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Cardio-Oncology: A Continually Evolving Subspecialty in Oncology Nursing

Anecita Fadol
CJON 2021, 25(1), 93-96 DOI: 10.1188/21.CJON.93-96

Cardio-oncology is a unique subspecialty within oncology nursing that focuses on the assessment, identification, and management of cardiotoxicity induced or exacerbated by cancer treatment. Nurses are pivotal to the delivery of evidence-based assessment of and care for individuals who have preexisting cardiac conditions, as well as those for whom cardiac complications are related to the known and emerging toxicities of cancer treatment.

AT A GLANCE

  • Cardio-oncology is a continually evolving specialty in the field of oncology nursing.
  • Cardio-oncology is focused on the unique cardiac toxicities that are caused by, as well as preexisting cardiac conditions that can be exacerbated by, a cancer diagnosis and its treatment.
  • As more patients receive care—both those with preexisting cardiac conditions and those with known or newly discovered treatment-related cardiotoxicities—it is important for oncology nurses to understand the foundational principles of cardio-oncology care, as well as opportunities for subspecialty in this area.

February, which is American Heart Month, is the optimal time to consider the unique role of heart health in the context of cancer care. As the two leading causes of death in the United States (National Center for Health Statistics, 2020), cancer and cardiac disease share an ominous connection that is further exacerbated when they occur concurrently. Increased overall survival for patients with cancer coupled with chronic cardiac conditions or treatment-induced cardiotoxicities increasingly requires comanagement of cancer and heart disease (Gilchrist et al., 2019). The number of cancer survivors is expected to increase to more than 22 million by 2024, the majority of whom (64%) are aged 65 years or older (Miller et al., 2019). This is the same age at which the risk of heart disease, including heart failure, is more likely to occur. Individuals with cancer may present with a preexisting cardiac condition or may develop treatment-induced cardiotoxicities, both of which can affect treatment course, symptom burden, and overall survival (Johnson et al., 2016). Cardiotoxicity is well established for anthracyclines and novel targeted kinase inhibitors (Bellinger et al., 2015; Herrmann & Lerman, 2014) but has also been observed with radiation therapy (Niska et al., 2018) and immunotherapies (Lobenwein et al., 2020) (see Table 1). Given the potential for cardiac complications induced or exacerbated by treatment and the increasing population of individuals with potential for these comorbidities, it is important for oncology nurses to have insight into the assessment, identification, and management of cardiac complications in the context of cancer care. In this article, the author presents the role of cardio-oncology as a subspecialty of oncology care, with insights into how nurses across practice settings can integrate evidence-based care for individuals with cancer and cardiac complications, as well as pursue educational and training opportunities to specialize in this increasingly important field of oncology nursing.

Defining Cardio-Oncology

Cardio-oncology is the intersection of two specialties (oncology and cardiology); the goal is the treatment of cardiovascular disease in patients with cancer (Cardinale et al., 2008; Herrmann & Lerman, 2014), with particular focus on the adverse effects of cancer therapy (Lenihan et al., 2016). Following cancer treatments in many patients, the risk of cardiovascular death may be higher than the actual risk of tumor recurrence (Yeh, 2006). Baseline risk factors and heart disease being equal, patients previously treated with chemotherapy (particularly those treated with anthracyclines) have been shown to have an increased risk of cardiomyopathy, heart failure, and myocardial infarction in the subsequent 20 years (Herrmann, 2020). With growing demand in cancer care, a number of cardio-oncology clinics (Fradley et al., 2017; Snipelisky et al., 2017) are emerging across the United States, not just in primary cancer institutions, but also in general hospitals and in community centers. As such, it is essential for nurses caring for these patients to have a basic understanding of cardio-oncology.

Role of the Cardio-Oncology Nurse

The nurse is at the heart of patient care in the cardio-oncology interprofessional team (Pirschel, 2020a). Nurses bridge the gap between cardiologists, oncologists, and the interprofessional team to provide seamless care for patients with cancer with multiple comorbidities, including concurrent cardiovascular disease (Pirschel, 2020b). The roles of nurses in cardio-oncology are diverse, depending on their scope of responsibility, either as bedside clinicians, advanced practice providers, educators, coordinators, or managers. A majority of their roles involve coordinating patient care and providing education to patients, families, caregivers, and other healthcare team members from diagnosis and treatment to survivorship and end-of-life care (Fradley et al., 2017; Pituskin et al., 2017). Nurses have also proven to be instrumental as part of interprofessional teams implementing cardio-oncology programs (Fitzgerald & Neilson, 2018; Fradley et al., 2017).

