Cancer & Cardiovascular Disease: Impacts at All Ages

March 19, 2024
Guest: Chelsea Kriesberg, DNP, CPNP-AC, CCRN, and Lisa Nodzon, PhD, APRN, AOCNP

While cancer survivorship rates continue to improve, there are CVD-related complications for patients before, during, and after cancer treatment. Guests Chelsea Kriesberg, DNP, CPNP-AC, CCRN, and Lisa Nodzon, PhD, APRN, AOCNP, describe the intersection of cancer and cardiovascular disease across the lifespan. Collaborative, team-based, and life-long care is illustrated through a case-based discussion.

Supported by the BMS-Pfizer Alliance.

Episode Resources

  • Cardiovascular risk calculator
  • Cardiac Disease in Childhood Cancer Survivors: Risk Prediction, Prevention, and Surveillance. Leerink, J, de Baat, E, Feijen, E. et al. Cardiac Disease in Childhood Cancer Survivors: Risk Prediction, Prevention, and Surveillance: JACC CardioOncology State-of-the-Art Review. J Am Coll Cardiol CardioOnc. 2020 Sep, 2 (3) 363–378.
  • Cardioprotective impacts of dexrazoxane: Lipshultz SE, Scully RE, Lipsitz SR, et al. Assessment of dexrazoxane as a cardioprotectant in doxorubicin-treated children with high-risk acute lymphoblastic leukaemia: long-term follow-up of a prospective, randomised, multicentre trial. Lancet Oncol. 2010 Oct;11(10):950-61. doi: 10.1016/S1470-2045(10)70204-7. Epub 2010 Sep 16. PMID: 20850381; PMCID: PMC3756093.
  • Improving quality and quantity of life for childhood cancer survivors: Ehrhardt MJ, Krull KR, Bhakta N, et al. Improving quality and quantity of life for childhood cancer survivors globally in the twenty-first century. Nat Rev Clin Oncol. 2023 Oct;20(10):678-696. doi: 10.1038/s41571-023-00802-w. Epub 2023 Jul 24. PMID: 37488230.

Welcome to Heart to Heart Nurses, brought to you by the Preventive Cardiovascular Nurses Association. PCNA's mission is to promote nurses as leaders in cardiovascular disease prevention and management.  

Geralyn Warfield (host): Welcome to our audience. In today's episode, we will be discussing the interrelationship of cancer and cardiovascular disease for patients of all ages. My guests today are Lisa Nodzon and Chelsea Kriesberg. Lisa, could you introduce yourself to us please?  

Lisa Nodzon (guest): Hi. Yes, thank you, Geralyn. I am a Lead Advanced Registered Nurse Practitioner in the Department of Malignant Hematology at the H. Lee Moffitt Cancer Center and Research Institute in Tampa, Florida. 

I've been practicing there since 2010 with a focus on chronic myeloid and chronic lymphoid leukemias. But I have a special interest as well in the mitigation and management of [00:01:00] cardiotoxicities imparted by the treatment modalities used in the management of these disease states. And we do a lot of coordination with patient care within our cardio-oncology department at Moffitt Cancer Center. 

And I'm also pleased to announce that I just joined ICOS [International Cardio-Oncology Society] as the Chair for Clinician Education. Thank you for having me here today.  

Geralyn Warfield (host): Chelsea, could you please introduce yourself to our audience? 

Chelsea Kriesberg (guest): Hi. Yes, absolutely. Thank you so much for having me. My name is Chelsea Kreisberg, and I am a Pediatric Nurse Practitioner with the Division of Cardiology at Advocate Children's Hospital outside of Chicago. 

I am also our institution's Team Lead for Pediatric Cardio-Oncology, and I'm the chair of the International Cardio-Oncology Society, or ICOS’—like Lisa mentioned--Pediatric Nursing subcommittee.  

My interest in cardio-oncology became a passion when I was practicing as a Nurse Practitioner on the advanced heart failure team here, and we received a couple of referrals for the evaluation of patients after receiving cancer therapy, [00:02:00] but only after there were changes on their echocardiograms or identified changes in their biomarkers. 

