An international survey of healthcare providers' knowledge of cardiac complications of cancer treatments

Reducing the impact of cardiovascular disease in older people with cancer: a qualitative study of healthcare providers

PURPOSE

Cancer survivors are at greater risk of cardiovascular disease (CVD) than cancer-free controls. Despite evidence-based guidelines recommending CVD risk factor assessment, surveillance and risk-reduction, many people with cancer do not receive adequate CVD care. To address potential barriers and enablers of care, we examined healthcare professionals' (HCPs) perceptions and experiences of CVD risk assessment and management in people with cancer.

METHODS

We conducted one focus group and 12 individual interviews to examine HCPs' perceptions and experiences of CVD care in care. We used reflexive thematic analysis to collect and analyse the qualitative data to construct and understand themes.

RESULTS

Twenty-one HCPs participated (8 oncologists, 5 nurses, 3 general practitioners, 2 dietitians, 1 cardiologist, 1 haematologist and 1 physiotherapist). Majority of HCPs were aware of CVD risk in cancer but were concerned they could not deliver CVD care alone due to system-level barriers including lack of time and training. HCPs also perceived patient-level barriers including socioeconomic disadvantage and fatalistic outlook. Despite barriers, HCPs suggested diverse solutions for improving CVD care in cancer including new models-of-care, clinical pathways, risk assessment/management tools and education.

CONCLUSIONS

The diversity of perceived barriers and suggested solutions identified by HCPs suggests the need for a multilevel approach tailored to context. Future research involving people with cancer is needed to co-design acceptable interventions.

IMPLICATIONS FOR CANCER SURVIVORS

Improved understanding of HCP's perceptions can inform the development of new interventions to deliver CVD care to people with cancer to reduce morbidity and mortality.

When Cancer and Cardiovascular Disease Intersect: The Challenge and the Opportunity of Cardio-Oncology

Cancer and cardiovascular disease (CVD) commonly coexist, with increasing evidence that long-term cancer survivors are more likely to die from CVD than the general population. Effective management of CVD and its risk factors requires identification of patients at increased risk who may benefit from early intervention and their appropriate monitoring across the disease trajectory. Improving outcomes requires new models of multidisciplinary cancer care supported by care pathways. Such pathways require a clear delineation of the roles and responsibilities of all team members and provision of appropriate enablers for their delivery. These include accessible point-of-care tools/risk calculators, patient resources, and the provision of tailored training opportunities for health care providers.

Using the consolidated framework for implementation research (CFIR) to guide implementation of cardio-oncology services

Introduction

Cardio-oncology focuses on diagnosing and preventing adverse cardiovascular outcomes in cancer patients. Interdisciplinary cardio-oncology services address the spectrum of prevention, detection, monitoring, and treatment of cancer patients at risk of cardio-toxicity and aim to improve the continuum of cardiac care for oncology patients. The goal of this study was to engage clinician and administrative stakeholders to assess multilevel needs, barriers, and expectations regarding cardio oncology services.

Methods

We interviewed clinicians and administrators at an academic medical center using the Consolidated Framework for Implementation Research (CFIR) to understand multilevel determinants influencing cardio-oncology service implementation. We also conducted a web-based survey to assess the knowledge, attitude, and perceptions of cardio-oncology services held by local and regional clinicians who may refer cardio-oncology patients to the study site.

Results

Multiple facilitators to cardio-oncology service implementation emerged. Interview participants believed cardio-oncology services could benefit patients and the organization by providing a competitive advantage. A majority (74%) of clinicians surveyed thought a cardio-oncology service would significantly improve cancer patients' prognoses. Implementation barriers discussed included costs and a siloed organizational structure that complicated cross-service collaboration. In the clinician survey, differences in the views toward cardio-oncology services held by cardiology versus oncology providers would need to be negotiated in future cardio-oncology service development. For example, while most providers accepted similar risk of cardio-toxicity when consenting patients for cancer therapy in a curative setting, cardiologists accepted significantly higher levels of risk than oncologists in an incurable setting: 75% of oncologists accepted 1-5% risk; 77% of cardiologists accepted ≥5% risk).

Conclusions

Participants supported implementation and development of cardio-oncology services. Respondents also noted multi-level barriers that could be addressed to maximize the potential for success. Engaging administrators and clinicians from cardiology and oncology disciplines in the future development of such services can help ensure maximal relevance and uptake.

