Cardiac Rehabilitation for Cardio-Oncology Patients

With the advances in early detection and treatment, the number of cancer survivors has steadily increased since the 1970s (1). However, cancer survivors are at risk for long-term effects that may occur as a result of the cancer itself and/or its treatment and can begin during therapy and persist beyond the end of treatment (1). Future cardiovascular disease remains one of the most serious and life-threatening complications of cancer treatment (1, 2). Specifically, cancer survivors living at least five years past their diagnosis have a 1.3- to 3.6-fold increased risk of cardiovascular-specific mortality, and a 1.7- to 18.5-fold increased incidence of cardiovascular risk factors, including hypertension, diabetes mellitus and dyslipidemia when compared to age-matched equivalents with no previous cancer history (3, 4). Moreover, as the Canadian population continues to age, this adds yet another layer of risk for future cardiovascular disease to this patient population (5). There has therefore been a call to address the increased risk of cardiovascular disease among cancer survivors.

One solution for preventing future cardiovascular disease among cancer survivors is cardiac rehabilitation (CR) (6). CR is “the provision of comprehensive long-term services involving medical evaluation, prescriptive exercise, cardiac risk factor modification, and education, counselling, and behavioural interventions” (7). The objectives of CR include increasing functional capacity, decreasing angina symptoms, supporting cardiovascular risk reduction, improving psychosocial well-being, and reducing recurrent hospitalizations and the associated morbidity and mortality of cardiovascular disease (8). It has further been reported that CR reduces cardiovascular disease mortality and hospital admissions, and improves health-related quality of life in patients with coronary artery disease (9). Therefore, to prevent or mitigate future cardiovascular events in this patient population, a cardio-oncology rehabilitation model has been recommended. Such a model would take place at the University of Ottawa Heart Institute (UOHI) Cardiac Prevention and Rehabilitation with necessary modifications for this patient population taught to the staff prior to program implementation.

Objectives used to achieve this Fellowship goal include: identifying and recruiting key stakeholders to support this initiative; set up a tracking database to monitor which physicians are referring their patients from The Ottawa Hospital Cardio-Oncology Clinic to the UOHI Cardiac Prevention and Rehabilitation; hold informal interviews with the referring cardiologists and oncologists as a means to examine ongoing barriers and facilitators for the referral process; evaluate patient self-management education by pre- and post-program surveys and interviews; evaluate the patient’s exercise capacity at program entry and exit; and evaluate, of the eligible cancer survivors referred to the CR program, how many participated (i.e. attended) at least one CR class, and how many completed their CR program.

Throughout this fellowship, I have learned the importance of teamwork, as well as good and frequent communication. Given the scope of this project, and that it crossed not only two different hospitals but two different specialties, it was extremely important to ensure that myself, the Cardio-Oncology Referral Clinic, as well as the Cardiac Rehabilitation program were all on the same page and aware of where the project was at. It was through an open-line of communication that we were able pivot who was able to refer to the program.

In addition, given the highly specialized nature of the patient population we were working with, it was helpful to be able to utilize the expertise of all the team members identified early on in the project, and seek their assistance with the creation of a process diagram, an audit tool, a referral slide deck, a lunch-and learn and accompanying staff booklet for the Cardiac Rehabilitation staff, a presentation for the oncology nursing staff, a satisfaction survey, and focus group questions for participating patients.