I then became driven to develop a program, not only for the treatment of these patients, but also for the screening and early prevention of cardiovascular effects in all patients who have been treated for cancer regardless of their risk. 

Geralyn Warfield (host):  Well, we definitely have a lot to learn from each of you about how cardiovascular disease and cancer are interrelated. And, Chelsea, I'm hoping you could start for us, with a little bit of an overview of how the rates of cancer and survivorship have continued to change.  

Chelsea Kriesberg (guest): Absolutely. So about 85% of children diagnosed with cancer will achieve five-year survival because of the advances in treatments, technologies, and the care that these patients now receive. 

In fact, a recently published article by Ehrhardt, et al [see show notes for link] stated that the number of childhood cancer survivors in the US alone is expected to reach about 580,000 by 2040. This is an [00:03:00] insane amount of survivors, even in comparison to 10, 20, and 30 years ago.  

Additionally, these childhood cancer survivors are at risk, or increased risk, for the development of cardiovascular-specific late effects over time, with a 10.6% incidence of heart failure within 40 years of cardiotoxic cancer therapy or treatment. 

Other significant risk factors include those including coronary artery disease, valve disease, and arrhythmias. 

Geralyn Warfield (host): Lisa, do you have more information that you could share with our audience?  

Lisa Nodzon (guest): Yeah, I was going to say, adding to that as well, we have improved progression-free survival [PFS] rates as well in some of our cancers, in particularly the oral agents we utilize to treat chronic myeloid leukemia [CML]. We tend to tell our CML patients now that they won't die from CML, rather, they'll die with CML, as our therapies are that effective and with improved survival.  

As well as in chronic lymphocytic leukemia—or CLL we call it-- [00:04:00] the malignant hematology. We do have significant PFS as well in the oral oncolytics we use for them. 

But of course, with the agents that we use in malignant hematology, we can affect survivorship and affect things in survivorship, like with the use of our anthracyclines or other combined chemo regimens. We use arsenic trioxide, carfilzomib in multiple myeloma, as well as some complex treatment modalities like bone marrow transplant. We now have bispecific antibodies. And then of course the new kid on the block is the chimeric antigen receptor treatment or CAR T.  

So not just that we can improve survivorship, but we have to remember that these modalities can produce short- as well as long-term cardiotoxicities. 

Supportive medications as well that we utilize as part of these regimens like Zofran® (ondansetron), managing a lot of the nausea that our patients may experience, can also affect cardiac function.  

So, while we have improved our [00:05:00] survival rates in these cancer disease states, we have also imparted some significant cardiotoxicities that can occur as well, too.  

Geralyn Warfield (host): I think for many of us in clinical practice, we get a little bit focused on what we're doing every day in practice and don't necessarily think about those connections between cancer and cardiovascular disease, or CVD, that you've alluded to and started our discussion about, Lisa.  

And I'm wondering if you could talk about those relationships between CVD and cancer for those of us that aren't, perhaps, cardio-oncology specialists. 

Lisa Nodzon (guest): Certainly. As we know that cancer is typically a consequence of aging. As we get older, we're more prone to having, right, the genomic errors and alterations in our cells. 

So as such, many of our patients will come into their diagnosis already with underlying cardiovascular disease, which we can certainly exacerbate by the treatment modalities that we give. Median age of diagnosis for both chronic lymphocytic leukemia, [00:06:00] as well as chronic myeloid leukemia, is around age 65, although we do see patients as young as 18 years old in our practice following referral from pediatric hematology or oncology.  

And as I mentioned above, the standard of care for these disease states is that of the oral targeted therapy. For example, with CLL, we use Bruin tyrosine kinase inhibitors, or BTKIs, as the mainstay of therapy as they've been shown to be more effective or improve PFS in our patients. 

But they can also cause the cardiotoxicities that we have to watch out for, particularly uncontrolled hypertension, increased bleeding risk for patients that are already on anti-platelet or anticoagulation agents, as well as arrhythmias—primary AFib or V-tach has also occurred as well as ventricular arrhythmias. 