COVID-19 self-isolation patterns in UK dental care professionals from February to April 2020

Aim Dentistry is routinely associated with aerosol generating procedures. It has been suggested that aerosol generating procedures may place the dental professionals at increased risk of infection from respiratory pathogens. In the absence of widespread testing of the dental workforce to ascertain the incidence of COVID-19, a web-based self-reporting survey captured self-isolation patterns in dental professionals.Method A web-based closed questionnaire via the Survey Monkey platform captured reported COVID-19 self-isolation patterns in the dental team.Results A total of 3,309 responses were collected: 2,888 (87.3%) responses contained valid data and 26.8% of respondents reported self-isolating. Of these, 31.2% did so because they were suffering from COVID-like symptoms, 21.3% did so in order to protect a vulnerable member of their household, 25.7% did because a member of their household was suffering from COVID-like symptoms, and 21.8% self-isolated to protect themselves.Conclusion Despite the inherent limitations of self-reporting surveys, a web-based self-reporting questionnaire rapidly captured self-isolating patterns in DCPs. The initial findings from this survey would suggest that between February and April 2020, dental professionals did not experience disproportionately higher levels of COVID-like symptoms than the general population.

Early Diagnosis of Chemotherapy-Linked Cardiotoxicity in Breast Cancer Patients Using Conventional Biomarker Panel: A Prospective Study Protocol

The prognosis of cancer treatment depends on, among other aspects, the cardiotoxicity of chemotherapy. This research aims to create a feasible algorithm for the early diagnosis of antitumor therapy cardiotoxicity in breast cancer patients. The paper represents a protocol for a prospective cohort study with N 120 eligible participants admitted for treatment with anthracyclines and/or trastuzumab. These patients will be allocated into four risk groups regarding potential cardiotoxic complications. Patients will be examined five times every three months for six biomarkers,: cardiac troponin I (cTnI), brain natriuretic peptide (BNP), C-reactive protein (CRP), myeloperoxidase (MPO), galectin-3 (Gal-3), and D-dimer, simultaneously with echocardiographic methods, including speckle tracking. The adjusted relative risk (aOR) of interrupting an entire course of chemotherapy due to cardiotoxic events will be assessed using multiple analyses of proportional Cox risks. The Cox model will also assess associations between baseline biomarker values and time to cardiotoxic events. Moreover, partly conditional survival models will be applied to determine associations between repeated assessments of changes in biomarkers from baseline and time to cancer therapy-related cardiac dysfunction. All models will be adjusted for cancer therapy regimen, baseline LVEF, groups at risk, baseline biomarker values, and age. The decision-tree and principal component analysis (PCA) methods will also be applied. Thus, feasible patterns will be detected.

Future steps in cardio-oncology-a national multidisciplinary survey among healthcare professionals in the Netherlands

BACKGROUND

The awareness of cancer therapy-related adverse cardiac effects is fueled by recent literature on cardiotoxicity incidence and detection strategies. Although this influences the sense of urgency, in current practice, cardiotoxicity monitoring and treatment is not structurally performed. With this study, we aimed to evaluate current perspectives on cardio-oncology and to assess needs, ultimately to determine an agenda for improvements in current practice.

MATERIAL AND METHODS

A national multidisciplinary 36-question survey was conducted. The survey was developed by a multidisciplinary team, theoretically based on an implementation checklist and distributed by email, through cardiology and oncology societies as well as social media.

RESULTS

One hundred ninety professionals completed the survey, of which 66 were cardiologists, 66 radiation oncologists, and 58 medical oncologists and hematologists. Many professionals were unaware of their specialisms' cardio-oncology guidelines: 62.1% of cardiologists and 29.3% of the hematologists and medical oncologists respectively. Many cardiologists (N = 46; 69.7%), radiation oncologists (N = 45; 68.2%), and hematologists and medical oncologists (N = 38; 65.5%) expressed that they did not have sufficient knowledge to treat cardio-oncology patients and would either refer a patient or aspire to gain more knowledge on the topic.

