Advances in cancer detection and treatment have extended survival, but many patients now face a greater risk of cardiovascular complications from cancer therapies than of cancer recurrence. In breast cancer survivors, cardiovascular mortality can exceed cancer mortality. Historically, cardiotoxic therapies were primarily intravenous agents such as anthracyclines and monoclonal antibodies, but the growing number of oral oncolytics has expanded the list of drugs associated with cardiac adverse events, including reductions in left ventricular ejection fraction, cardiomyopathy, hypertension, arrhythmias, and immune-mediated cardiac injury.
A pilot project implemented an oncology-trained pharmacist in a cardio-oncology clinic to support prevention, diagnosis, surveillance, and management of cardiovascular disease related to cancer therapy and to enhance multidisciplinary care. Planning included a literature review, consultations with established cardio-oncology pharmacists, and coordination with the clinic cardiologist and program manager to develop workflow, documentation templates, and data collection methods.
Patients were referred to the clinic from oncology for baseline cardiovascular risk evaluation prior to potentially cardiotoxic therapy, for management of chemotherapy-related cardiac adverse events, after hospitalization for cardiac events during cancer treatment, and for preconditioning cardiovascular assessment before stem cell transplant. The pharmacist performed previsit chart reviews, joined cardiology visits when interventions or medication questions arose, and documented assessments and recommendations in the electronic medical record using standardized templates. Drug–drug interactions were evaluated using Lexicomp and guidance from cardio-oncology statements, and monitoring recommendations followed the 2022 European Society of Cardiology cardio-oncology guidelines and patient-specific risk factors.
Between February 5 and March 8, 2024, the clinic saw 118 patients across 10 clinic days; documentation was completed for 57 patients and two additional pharmacist-evaluated patients were excluded from analysis. Breast cancer was the most common diagnosis among clinic patients. Pharmacist interventions were recorded for 47 of 57 documented patients (82.5%). The most frequent interventions were individualized monitoring plans tailored to baseline risk and chemotherapy regimen (30 patients), initiation of cardioprotective therapy for chemotherapy-induced cardiac events (14 patients), and assessment of drug–drug interactions (8 patients). All pharmacist recommendations were accepted by the care team. Ten patients had no active interventions but received baseline assessments and documentation.
Previsit chart review averaged 40 minutes and total pharmacist time per patient, including the visit and postvisit updates, averaged about 60 minutes. Chart review was prioritized for patients on active treatment, stem cell transplant recipients, and childhood and adolescent cancer survivors. No cancer therapy was discontinued due to cardiovascular disease during the pilot.
Early in the pilot, pharmacist documentation templates were refined to align assessments with ESC cardio-oncology guidance and drug-specific cardiovascular adverse events. Clinic assessments incorporated venous thromboembolism risk scoring and 10-year atherosclerotic cardiovascular disease risk estimates when appropriate. Areas identified for improvement included expanded patient and clinician education on cardiac risks and drug interactions, prospective and retrospective studies of cardioprotective agent use during cancer treatment, development of a collaborative practice agreement to allow expanded pharmacist-led management, and creation of a cardio-oncology rotation for a PGY2 oncology pharmacy residency.
The pharmacist also contributed beyond scheduled visits, advising on inpatient cases of suspected immune checkpoint inhibitor myocarditis and lenvatinib-associated heart failure, providing dose-adjustment recommendations, answering drug-information queries, conducting literature searches on rare adverse events, and estimating cumulative anthracycline exposure for survivors.
Limitations of the pilot include its short, four-week duration, which restricted assessment of long-term impact, patient volume patterns, and outcomes of pharmacist-led interventions. The significant chart-review time required highlights the need for workflow efficiency tools, such as an electronic patient acuity tool that incorporates cardiovascular risk, visit status, and treatment status. The pilot could not determine the proportion of oncology patients who would qualify for cardio-oncology referral due to overlapping clinic duties and evolving referral practices among oncology providers. Despite these limitations, institutional support was secured for a 0.5 full-time-equivalent pharmacist position to continue data collection and expand the role.
The pilot demonstrates that an oncology-trained pharmacist integrated into a cardio-oncology clinic can enhance multidisciplinary care by individualizing guideline-recommended monitoring, managing drug–drug interactions, initiating cardioprotective therapy when indicated, and supporting clinician education. Expanded data collection, longer follow-up, and workflow optimization are needed to better quantify clinical benefits, refine the pharmacist role, and justify sustained or increased staffing.
Author disclosure statement: 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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