So, patients that come into CLL, for example, that have hypertension, again just the fact that these BTKIs can exacerbate is of [00:07:00] concern.  

In CML, as I mentioned above, we use the oral targeted agents, tyrosine kinase inhibitors, or TKIs that we like to call them. Mainstay of therapy; they've improved survival. 

As I indicated, patients typically will die with CML and not from CML.  

There's five on the market. Each, to a varying degree, can increase risk for different cardio dysfunction, if you will, particularly with risk for alterations in glucose metabolism. So leading patients to diabetes if they're not pre-diabetic coming into CML. 

One of our TKIs in particular, nilotinib, can do this. Increased risk for atherosclerosis as well as myocardial infarctions, uncontrolled hypertension due to VGEF inhibition, particularly with ponatinib that we utilize, peripheral arterial disease, pulmonary pericardial effusions, for example. 

So, you can see there's a plethora of cardiac dysfunction coming from the medications that we utilize. 

As well as something we have to think [00:08:00] about is just the common side effect of diarrhea with these agents can cause electrolyte shifts, particularly on our patients, that are already on diuretics or have known chronic kidney disease. 

So, we have to make sure we always have a nice balance between controlling disease state as well as modifying those risk factors that are coming from the patient. So, a lot of these patients we identify as being high-risk for these particular events are referred to our cardio-oncologist at Moffitt Cancer Center. We try every effort to mitigate the risk involved.  

Geralyn Warfield (host): So, we've already heard about how cancer survivors are living longer and also about the potential cardiovascular impacts of some of these cancer treatments. So as clinicians, no matter where it is that we are working, what our setting might be, what can we do to help our patients reduce their cardiovascular disease or CVD risk before, during, and after cancer treatment? 

Lisa Nodzon (guest): Yeah, that's a big question. It's an ongoing question and [00:09:00] something that we have to address at every clinic visit with our patient. Patient education is key, so we really aim for awareness both to the patient as well as their caregiver when they come in for clinic visits.  

We do a lot of lifestyle modification discussions, talk about healthy diet. Smoking cessation is a big one. Increasing exercise. All in effort to mitigate these measures that occur with these agents we use. 

I think the key point here is to be proactive for our patients. So, for any patient initiating a regimen that we know has known cardiovascular risks, again, we collaborate with cardio-oncology. Patients will go in to see their team.  

They're assessed for cardiovascular risk. Of course, each patient will be different whether their background is hypertension, or they need lipid management, or tight glycemic control.  

Medication assessment is really important as well. We know we've got a lot of drug-to-drug interactions, as well as other, what we call ‘housekeeping’ medications that can impart increased risk, you know, for patients [00:10:00] that are already on antidepressants, antifungals. Vaping and drug abuse, as well, are known risk factors in our patients. Macrolides, anti-emetics, as well as compliance for their medications that are utilized in the cardiovascular setting. So that's really important, um, that these key discussions are had. 

Cardio-oncologists may have to order a baseline EKG or an echo for our patients. Consideration is also there for ankle brachial index if insurance will approve, and the patient is a good candidate for it.  

So again, reiterating just the key point is to be proactive with these patients and something that we have to visit at every single clinic visit. 

Chelsea Kriesberg (guest): I absolutely agree. And Lisa, like you mentioned, most of these prevention strategies are actually applicable to both the pediatric and the adult populations. The European Society of Cardiology just put out in 2022 some new guidelines for really closely monitoring these patients [00:11:00] before, during, and after cancer therapies. 

For example, I can give you a little bit of a breakdown about each of those. You know, so before receiving cancer treatment, patients should undergo individualized cardiovascular evaluation that Lisa was mentioning. So, this can include a review of family and personal history. This should absolutely include heart disease, hyperlipidemia, hypertension, and coronary artery disease. 

In some patients, this—in all patients really—this should also include evaluation of dysrhythmia. So back to that 12-lead EKG that Lisa had mentioned, getting a baseline echocardiogram, always very, very important along with some labs.  

