The one thing about these patients is, we are less excited about sending them to surgery. We try to manage them with medication as much as possible.”

Dr Tamarappoo went on to say that he would recommend against surgery, especially for patients who have received radiation, due to concerns regarding wound healing.

Dr Goldberg said treatment should be driven by the patient’s condition.

“Individuals with left ventricular dysfunction or heart failure need guideline therapy: ACE [angiotensin-converting enzyme] inhibitors, beta blockers and diuretics if they are fluid overloaded. I take echocardiograms at baseline and then follow with an echo after each course of chemotherapy, and certainly after there is an increase in dose of chemo,” she said.

Patients at Elevated Risk and Future Directions

In most cases, the treating oncologist refers a patient who could be at risk for cardiotoxicity to a cardiologist. In an ideal world, the cardiologist would get to make that determination, said Dr Tamarappoo.

“I would have a cardiologist reviewing the echocardiograms, or at least the echo reports, for every patient who is going to get anthracycline-based chemotherapy regimen and flag those who are even borderline at-risk,” he said.

At present, there is no established method for identifying patients who are at an elevated risk for cardiotoxicity. As noted by Aleman et al, physicians treating cardiotoxicity in patients with cancer need imaging screening tools and surrogate markers for treatment-related cardiac diseases because clinical end points often do not appear until at least a decade or more.¹⁰