Carolyn Reilly, PhD, RN, CHFN, FAHA
Katherine Yeager, PhD, RNCarolyn Reilly is an assistant professor and Kate Yeager is an assistant professor at the Nell Hodgson Woodruff School of Nursing at Emory University in Atlanta, Georgia.
But are cancer survivors getting the specific care they need?
The Institute of Medicine’s report From Cancer Patient to Cancer Survivor: Lost in Transition1 recognizes that the current US healthcare system does not often deliver the comprehensive and coordinated follow-up care that cancer survivors require. The reports calls on providers not only to arrange for surveillance for cancer recurrence but also offer holistic care addressing chronic effects of cancer and treatment side effects, monitoring for and preventing late effects like heart disease, and promoting a healthy lifestyle.
Cardiotoxicity and Cancer
Because nursing has a significant role on the “front lines” of cancer care both in hospitals and ambulatory settings, nurses must serve as a source of knowledge and advocacy for cancer survivors. One specific area that requires attention and research is cardiac health in cancer survivors.
Cancer survivors have nearly an 8-fold increased risk of death due to cardiovascular disease compared with the general population. Potential mechanisms include the cardiotoxic effects of chemotherapy and radiation, and modifiable risk factors related to cardiac health including inactivity, poor diet composition, and excess weight. In addition, cancer survivors experience disease- or treatment-related symptoms that persist post-therapy which are often barriers to an active lifestyle.
Both radiation and chemotherapy can result in cardiotoxicity. Pericardial effusion, pericardial constriction, myocardial dysfunction, and heart failure may be serious clinical conditions encountered among cancer survivors. Effects of chest radiotherapy are manifested as coronary artery disease and valvular dysfunction.
Chest irradiation can also contribute to cardiac dysfunction after the myocardium gets exposed to certain dose levels of radiation. Specific to chemotherapy, anthracyclines (such as doxorubin, epirubicin, liposomal doxorubicin, or mitoxantrone) are major contributors of cardiomyopathy. Unfortunately, these cardiotoxic side effects from treatments are often exacerbated by coexisting conditions like hyperlipidemia and hypertension.
Carolyn Reilly, an assistant professor at the Nell Hodgson Woodruff School of Nursing at Emory University, recently completed a study to describe the prevalence of cardiovascular disease in lymphoma survivors.2
Participants (N = 31) in this cross-sectional, correlational study were a mean age of 47.6 years; most were males (55%) and white (84%). Participants averaged 5 years since lymphoma treatment. Routine laboratory tests and fasting lipid levels, coronary artery calcification computed tomography, echocardiography, and patient-reported outcomes were measured.
Subclinical disease was detected in 35% of the sample, with 28.6% of the women having diastolic dysfunction. Women scored lower than men in health-related quality of life measures and had more symptoms (bloating and diarrhea). Of those with subclinical disease, women were more likely to report pain, numbness in hands or feet, and shortness of breath.
These results demonstrate the need for assessment of symptoms that could uncover subclinical disease and lead to timely referral for follow-up and treatment.
Interventions to Improve Cardiac Health
Nurses can promote heart health by teaching their patients about the benefits of exercise. Increasing physical activity can decrease the modifiable cardiac risk factors of inactivity and excess weight.
The best treatment identified to reduce fatigue and to improve psychological distress in cancer survivors is increased physical activity. Regular physical activity prolongs overall survival and disease-free intervals, improves quality of life, mood, fitness, physical function, and decreases fatigue.
More work is needed to determine the best approach to increasing physical activity in cancer survivors. Information is needed to determine the specifics of interventions for cancer survivors including the best type, duration, frequency, and intensity.
What Works Best for Survivors?
A recent Cochrane review of 14 randomized clinical trials of exercise interventions in sedentary cancer survivors3 found that although none achieved an adherence of 75% or greater to the recommended 150 minutes of moderate to strenuous aerobic activity per week, three did achieve 75% adherence to a lower goal, resulting in improved exercise tolerance.
The most successful interventions involved components such as setting program goals, encouraging practice and self-monitoring, and teaching participants to use skills learned in supervised exercise environments in other areas of their day-to-day life.
Additional research is needed to determine the best approach to deliver comprehensive and coordinated follow-up care for cancer survivors. Assessment of cardiac risk is needed in future programs, along with evidence-based interventions to decrease modifiable risk factors. Nurses as researchers, clinicians, advocates, and teachers are in a prime position to lead these efforts. Cancer survivors need our continued care!
- Institute of Medicine and National Research Council. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press; 2005.
- Reilly C, Esiashvili N, Parashar S, Higgins M. Subclinical cardiovascular disease in lymphoma survivors by gender [published March 23, 2016]. J Obstet Gynecol Neonatal Nurs.
- Bourke L, Homer KE, Thaha MA, et al. Interventions for promoting habitual exercise in people living with and beyond cancer. Cochrane Database Syst Rev. 2013;9:CD010192.