So, you want to trend those biomarkers, specifically the NT-proBNP, which has shown a lot of promise as far as trend in recent research. Troponin levels, electrolytes, and different measures of end organ function by lab. These studies can then all be referenced throughout the patient's treatment course, not only by the oncologist, but if the patient is then referred to a [00:12:00] cardiologist or a cardio-oncologist when necessary. 

For patients undergoing active treatment with immune checkpoint inhibitors, for example, these ICIs, baseline EKGs, and even troponin levels have proven very increasingly helpful in the management of ICI-related myocarditis, a topic that is gaining a lot of airtime lately.  

During treatment, dexrazoxane or a medication called Zinecard®, is an IV medication that can be given or is given concomitantly with the infusion of an anthracycline chemotherapy. And this medication, while initially controversial, has been proven in clinical trials as an infected measure of cardioprotection, resulting in about 60 to 80% reduction in the risk for developing cardiotoxicity in pediatric patients.  

This is a huge, huge change in that almost all, and I can almost safely say that all of our providers here are giving [00:13:00] Zinecard® and dexrazoxane with planned anthracycline administrations, typically, in patients that are at moderate- or high-risk, those receiving moderate or large to high amounts of anthracyclines.  

Targeted radiation, when you're thinking about patients that are about to undergo or are undergoing radiation. Targeted radiation uses 2D and 3D models that can help avoid risk areas and decrease the volume of radiation administered to the heart. This, again, is a newer technology that has been overwhelmingly helpful in the prevention of cancer treatment-related cardiac dysfunction, or CTRCD prevention.  

And then, following the completion of their cancer therapy, the ‘ringing of the bell’ for those patients, it's important to continue to closely monitor all of these patients, regardless of their age, for CTRCD as I mentioned, to ensure that these survivors have the ability to support, and lead healthy lives with the highest quality of life possible.  

So many [00:14:00] recommendations exist in the pediatric and the adult worlds. However, maybe, you know, as Lisa was mentioning, the most important is the collaboration of a multidisciplinary team, including the survivorship team, a primary care provider, oncologist, cardiologist, even dietician for some of those, hyperlipidemia, hypertension, pre-diabetes or diabetes patients, along with other supporting subspecialties, to really monitor for cardiovascular side effects.  

You know, something as simple as fatigue, shortness of breath, chest pain, palpitations, and changes in actual cardiac structure or biventricular function by echocardiogram, and other age-related associated disease processes makes all the difference in preventing these patients or catching and capturing these effects of cancer therapy before it can really, truly affect the patient's life. 

Lisa Nodzon (guest): Yeah. Thanks Chelsea. I totally agree. I mean, so we can see that there's so many different things that can happen to the patient [00:15:00] before, during, and well into survivorship when it comes to these cardiotoxicities.  

Something that arises a lot for us in oncology or even hematology, is that in select cases, we sometimes have to discontinue or even dose reduce some of the agents that we're utilizing. Like for example, you know, anthracyclines have a limit how much a patient can receive over their lifetime.  

We have to consider drug-to-drug interactions as well. This sometimes can lead to a need for balancing, or even ethical dilemmas in how we manage our patients. Where we have to look at benefit versus risk, for example. In some of our patients, for example, if a patient has congestive heart failure and we know that the best standard of care therapy for the patient may exacerbate fluid shifts or even lead to arrhythmias, increasing the risk in the patient where therapy is risky. 

Some patients such as this, with significant cardiac comorbid conditions, may not be eligible, therefore, for clinical trial. They might not have the [00:16:00] eligibility requirements mandated per the clinical trial and even with standard of care. So again, looking at ethical dilemmas does arise during the patient's cancer journey. 

Sometimes we have to then go to a goal of care discussion for the patient, or even palliative care. So, you can see how before, during, and after, [it’s] really pivotal that we are monitoring these patients appropriately and just trying to mitigate these risk and modifying lifestyle factors as much as possible. 

Geralyn Warfield (host): From our discussion thus far, it's evident that cancer has significant impacts on the human body as do the treatments. And I'm wondering what kind of impacts we see in the vascular system specifically. Chelsea, could you talk about that for us?  