The Cardio-Oncology Subspecialty

With expanding populations of individuals with cardiotoxicities induced or exacerbated by cancer treatment, there is a unique demand for nurses with cardio-oncology backgrounds to care for this population. As such, there is a tremendous opportunity to develop formalized training for nurses in the field of cardio-oncology. Cardio-oncology nursing requires a knowledge of cardiology and oncology; however, there are no known academic training programs or certifications in this specific field. Instead, the combined knowledge of this specialty area is primarily derived from the practice setting. Oncology nurses can gain insight through continuing education of clinical practice in cardiology, whereas nurses with cardiology backgrounds can gain further training and experience in oncology. Certification exists for oncology (Oncology Nursing Certification Corporation, 2020) and cardiovascular nurses (American Nurses Credentialing Center, 2020). Current practices in cardio-oncology are largely extrapolated from existing cardiology and oncology literature, and research specific to cardio-oncology is ongoing to support evidence-based practice.

However, there are some barriers to cardio-oncology specialization, including the following:

•  The lack of academic and clinical mentorship in cardio-oncology

•  A shortage of evidence-based cardio-oncology clinical standards

•  Few opportunities for specialized education and training

Whereas physicians have access to dedicated cardio-oncology fellowships (Johnson et al., 2017; Lenihan et al., 2016) emerging in universities affiliated with academic medical centers, no such programs are known to exist for nurses. Therefore, it is imperative to cultivate nurse leaders who will champion specialized patient care, education, and research to expand knowledge in the evolving specialty of cardio-oncology.

Cardio-Oncology Resources

In the absence of formal training programs, and for nurses interested in furthering their knowledge of cardio-oncology to support evidence-based practice, there are several available resources (see Figure 1). Nurses employed in cancer centers have the advantage of learning from an interprofessional group of practitioners comprised of cardiologists, hematologists-oncologists, pharmacists, and other nurses. Pharmacists serve as particularly useful resources because their expertise covers different cancer therapeutics, potential cardiotoxicities, and pharmacologic management of cardiac complications. Nurse coordinators can educate the cardio-oncology trainee about the complexities of coordinating care for this patient population, as well as the psychosocial challenges many of these patients face on a regular basis (Fradley et al., 2017; Johnson et al., 2017; Lenihan et al., 2016; Okwuosa & Barac, 2015).

For professional growth and development in cardio-oncology nursing, nurses can increase their knowledge of the specialty by attending cardio-oncology lectures and participating in cardio-oncology–focused scientific meetings, such as the American College of Cardiology (2020)–sponsored “Advancing the Cardiovascular Care of the Oncology Patient” or the Global Cardio-Oncology Summit, and focused lectures and sessions on cardio-oncology at the annual Oncology Nursing Society (2020) Congress. In addition, accessing current research, published evidence, clinical practice guidelines, and virtually available education can support practice based on current and best available evidence.

Conclusion

With the rapid development of the field of cardio-oncology, the need has increased for specialty-trained nurses. As such, it is essential to develop dedicated training programs to educate nurses about best practices and to ensure that high-quality standardized cardiovascular care is provided to patients with cancer. Currently available resources, including educational offerings and reference materials, provide a foundational source of evidence-based information for nurses interested in exploring this unique and evolving field.

About the Author(s)

Anecita Fadol, PhD, RN, FAANP, FAAN, is an associate professor in the Departments of Nursing and Cardiology at the University of Texas MD Anderson Cancer Center in Houston. The author takes full responsibility for this content and did not receive honoraria or disclose any relevant financial relationships. Fadol can be reached at afadol@mdanderson.org, with copy to CJONEditor@ons.org.

 

References 

American College of Cardiology. (2020, February 14–16). Advancing the cardiovascular care of the oncology patient [Live course]. https://www.acc.org/cvoncology

American Nurses Credentialing Center. (2020). Cardiac Vascular Nursing Certification (CV-BCTM). https://www.nursingworld.org/our-certifications/cardiac-vascular-nurse

Bellinger, A.M., Arteaga, C.L., Force, T., Humphreys, B.D., Demetri, G.D., Druker, B.J., & Moslehi, J.J. (2015). Cardio-oncology: How new targeted cancer therapies and precision medicine can inform cardiovascular discovery. Circulation, 132(23), 2248–2258. https://doi.org/10.1161/CIRCULATIONAHA.115.010484

Cardinale, D., Colombo, A., & Cipolla, C.M. (2008). Prevention and treatment of cardiomyopathy and heart failure in patients receiving cancer chemotherapy. Current Treatment Options in Cardiovascuar Medicine, 10(6), 486–495. https://doi.org/10.1007/s11936-008-0041-x

Fitzgerald, L.W., & Neilson, P. (2018). Development of an outpatient cardio-oncology program. Oncology Issues, 33(3), 44–53. https://doi.org/10.1080/10463356.2018.1456174

Fradley, M.G., Brown, A.C., Shields, B., Viganego, F., Damrongwatanasuk, R., Patel, A.A., . . . Ismail-Khan, R. (2017). Developing a comprehensive cardio-oncology program at a cancer institute: The Moffitt Cancer Center experience. Oncology Reviews, 11(2), 340. https://doi.org/10.4081/oncol.2017.340