CONCLUSION

The field of cardio-oncology is advancing rapidly, with progress in stratification and detection strategies leading to the development of new guidelines and consensus statements. However, the application of these guidelines in current practice appears to be lagging. Professionals express a need for additional training and a practical guideline including risk stratification, monitoring, and treatment strategies. Multidisciplinary discussion and consensus on cardio-oncology care is vital to improve implementation of cardio-oncology guidelines, ultimately to improve cardiac care for oncology patients.

Digital Transformation in Medical Affairs Sparked by the Pandemic: Insights and Learnings from COVID-19 Era and Beyond

A number of developments, including increasing regulatory and compliance scrutiny, increased transparency expectations, an increasingly vocal patient, patient centricity and greater requirements for real-world evidence, have driven the growth and importance of medical affairs as a trusted, science-driven partner over the past decade. The healthcare environment is shifting towards a digital, data-driven and payor-focused model. Likewise, medical affairs as a function within the pharmaceutical industry has become more "patient-centric" with strategic engagements embracing payers and patients apart from clinicians. The pandemic has impacted the healthcare industry as well as the function of medical affairs in numerous ways and has brought new challenges and demands to tackle. There is indeed a silver lining due to intense digital transformation within this crisis. The emerging digital innovation and new technologies in healthcare, medical education and virtual communications are likely to stay and advance further. In this review, we discuss how the digital transformation sparked by the pandemic has impacted the medical affairs function in pharmaceuticals and provide further insights and learnings from the COVID-19 era and beyond. Based on the learning and insights, digital innovation in three key strategic imperatives of medical affairs-HCP engagement, external partnerships and data generation will enable medical affairs to become future-fit as a strategic leadership function.

Health Disparities: Impact of Health Disparities and Treatment Decision-Making Biases on Cancer Adverse Effects Among Black Cancer Survivors

BACKGROUND

Health disparities affect cancer incidence, treatment decisions, and adverse effects. Oncology providers may hold biases in the decision-making process, which can perpetuate health disparities.

OBJECTIVES

The purpose of this article is to describe health disparities across treatment decisions and adverse effects, describe decision-making biases, and provide suggestions for nurses to mitigate adverse outcomes.

METHODS

A scoping review of the literature was conducted.

FINDINGS

Factors affecting health disparities stem, in part, from structural racism and decision-making biases, such as implicit bias, which occurs when individuals have unconscious negative thoughts or feelings toward a particular group. Other decision-making biases, seemingly unrelated to race, include default bias, delay discounting bias, and availability bias. Nurses and nurse navigators can mitigate health disparities by providing culturally appropriate care, assessing health literacy, providing education regarding adverse effects, serving as patient advocates, empowering patients, evaluating personal level of disease knowledge, and monitoring and managing cancer treatment adverse effects.

Decision Science Can Inform Clinical Trade-Offs Regarding Cardiotoxic Cancer Treatments

Cancer treatment-related cardiotoxicity (ie, heart failure, coronary artery disease, vascular diseases, arrhythmia) is a growing cancer survivorship concern within oncology practice; heart disease is the leading cause of noncancer death in cancer survivors and surpasses cancer as the leading cause of death for some cancers with higher survival rates. The issue of cardiotoxicity introduces a critical tradeoff that must be acknowledged and reconciled in clinical oncology practice: treating cancer aggressively and effectively in the present vs preventing future cardiotoxicity. Although many cancers must be treated as aggressively as possible, for others, multiple treatment options are available. Yet even when effective and less cardiotoxic treatments are available, they are not always chosen. Wariness to choose equally effective but less cardiotoxic treatment options may result in part from providers' and patients' reliance on "cognitive heuristics," or mental shortcuts that people (including, research shows, medical professionals) use to simplify complex judgments. These heuristics include delay discounting, availability and affect heuristics, and default bias. In the current commentary, we describe relevant research that illuminates how use of heuristics leads to biased medical decision making and translate how this research may apply when the tradeoff between aggressive cancer treatment and preventing future cardiotoxicity is considered. We discuss the implications of these biases in oncology practice, offer potential solutions to reduce bias, and call for future research in this area.

Cardio-oncology: rationale, aims and future directions

PURPOSE OF REVIEW

Cardiovascular comorbidity among cancer patients is a growing clinical problem with the dramatic improvements in cancer survival. Cardio-oncology has developed as a new medical field dedicated to addressing the complex issues faced by patients who have both cancer and cardiovascular disease. This article explains to the reader what cardio-oncology services provide and the nature of cardiovascular problems caused by the growing array of modern cancer therapies.