Chelsea Kriesberg (guest): Sure. So, cancer treatment can have a significant impact on the cardiovascular system, especially in patients, as mentioned, receiving high or cumulative doses of both chemotherapy, or high doses of chemotherapy alone, or both chemotherapy and radiation. Anthracycline [00:17:00] chemotherapy—probably the most talked-about kind of culprit—results in the formation of what are called free radicals and oxidative stress within the mitochondria of the cardiomyocyte, and leads to cell death. 

This also leads to inhibition of biogenesis, and oftentimes then can be seen as resulting in cardiac dysfunction and possible future structure abnormalities. For example, the changes in the dimension of the left ventricle, which can lead to decreased LV ejection fraction (or left ventricular ejection fraction), and sometimes heart failure. 

Patients who receive radiation, for example, are at increased risk for the development of coronary artery disease, valve anomalies, heart failure secondary to cardiomyopathies, arrhythmias, pericarditis, and in some cases VTE or thromboembolism. The severity or extent of this cardiotoxicity after radiation is also associated with cellular composition, replication of the cell, differentiation, and radiation [00:18:00] sensitivity. 

So, this can vary patient to patient. More specifically, exposure to radiation at a young age. So, our pediatric patients receiving radiation in combination with chemotherapeutic agents, irradiated cardiac volume, and cumulative dose of radiation, further increase that patient's risk for CV side effects. 

Lisa Nodzon (guest): Yeah, so we can definitely see that a lot of what we do to our patients can have a lot of negative impacts. So hence the need for the multidisciplinary care. Over in hematology or oncology world, we know based on clinical trial data, what we see with cardiotoxicities. And then there's the real world, right? I mean, sure, Chelsea can testify to that.  

For example, in the treatment of CML, we utilize nilotinib as a standard of care based on the phase 3 trial data for nilotinib, patients experienced a higher cumulative increase in total blood cholesterol at around 27%, glucose elevations at 49%, as well as [00:19:00] hypercholesterolemia. Hence the need for patients having to start a statin, concomitantly, obviously with the nilotinib. 

So, we also see ischemic heart disease, 3.9% from the trial data, ischemic vascular events at 1.4%. So, we can see that not only does the patient have the underlying comorbid conditions, but what the drugs can do. 

All of these increased risks occur in time. So, the longer the patient's on nilotinib, the increased risk. When patients start TKI therapy for CML, they go indefinitely. So, you can see that over the course of their CML journey, perhaps these risks can be increased.  

Ibrutinib mainstay therapy, BTKI, has really revolutionized how we treat our B-cell malignancies in terms of survival, and as I mentioned earlier, PFS. If we looked at pool trial data from four randomized controlled trials, they show that atrial fibrillation occurs in around 6-16% of patients, independent predictors being aged greater [00:20:00] than 65, as well as a history of AFib. Of course, de novo AFib can occur with these agents as well. Patients with uncontrolled hypertension, or with hypertension, have an increased risk.  

Ponatinib is another TKI that we utilize in CML therapy, particularly in our higher risk patients, our patients that have failed other lines of TKIs. This is a VEGF inhibitor and we know VEGF inhibitors can lead to uncontrolled hypertension, thus precursor for cardiovascular risk as well. 

Geralyn Warfield (host): So, it's definitely a delicate balancing act in terms of what to do in terms of treatment and what to do in terms of prevention or management of cardiovascular disease. And I'm thinking that there are some types of things that you will be seeing in practice that go beyond the vascular impact. So, what other things do you see beyond what we've already discussed? 

Lisa Nodzon (guest): Yeah, so the disease state as well. A lot of our patients can be more sedentary just due [00:21:00] to maybe anemia secondary to the disease, or the treatment we give, or just being fairly fatigued from the treatment that we give in general. We can see frequent hospitalizations also leading to more sedentary state just due to disease complications. 

We have infection risk with the peripheral or central lines, which can also increase risk for venous thromboembolisms in our patient population with the risk being around 5- 20%. Or even pulmonary emboli.  

A special concern obviously is the cancer itself, increasing risk for inflammation within the body, just increasing inflammatory state, increasing risk for the complications for patients with history of peripheral arterial disease. Nilotinib or ponatinib, for example, may exacerbate that condition, which has been shown to also lead to loss of limbs.  

