The cardio-oncology multidisciplinary team: beyond the basics

Abstract

A cardio-oncology multidisciplinary team is essential for the successful delivery of patient-centred care. The roles of oncologists, haematologists, and cardiologists have been clearly articulated in literature pertaining to the creation of cardio-oncology clinics. However, the involvement of other key team members, such as pharmacists, nurses and nurse practitioners, social workers, psychologists and other allied health professionals has been less well-defined. In this review we aim to define the role of pharmacists and nurses as part of a multidisciplinary cardio-oncology team. We also discuss models of care and opportunities to expand the delivery of cardio-oncology services to further enhance outcomes for individuals with cancer, and highlight the challenges experienced by those living in regional, rural, and remote communities.

Background

Cardiovascular disease (CVD) and cancer are the two leading causes of morbidity and mortality in the Western world [1]. Currently, there are over 30 million cancer survivors worldwide [2]. The number of cancer survivors is projected to increase by 30%, with nearly 2 million Australians estimated to be living post cancer by 2040; [3] a result of improved cancer screening, treatments, and the aging population [4].

CVD is a leading cause of long-term morbidity and mortality among cancer survivors [5–7] and is an all-too-common consequence of cancer therapy-related cardiovascular toxicity (CTR-CVT); [8] a complication that can be amplified through the presence of pre-existing cardiovascular risk factors including hypertension (HTN), diabetes mellitus (DM), dyslipidaemia, obesity, and advanced age [9]. A number of professional societies including the European Society of Cardiology (ESC) [10], the International Cardio-Oncology Society (IC-OS) [11], the European Society of Medical Oncology (ESMO) [12], and the American Society of Clinical Oncology (ASCO) [13], have published guidelines or position statements that define the importance of baseline cardiovascular (CV) surveillance and care during cancer treatment and throughout patient survivorship. Whilst tremendous international effort has culminated in the formation of the first guideline published by ASCO in 2017 for the management of complex and a diverse range of CTR-CVT [13], there is a clear lack of evidence-based, CV-focussed care pathways for cancer patients from the time of diagnosis to survivorship [14].

The need for a multidisciplinary approach to patient care is becoming increasingly apparent as complications secondary to cancer therapy emerge; particularly during the treatment phase of a patient’s cancer journey [15]. The clinical needs of people with cancer are complex, especially considering the intricate interplay between cancer treatment, comorbidities and ageing [16]. As more patients survive a cancer diagnosis, the requirement of new innovative models of care to address these needs remain vital [17, 18]. The cardio-oncology multidisciplinary team (CO-MDT) continues to establish itself as a cornerstone for appropriate prevention, mitigation and management of CV toxicities associated with cancer treatment, whilst providing ongoing support for the treatment of cancer [19, 20].

The roles of pharmacy, nursing and allied health are ingrained in clinical practice in all cardiology specialties including heart failure (HF), atrial fibrillation (AF), and cardiac rehabilitation. These personalized models of care have been shown to improve patient outcomes and access to care, are easily adopted, and are economically viable [21–27]. However the role of pharmacy, nursing, and allied health within the CO-MDT has been less clearly defined. It is therefore critically important to create cardio-oncology (CO) care pathways to mitigate CVD development for patients living with, through and beyond cancer [28–30]. In this review, we discuss the proposed roles and responsibilities of pharmacists, nurses, and nurse practitioners, along with other key supportive care providers, as part of the broader CO-MDT.

The cardio-oncology pharmacist

The role of a pharmacist has been clearly articulated in many clinical settings, which often involves the provision of education and tailored support to patients, medication management solutions, detecting drug-drug and drug-disease interactions, and supporting the safe and effective prescribing of medications [31–36]. Although the need for pharmacists within a CO-MDT is well established in literature describing the development of successful CO clinics [19, 20, 37, 38], their particular role within CO is yet to be completely extrapolated.

The clinical utility of pharmacists within the space of CO clinics — both physical and virtual — is diverse in their support of cardiologists and oncologists in the management of CTR-CVT. A pharmacist’s role varies depending on the size of the institution and the apparent need for their entire scope of practice [20]. Cardiology and oncology pharmacists can assist the broader CO-MDT (see Table 1) by participating in shared clinical decision-making in response to changes in a patient’s CV function, along with formulating and updating cancer treatment-specific pathways based on current available evidence [39]. Appropriate pharmacist-led education on CTR-CVT is also essential for the optimal care of people with cancer [37].

