Advances in cancer detection and treatment have improved survival but increased the relative risk of cardiovascular complications from cancer therapies. In some populations, including breast cancer survivors, cardiovascular mortality now exceeds cancer-related mortality. Historically, cardiotoxicity has been linked to intravenous agents such as anthracyclines and monoclonal antibodies; the growing number of oral oncolytic agents has expanded the spectrum of cardiac adverse events.
Cardio-oncology aims to prevent, diagnose, monitor, and manage cardiovascular disease in patients undergoing or completing cancer treatment. Multidisciplinary teams typically include cardiologists, oncologists, nurses, pharmacists and other specialists. Oncology pharmacists can contribute medication expertise on oncolytic therapies, adverse event profiles, drug–drug interactions, monitoring and patient and team education, but their role in cardio-oncology programs is not well characterized.
A pilot project implemented an oncology-trained pharmacist position within a cardio-oncology clinic to support multidisciplinary care and improve medication management. The project team reviewed literature, consulted established cardio-oncology pharmacists, developed workflows and electronic medical record (EMR) smart phrases, and obtained institutional review board exemption for data collection. The pharmacist completed chart reviews before clinic visits, joined the cardiologist during patient encounters when needed, documented assessments and recommendations in the EMR, and tracked workload and interventions.
Patients were referred from oncology for baseline cardiovascular evaluation before potentially cardiotoxic therapy, for management of chemotherapy-related cardiac adverse events, after cardiac hospitalization during active cancer treatment, and for preconditioning cardiovascular assessment before stem cell transplantation. Drug–drug interactions were assessed using Lexicomp and guideline statements, and monitoring recommendations followed current cardio-oncology guidance and patient-specific risk factors.
From February 5 to March 8, 2024, the clinic saw 118 patients over 10 clinic days. Documentation was completed for 57 patients and two additional cases seen outside clinic were excluded from final analysis. The most common cancer diagnoses included breast cancer, diffuse large B-cell lymphoma and prostate cancer. Interventions were performed for 47 of the 57 documented patients (82.5%). The most frequent interventions were individualized monitoring plans (n=30), initiation of cardioprotective therapy for chemotherapy-induced cardiac adverse events (n=14), and assessment of drug–drug interactions (n=8). Monitoring recommendations included baseline and follow-up echocardiograms, follow-up lipid panels for patients on hormonal therapy, and baseline cardiac biomarkers for high-risk patients receiving immune checkpoint inhibitors. All reviewed patients received a drug–drug interaction assessment; in several cases the pharmacist advised on which cardiovascular medications could be safely initiated if needed. Of the 47 patients receiving interventions, 39 had one intervention and eight had two. All pharmacist recommendations were accepted. Ten documented patients had no interventions but received baseline assessments and documentation. Average chart-review time before visits was 40 minutes, with total time per patient around 60 minutes. No cancer therapy was discontinued due to cardiovascular disease during the pilot.
Early modifications to EMR documentation aligned pharmacist assessments with cardiovascular baseline risk frameworks and drug-specific adverse event profiles. Clinic assessments also incorporated venous thromboembolism and 10-year atherosclerotic cardiovascular disease risk scoring where appropriate. Patients without pharmacist interventions were generally on active surveillance or were seen during initial workflow refinement. Identified opportunities for improvement include enhanced patient education about cardiotoxicity and drug–drug interactions, ongoing clinician education about new cancer therapies, prospective studies on cardioprotective agents, establishment of collaborative practice agreements, and development of a cardio-oncology rotation for pharmacy residents.
The pharmacist also contributed outside scheduled clinic visits by advising on suspected immune checkpoint inhibitor–associated myocarditis and recommending lenvatinib dose adjustment for new-onset heart failure, and by providing drug information, literature reviews on rare adverse events, and anthracycline lifetime dose assessments for childhood and adolescent cancer survivors.
Limitations of the pilot include its four-week duration, which restricted assessment of long-term clinical impact and volume estimates. Chart review demands and limited pharmacist full-time equivalent (FTE) resources may constrain scalability; a patient acuity tool in the EMR could improve prioritization. Transition-period overlap between general cardiology and cardio-oncology clinics limited the ability to calculate the proportion of oncology patients who would qualify for referral. Longer-term data collection and defined quality measures are needed to evaluate outcomes and justify expanded pharmacist staffing.
Patients most likely to benefit from cardio-oncology assessment include those with cardiovascular risk factors who are receiving anthracyclines, HER2-targeted therapies, vascular endothelial growth factor inhibitors, BCR-ABL tyrosine kinase inhibitors, selected multiple myeloma therapies, BRAF and MEK inhibitors, and other high-risk agents that warrant baseline cardiovascular risk stratification.
The pilot demonstrated that integrating an oncology-trained pharmacist into a cardio-oncology clinic supported interdisciplinary management of chemotherapy-related cardiac adverse events, individualized guideline-recommended monitoring, safer medication management, and assessment of drug–drug interactions. Extended data collection and evaluation of expanded pharmacist responsibilities during follow-up visits are needed to refine workflow, optimize impact, and support continued investment in pharmacist FTEs for cardio-oncology services.
Author disclosures: Dr. Mancini is a consultant to GSK and on the speakers bureau of Janssen and Genmab/AbbVie; Dr. Ayres has received honoraria from BTG Pharmaceuticals (now SERB Pharmaceuticals) and Curio Science; Dr. Heiss has received honoraria from Sumitomo Pharma.
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