So really in addition to what I previously discussed above, we have to be really cautious in our patients as well, particularly when they're already on anticoagulation or antiplatelet therapy. Why? Our patients may be at a higher bleeding risk just due [00:22:00] to the disease itself. Thrombocytopenia, platelets getting into low 10,000 range, or even the need for platelet transfusions can be obviously of concern where we have to hold anticoagulants, or we have to hold antiplatelet therapy, because of the bleeding risk. 

Some of our disease states as well can lead to disseminated intravascular coagulation. So obviously patients are bleeding in the hospital state. Liver failure, thrombocytopenia as well, where I mentioned above, you have to hold certain agents for platelets less than 50,000. So, thinking about the patients perhaps that are in AFib or already are undergoing therapy for having pulmonary emboli or even DVTs, can be risky in them.  

Autoimmune or idiopathic thrombocytopenia purpura can occur in our patients, leading to the destruction of the red blood cells or the platelets respectively. So, this is also an increasing the patient's risk for bleeding.  

We have to know when to hold these agents as well. The patients undergoing a bone marrow [00:23:00] biopsy or perhaps a procedure, increasing their risk for complications post-procedure with bleeding.  

So as well, we do see hemorrhagic strokes in our patients with thrombocytopenia or with our particular agents just due to these increased bleeding risk. 

Hypertension must really be monitored in our patients with thrombocytopenia. As I mentioned, it's, it's really not unheard of for particularly patients in cancer to have low platelets, sometimes even less than 10,000 or 30,000, just as a consequence of the bone marrow infiltration or the therapies themselves.So, our patients may never achieve adequate platelet levels.  

Due to these inherent risks, obviously with anticoagulation, cancer patients are of a special concern. Moffitt Cancer Center has internal guidelines for how do we manage anticoagulation in our patients. We do not use thromboprophylaxis in the ambulatory setting patients receiving cancer therapy, or with low risk for venous thromboembolism. If needed, low molecular weight [00:24:00] heparin is preferred.  

Hospitalized patients also have a unique concern. Risk-benefit ratio has to be considered in our patients. Why are the platelets low? Do we expect impending thrombocytopenia? Is the patient being hospitalized for DIC? So, special consideration is given if patients will receive dalteparin, or enoxaparin, or unfractionated heparin.  

And in fact, in a recent study, which actually gave us some data on what should we be using in our malignant hematology patients, the Caravaggio trial actually looked at comparing apixaban versus dalteparin for cancer-associated venous thromboembolism showing similar rates of major bleeding as well as major GI bleeding. So, it kind of gave us a bit of a guideline, where cancer patients typically were excluded from these sort of clinical trials on what we can utilize.  

But we also know that oral anticoagulation in our patients does improve compliance. It's got ease of administration. So, it was nice to [00:25:00] have some data on this subject for what we can do in terms of steering our practice. 

We do use apixaban after risk-benefit as well in our patients. Why? Because there's a longer half-life. Sometimes we have absorption issues in the stomach and small bowel, but we know for our patients with GI lesions, this would be contraindicated. So, we have to think about as well, the agent that we're giving the cancer in the background. So, you can see the complexity that already imparts upon our cancer patients.  

Warfarin is one that I want to bring up, not recommended for our patients as an anticoagulant. Why? Because of the increased risk with affecting the INR, the patient's diet might be altered. We know that, green things contraindicated for patients on warfarin, but the antibiotics that these patients typically will receive prophylactically or due to the increased infections, can also affect the INR.  

So outside of the absolute need for warfarin, um, is indicated for some of our [00:26:00] patients that have the particular valves where it's mandated, not recommended for patients to be started on with cancer. 

Chelsea Kriesberg (guest): And in the pediatric population, you know, these patients are at risk and, and at risk for future development of heart failure, or ischemic heart disease, and sometimes stroke. So, in talking about those PTE risks and the anticoagulants that you mentioned, Lisa, these are things that we take into consideration just maybe in a different light. 