Table 1.

Roles and responsibilities of specialised pharmacists in cardiology and oncology. Nuances exist between the roles of cardiology and oncology/haematology pharmacists. However, the core responsibilities are very similar. pharmacists within these disciplines are at the forefront of medication education, reconciliation, and optimisation for patients

Roles and Responsibilities of Specialised Pharmacists
Cardiology Pharmacist [24, 43]	Oncology/Haematology Pharmacist [44, 45]
• Patient education • Drug information • Medication reconciliation and review • Medication optimization and titration • Monitoring and management of adverse effects and drug interactions • Collaborative clinical decision-making, including drug selection and dosing for cardiovascular disease • Pharmacovigilance and medication safety • Implementation and review of local hospital protocols, guidelines, and policies • Dose adjustments based on pharmacokinetics and pharmacodynamics	• Pharmacotherapy management of patients with cancer and coordination of anticancer administration • Patient and staff education • Medication therapy management • Sterile compounding of anticancer treatment • Adverse drug reaction prevention and monitoring • Shared decision-making • Dose adjustments for organ dysfunction, weight, and age • Therapeutic drug monitoring • Laboratory monitoring • Formulation/route of administration optimisation • Medication reconciliation • Assuring medication regimen concordance

The multidisciplinary Team IntervenTion in cArdio-oNcology (TITAN) trial (NCT01621659) established a design for a multidisciplinary CO service [40]. Patients were recruited from a single site at the Cross Cancer Institute, Edmonton, Alberta, Canada [41]. The study aims to determine the effects of a multidisciplinary team approach on the early identification and intervention of CV risk factors to prevent left ventricle (LV) remodeling in people with cancer receiving adjuvant therapy [40, 41]. Within this unit, clinical pharmacists monitor cancer patients’ prescribed medication and provide ongoing monitoring and support where indicated to support early management of CV risk factors during cancer treatment and reduce LV remodelling [40]. The TITAN trial remains active and hence results are unavailable at the time of writing, particularly surrounding the pharmacist assessment and counselling intervention, and treatment of CV risk factors.

The virtual-hybrid CO service proposed by Brown and colleagues highlights the full scope of practice clinical pharmacists deliver within their model of care [42]. This includes discussing and reviewing essential pharmacotherapies to manage comorbidities such as HTN, dyslipidaemia, and CTR-CVT such as HF, as well as commenting on potential drug-drug interactions between anticancer therapies and a patient’s concurrent medication regimen [42]. Pharmacists can also assist with medication titration and prescription, as well as providing medication education and smoking cessation advice for patients [42].

Recently, Merali and colleagues [46] described the perspectives of Canadian pharmacists who provide care for oncological patients at risk of CTR-CVT (Fig. 1). Participants highlighted the benefit of pharmacist involvement in patient care through the utilisation of specialised drug knowledge to enhance patient-centred care. A key challenge identified by these pharmacists was a lack of role recognition, demonstrating the need to define the position of pharmacists more clearly within a CO-MDT.

Fig. 1.

Barriers, enablers, and benefits of inclusion of pharmacists into the cardio-oncology multidisciplinary team. Whilst the inclusion of pharmacists into the cardio-oncology multidisciplinary team is widely accepted, several barriers have been identified that hinder their involvement, including lack of role recognition and resources available to cardio-oncology pharmacists. Postulated solutions to overcome these barriers include integration of pharmacists into cardio-oncology clinics to increase pharmacist exposure, along with the development of structured education or training schemes. This must also be reflected in cardio-oncology guidelines pertaining to the development of multidisciplinary teams. Adapted from Merali A et al. “Exploration of current pharmacy practice in cardio-oncology: Experiences & perspectives”. J Oncol Pharm Pract. 2023;29(8):1844–52

Patel and colleagues [47] propose a multidisciplinary team-based model for the management of HTN secondary to angiogenesis inhibitors such as sunitinib and bevacizumab. In this model, pharmacists act as ‘liaisons’ between oncology and cardiology teams, as well as ensuring appropriate access to treatment — particularly for oral angiogenesis inhibitors. After the creation of an initial care plan by the oncology team, patients are referred to a pharmacist for a comprehensive baseline CV risk assessment. Subsequent blood pressure goals following this CV risk assessment are incorporated into the patient’s treatment plan. Pharmacists then assist with the optimization of patient-specific risk factors — including pre-existing HTN — prior to commencing anticancer therapy through pharmacological and non-pharmacological interventions. Within this model [47], pharmacists provide patients with drug- and disease-specific education and self-monitoring tools. Follow-up consultations are arranged for pharmacists to assist with the ongoing monitoring of pathologies and blood pressure goals, along with continual medication reconciliation. This provides a referral pathway for patients to cardiology if blood pressure is inadequately managed [47]. Greater clarity surrounding the role of specialised CO pharmacists within a CO-MDT will empower pharmacists to provide tailored support and education to patients with cancer, along with contributing detailed knowledge to the broader MDT, thereby enhancing the quality of care provided during treatment and throughout survivorship (see Fig. 2).