Gilchrist, S.C., Barac, A., Ades, P.A., Alfano, C.M., Franklin, B.A., Jones, L.W., . . . Wright, J.S. (2019). Cardio-oncology rehabilitation to manage cardiovascular outcomes in cancer patients and survivors: A scientific statement from the American Heart Association. Circulation, 139(21), e997–e1012. https://doi.org/10.1161/CIR.0000000000000679

Herrmann, J. (2020). Adverse cardiac effects of cancer therapies: Cardiotoxicity and arrhythmia. Nature Reviews Cardiology, 17(8), 474–502. https://doi.org/10.1038/s41569-020-0348-1

Herrmann, J., & Lerman, A. (2014). An update on cardio-oncology. Trends in Cardiovascular Medicine, 24(7), 285–295. https://doi.org/10.1016/j.tcm.2014.07.003

Johnson, C.B., Davis, M.K., Law, A., & Sulpher, J. (2016). Shared risk factors for cardiovascular disease and cancer: Implications for preventive health and clinical care in oncology patients. Canadian Journal of Cardiology, 32(7), 900–907. https://doi.org/10.1016/j.cjca.2016.04.008

Johnson, M.N., Steingart, R., & Carver, J. (2017). How to develop a cardio-oncology fellowship. Heart Failure Clinics, 13(2), 361–366. https://doi.org/10.1016/j.hfc.2016.12.012

Lenihan, D.J., Hartlage, G., DeCara, J., Blaes, A., Finet, J.E., Lyon, A.R., . . . Carver, J. (2016). Cardio-oncology training: A proposal from the International Cardioncology Society and Canadian Cardiac Oncology Network for a new multidisciplinary specialty. Journal of Cardiac Failure, 22(6), 465–471. https://doi.org/10.1016/j.cardfail.2016.03.012

Lobenwein, D., Kocher, F., Dobner, S., Gollmann-Tepeköylü, C., & Holfeld, J. (2020). Cardiotoxic mechanisms of cancer immunotherapy—A systematic review. International Journal of Cardiology, 323, 179–187. https://doi.org/10.1016/j.ijcard.2020.08.033

Miller, K.D., Nogueira, L., Mariotto, A.B., Rowland, J.H., Yabroff, K.R., Alfano, C.M., . . . Siegel, R.L. (2019). Cancer treatment and survivorship statistics, 2019. CA: A Cancer Journal for Clinicians, 69(5), 363–385. https://doi.org/10.3322/caac.21565

National Center for Health Statistics. (2020, October 30). Leading causes of death. https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm

Niska, J.R., Thorpe, C.S., Allen, S.M., Daniels, T.B., Rule, W.G., Schild, S.E., . . . Mookadam, F. (2018). Radiation and the heart: Systematic review of dosimetry and cardiac endpoints. Expert Review of Cardiovascular Therapy, 16(12), 931–950. https://doi.org/10.1080/14779072.2018.1538785

Okwuosa, T.M., & Barac, A. (2015). Burgeoning cardio-oncology programs: Challenges and opportunities for early career cardiologists/faculty directors. Journal of the American College of Cardiology, 66(10), 1193–1197. https://doi.org/10.1016/j.jacc.2015.07.033

Oncology Nursing Certification Corporation. (2020). Certifications. https://www.oncc.org/certifications

Oncology Nursing Society. (2020). ONS Congress. https://congress.ons.org

Pirschel, C. (2020a). Advanced practice nurses are at the heart of patient care in cardio-oncology. ONS Voice. https://voice.ons.org/conferences/advanced-practice-nurses-are-at-the-he...

Pirschel, C. (2020b). Cardio-oncology program monitors heart toxicities throughout survivorship. ONS Voice. https://voice.ons.org/stories/cardio-oncology-program-monitors-heart-tox...

Pituskin, E., Paterson, I., Cox-Kennett, N., Rothe, D., Perri, M., & Becher, H. (2017). The role of cardio-oncology in the interprofessional care of adult patients receiving cancer therapy. Seminars in Oncology Nursing, 33(4), 384–392. https://doi.org/10.1016/j.soncn.2017.08.010

Snipelisky, D., Park, J.Y., Lerman, A., Mulvagh, S., Lin, G., Pereira, N., . . . Herrmann, J. (2017). How to develop a cardio-oncology clinic. Heart Failure Clinics, 13(2), 347–359. https://doi.org/10.1016/j.hfc.2016.12.011

Yeh, E.T.H. (2006). Cardiotoxicity induced by chemotherapy and antibody therapy. Annual Review of Medicine, 57(1), 485–498. https://doi.org/10.1146/annurev.med.57.121304.131240