St. Jude and the Childhood Cancer Survivor study, or the CCSS, have actually developed and published a very easy to use risk assessment tool to predict these risks among survivors of childhood cancer by age 50 years, taking into account the gender of the patient, the age at cancer diagnosis, the treatment received including total anthracycline dose, total volume of radiation, and the site of the radiation, along with [00:27:00] alkylators and platinum agents. 

Additional considerations when evaluating and treating the pediatric or even the adult survivors should also include evaluation and screening for hypertension, like we've talked about, those diabetic patients, dyslipidemia, and making the connection between the cardio-oncology and survivorship teams, along with the patient's primary physician, more important and influential in the patient's long-term care and overall lifelong health. 

Geralyn Warfield (host): We are going to take a quick break and we will be right back.  


Geralyn Warfield (host): We are back for more discussion about cardiovascular risk of cancer and how that affects individuals or patients across the lifespan from pediatric through adults.  

And we know that cancer treatments have changed dramatically over time. If you look at cancer treatments that happened 10, 20 or more years ago, things look much differently now in those cancer treatment options. And in order for patients to receive those best options for them, [00:28:00] what does that process look like in practice?  

Lisa Nodzon (guest): Yeah, so I can run a quick case study by everyone just to kind of show what we would see coming into our clinical practice and who are the team members that would be involved, particularly in our referrals. 

So, let's say we have a 24-year-old male patient with chronic phase chronic myeloid leukemia. He was diagnosed at age 16, so he'd be coming to us from Chelsea's world, the pediatric oncology world, if you will. 

He's receiving frontline nilotinib 300 milligrams by mouth, twice a day, standard dosing. 

He's been on it for the past eight years. As I mentioned earlier, with the NSND data, this patient's going to be in an increased risk for cardiovascular events. 

Past medical history: let's say hyperlipidemia, as well as obesity. He's on rosuvastatin as well as daily aspirin to mitigate these comorbid conditions. 

So, for a patient like this coming into our clinical practice, being that we're malignant hematology, we'd be very focused on the CML as well as the management [00:29:00] of the nilotinib. However, looking at these underlying cardiovascular risks between the drug as well as the patient's comorbid risk factors, we would refer such a patient to cardio-oncology. And then as Chelsea mentioned earlier, making sure that the patient's primary care physician is also on board.  

So, you can already begin to see development of this multidisciplinary team between primary care, cardio-oncology, as well as oncology. Over in cardio-oncology, Chelsea can probably speak a little bit more in depth on this, with regard to baseline assessment that would have to occur once this kind of a patient would land on the cardio-oncology doorstep. 

Such assessment may occur with looking at Framingham Cardiovascular Risk Scores, management of the cardiac risk factors; patient's hypertension would have to be controlled. We see cardio-oncology optimizing lipid management, as well as looking at hemoglobin A1C. And then these tests would be run at particular [00:30:00] time points based on that patient's individualized risk. 

EKGs are also performed when patients start on nilotinib prior to, as well as about a week or so after starting therapy, due to the increased risk for QTC prolongation as well. This patient is also at increased risk for peripheral arterial occlusive disease. So, management surrounding that, whether an ankle brachial index would need to be performed would be up to the cardio-oncologist.  

They may also check baseline atherothrombotic risk markers such as the CRP, as well as looking at the, as I mentioned, ABI. We see a lot of use of the A-B-C-D-E algorithm. Utilized kind of as a simplified approach in systematically looking at the guidelines for patients with comprehensive management plan for primary and as well as secondary prevention of cardiovascular disease. 

So, I see this utilized a lot in [00:31:00] cardio-oncology when looking through their dictations after our patients have been seen over there with A standing for anti-platelet therapy, blood pressure control for B. C: cholesterol lowering therapy, as well as cigarette cessation. That's a really big one in our patients, as well as thinking about the patients that are also vaping. D: diet modification, also very huge. As well as trying to teach diet modification, we might have to get a nutritionist involved or a diabetes counselor in our patient population. We know behavioral modification is not something that occurs overnight, but over a course. 