RECENT FINDINGS

The list of potentially cardiotoxic cancer therapeutic agents is ever growing and dedicated cardio-oncology experts are required to tackle cardiovascular complications with minimal delay to necessary cancer therapy. Cardio-oncology services originated in academic centres but are now being set up around the world in all hospitals and clinics that provide care to cancer patients. Cardio-oncology plays an increasingly active role at every stage of cancer therapy including baseline risk assessment pretreatment, surveillance and prevention during treatment, response to acute complications and assessment in survivors post cardiotoxic treatments. New treatment strategies exist to optimize cancer treatment so it can be completed safely.

SUMMARY

In the present review, we explore the rationale, aims and roles of cardio-oncology, as well as future directions, which will certainly require multidisciplinary international collaboration.

What Does a Cardio-oncology Service Offer to the Oncologist and the Haematologist?

Cardio-oncology is an emerging subspecialty arising from the need for multidisciplinary collaboration to address the increasing prominence of cardiovascular disease (CVD) among cancer patients. This overview outlines the case for establishing cardio-oncology services and defines the ways in which these services benefit cancer patients. The primary objective of cardio-oncology is to manage CVDs in order to allow cancer patients to complete the best cancer treatments safely and with minimal interruption. In the decades since the first discovery of heart failure induced by anthracycline chemotherapy, both cardiovascular and oncological science have advanced considerably. Cardio-oncology services aim to bring together expertise from these two fast moving fields in order to provide optimal evidence-based care for cancer patients with CVDs. Here we discuss the basis of cardio-oncology services by presenting their rationale and key components, as well as their essential roles in education, training and research. At each stage of the cancer care pathway, a cardio-oncology service can add value by ensuring cancer patients have timely access to specialist care backed up by cutting edge diagnostic tools and treatment options, as well as holistic supports. We highlight areas of recent and upcoming developments in the field that are likely to change established clinical practice. Improved cardiac imaging modalities can detect chemotherapy-related cardiac dysfunction earlier and are also essential for the prompt diagnosis of an expanding range of cardiovascular effects complicating newer cancer therapeutics, such as immune checkpoint inhibitors and other targeted therapies. Modern cancer therapy has dramatically improved cancer survival and as such CVD is becoming one of the principal determinants of overall outcome for cancer patients. A dedicated cardio-oncology service can facilitate the optimisation of cardiovascular treatment and enable the completion of cancer therapy. A multidisciplinary collaborative approach is key to achieving these objectives.

Oncology professionals' perspectives towards cardiac surveillance in breast cancer patients with high cardiotoxicity risk: A qualitative study

Breast cancer (BC) patients have an increased risk of developing cancer therapy-related cardiac dysfunction (CTRCD) and cardiovascular morbidity, which seems to have a substantial prognostic impact. Oncologists, in collaboration with dedicated cardiologists, have the opportunity to perform cardiovascular risk stratification. Despite guideline recommendations, strategies to detect cardiac damage at an early stage are not structurally implemented in clinical practice. The perspectives of oncology professionals regarding cardiac surveillance in BC patients have not been qualitatively evaluated. We aim to explore the perceptions of oncology professionals regarding cardiac surveillance in BC patients and, more specifically, the influencing factors of delivering cardiac surveillance. A qualitative study with semi-structured interviews was conducted and thematically analyzed. Twelve oncology professionals participated in this study. Four themes were selected to answer the study objectives: (1) sense of urgency, (2) multidisciplinary collaboration, (3) patient burden, and (4) practical tools for cardiac surveillance. Most professionals did not feel the need to deliver cardiac surveillance as they considered the incidence of CTRCD as rare. Multidisciplinary collaboration was also perceived as unnecessary, and cardiac surveillance was considered disproportionately burdensome with respect to its benefits. Nevertheless, professionals affirmed the need for practical tools to deliver cardiac surveillance. Most professionals are currently unaware of CTRCD incidence and cardiac surveillance benefits. Encouraging multidisciplinary collaboration and improving their knowledge of cardiotoxic effects of treatments and possibility of early detection can lead to structured cardiac surveillance for breast cancer patients.

#CardioOncology: Twitter chat as a mechanism for increasing awareness of heart health for cancer patients

Consideration of heart health for cancer survivors is increasingly important, as improved cancer survivorship has resulted in a growing number of survivors affected by cardiovascular disease. However, there is limited knowledge of cardio-oncology among both patients and a variety of health professionals. Thus, efforts are needed to increase awareness about cardio-oncology. Social media represents one potential opportunity to disseminate information about cardio-oncology to a large audience. We highlight one example of a social media educational/advocacy campaign conducted on Twitter (a "Twitter Chat") that garnered nearly 1.2 million impressions (views by Twitter users) in just 24 h. We provide both quantitative and qualitative data to support the efficacy of using Twitter for such educational/advocacy campaigns, and describe key features that contributed to its success. Twitter Chats inexpensively utilize innovative technology to provide education and foster community. Long-term studies are needed to understand whether Twitter Chats can change knowledge and behavior related to cardio-oncology.

Healthcare utilization and hospital variation in cardiac surveillance during breast cancer treatment: a nationwide prospective study in 5000 Dutch breast cancer patients

Background

Various breast cancer (BC) treatments, such as chemotherapy and targeted therapies, increase cardiotoxicity-risk and lead to premature ischemic heart disease and heart failure among survivors. Reducing this adverse risk through early recognition and (preventive) treatment is therefore important. Conversely, we feel that screening for cardiotoxicity is currently insufficiently standardized in daily practice. A fundamental first step in identifying areas of improvement is providing an overview of current practice.

Objective

This study aims to describe current cardiac surveillance for women with BC during and after cardiotoxic cancer treatment, using routinely collected hospital data in the Netherlands. The study also describes hospital variation in cardiac surveillance.

Methods

This observational study was performed on claims data provided by Statistics Netherlands. From the data, newly diagnosed BC patients in 2013 (N = 16,040) were selected and followed up until 2015. Healthcare utilization analyses were performed for all cardiac and oncologic healthcare activities but with a specific focus on cardiac surveillance healthcare activities. In addition, differences between types and individual hospitals were evaluated.

Results

Almost one third of all BC patients received high risk cardiotoxic treatments (N = 5157), but cardiac surveillance was rarely performed. Cardiac care provided to patients mainly consisted of ECGs (52.0%) and MUGA scans (26.5%). Cardiac MRI was performed in 0.7% of the patients, echocardiography in 17.7%, and measurement of Troponin and NT-proBNP in 5.1 and 5.8%, respectively. Moreover, we observed a substantial variation in cardiac surveillance between different hospital types and between individual hospitals.

Conclusion

This study shows that women treated for BC with cardiotoxic treatments do not receive recommended cardiac surveillance. Standardized approaches in clinical care are lacking, resulting in low rates of diagnostic testing and a substantial variation in surveillance between hospitals. A structured approach and increased interprofessional collaboration could lead to tailored cardiac surveillance for early detection of cardiotoxicity and therefore start of treatment.

Oncocardiology: new challenges, new opportunities

Patients with cancer are at a higher risk of cardiovascular disease, which contributes to significant morbidity and mortality. The rapid progress in the field of oncological treatments has led to a steady increase in long-term cancer survivors. Care for cardiovascular complications is therefore becoming increasingly important. In addition, the establishment of new oncological therapies has resulted in the identification of previously unknown cardiovascular side effects. Oncocardiology aims to detect and treat cardiovascular diseases associated with cancer and cancer therapy. Continuous scientific, clinical, and structural developments are necessary as the basis for the best care of the growing number of affected patients. This review summarizes current developments in the field of oncocardiology with regard to advances in cancer therapy and challenges in clinical oncocardiology work. Cardiovascular side effects by targeted cancer therapies are characterized and recent advances in the field of cardiovascular diagnostics are outlined. Developments to better integrate oncocardiology into the medical care system and perspectives for modern, patient-oriented care are shown. In light of the coronavirus disease 2019 (COVID-19) pandemic, current challenges and opportunities are highlighted. The relevance of profitable further advances in oncocardiology including standardized guidelines and educational programs is delineated as a mandatory requirement for the successful development of oncocardiology.