This is really important here for prevention or management of the condition as well as E for exercise. As I mentioned above, not all of our patients feel up for exercise, but really, really important for that assessment to occur; working with primary care physician, physical therapy for that.  

So you can see really it does take a village when it comes to management of these patients, particularly between oncology and [00:32:00] cardiology themselves, but also with the other ancillary players: pharmacy, RNs—extremely important, social workers as well. It kind of takes everybody to monitor out for their kind of piece of the pie when it comes to our patient care.  

But something else that I wanted to throw out that's also a risk in our patients is a lot of our drugs that we utilize in the cancer world come from specialty pharmacies. So, drug-to-drug interactions is really of a concern. Strong CYP3A inhibitors as well as inducers can really affect bioavailability of our drugs. And we know that specialty pharmacy doesn't interplay with the patient's local pharmacies. So, pharmacists are really important when it comes to also the multidisciplinary management of our patients in looking at the medication list and making sure that all pharmacies that the patient is utilizing have that updated medication rec. 

Really, really important. Really important tip there.  

Chelsea Kriesberg (guest): I think that this is a great case, [00:33:00] Lisa and I absolutely agree with you. In my experience, focusing on the interprofessional or multidisciplinary approach, along with partnering in our case with the patient's parents or guardians, has always, and always probably will, make for a better relationship during and after treatment into survivorship. 

And because of that trust and hopefully an established rapport, the transition then from pediatric providers to an adult cardio-oncology program can maybe be a little bit more seamless. Childhood cancer survivors should be empowered by the time that they're adults and even moving into adulthood as early as their teenage years, as they grow up to be participants in their own care. Starting, like I said, as early as their teen years, and take some personal pride and responsibility for their healthcare moving into adulthood when they see you guys. 

Teaching a pediatric survivor about possible late effects of cancer therapy early helps them to understand [00:34:00] the importance of long-term follow-up care. And this can lead to prevention of these side effects that we've mentioned, you know, throughout our conversation today. Specifically as we're talking about the cardiac-related side effects. 

Geralyn Warfield (host): If you had one takeaway for our listeners about the links between cancer and cardiovascular disease across the lifespan, what would it be? 

Lisa Nodzon (guest): Yeah, I would say that, you know, based on our podcast discussion today, we can really see the complexity of care with cancer patients being at increased risk for cardiovascular disease as well as these events just secondary to the treatment modalities perhaps that we're giving the patients the disease state. 

We also see that we have improved survival and sometimes we have to utilize goals of cancer care. So really what we focused on here today is how much multidisciplinary management it takes for one patient to go on therapy.  

Chelsea Kriesberg (guest): A takeaway for the listeners, you know, from my perspective is prevention. Prevention is key. [00:35:00] This includes the early screening, risk stratification, and identification of both pediatric and adult patients with cardiovascular complications related to their cancer treatment. This will improve outcomes by not only initiating timely and appropriate medical therapy, but will hopefully, and should, decrease the morbidity and mortality among these survivors. 

Geralyn Warfield (host): Is there anything else that either of you would like to add?  

Chelsea Kriesberg (guest): No. Thank you so much for including me in today's discussion. I would encourage anyone interested in learning more about cardio-oncology—pediatric and adults—in joining the International Cardio-Oncology Society, or ICOS, and truly submerging themselves in the opportunity to learn more about this growing field. 

Additionally, feel free to contact me with questions, or if you or your colleagues are looking for additional information, conference opportunities and webinars.  

Lisa Nodzon (guest): Yeah. And I second everything that Chelsea just said and want to also say thank you so much for including me here today on this podcast, coming from the [00:36:00] oncology world, dipping into cardio-oncology. 

And please feel free to reach me if you have any further questions. So, thank you for having me.  

Geralyn Warfield (host): We are so grateful to our guests, Lisa Nodzon and Chelsea Kriesberg, for sharing their expertise with us.  

We'd also like to thank Pfizer-Bristol Myers Squibb Alliance for funding support for this particular episode. 

This is your host, Geralyn Warfield, and we will see you next time. 

Thank you for listening to Heart to Heart Nurses. We invite you to visit for clinical resources, continuing education, and much more. 

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