Fig. 2.

Role of the pharmacist as part of a cardio-oncology multidisciplinary team. Pharmacists are well-positioned to provide a range of medication-centric services to enhance both cancer and cardiovascular outcomes. Such services target optimising medication use and management and providing patient-centred education to improve the quality use of medicines

Pharmacist medication management in cardio-oncology

Complex medication regimens are associated with poorer medication adherence and a greater likelihood of hospitalization relating to adverse medication-related events [48, 49]. Cancer therapy initiation may then further increase the complexity of a patient’s existing drug regimen, requiring additional medication management support to minimize medication-related harm. Proposed roles of pharmacists within a CO-MDT largely focus on medication reconciliation, as illustrated in Table 2. Current gaps in care identified by cancer patients themselves include gaps in communication amongst stakeholders [50] and understanding the potential adverse impacts of anti-cancer drugs regimes [51].

Table 2.

Studies investigating the roles of pharmacists and nurses as part of a cardio-oncology multidisciplinary team. The importance of both pharmacists and nurses as part of a multidisciplinary team has been well-established. However, literature pertaining to their specific role within a cardio-oncology multidisciplinary team is scarce. However, the limited evidence demonstrates the clinical utility of pharmacists and nurses within a cardio-oncology multidisciplinary team to enhance quality of care and maximise positive patient outcomes. CV, cardiovascular; CVD, cardiovascular disease; CO, cardio-oncology; CO-MDT, cardio-oncology multidisciplinary team; acei/arb, angiotensin converting enzyme inhibitor/angiotensin receptor blocker

Author	Study Design	Cardio-Oncology Clinical Setting or Model of Care	Outcomes/Findings
Pharmacists within a Cardio-Oncology Multidisciplinary Team
Yaseen and Farhan, [105] 2022	Prospective observational study of 333 cancer patients referred to the Iraqi Cardio-Oncology Program-Pharmacist (iCOP-pharm) program.	Cardiologist and cardiology pharmacist model of care. • Medication reconciliation performed by a pharmacist, providing CV drug interventions (drug titration, switching, cessation, or initiation) • Echocardiography provided by cardiologist • Discussion between pharmacist and cardiologist regarding medical history and drug interventions • Joint decision-making between cardiologist and pharmacist	• 200 cancer patients identified as having established CVD and/or concurrent CV risk factors • Cardiology pharmacist responsible for 75% of total CV drug interventions • CV drug initiation was the most common intervention • Limited by small sample size
Merali, et al., [47] 2022	Qualitative telephone interview study of experiences and perspectives of pharmacists on current pharmacy practice in CO.	Survey conducted across multiple regions of Canada, including Ontario, British Columbia, and Alberta. • One pharmacist in community (outpatient/inpatient) • Four pharmacists working in an ambulatory hospital setting • Two pharmacists residing in ambulatory settings (including regional) • One pharmacist working in an ambulatory and hospital inpatient settings	• Pharmacist involvement enhanced patient-centred care and provision of specialised medication-related knowledge • Barriers to optimization of care included lack of role recognition and resources for pharmacists working in CO • Poor communication across healthcare teams impeded continuity of care for cancer patients • Suggested solutions for barriers were the establishment of survivorship programs for long-term follow-up and to increase integration of pharmacists into CO-MDTs • Guidelines or standards of care recommended to standardise delivery of clinical services
Einsfeld, et al., [106] 2023	Case study of 15-day CO rotation program for onco-haematology pharmacy residents at a university hospital in Porto Alegre, Brazil.	Two-week program objectives to develop clinical skills in CO: • Understand mechanisms of CV toxicity from cancer treatment • Experience CV assessment facilitated by a cardiologist • Focus on pharmacological management of CVD, particularly heart failure and myocardial damage prevention • Participate in care of patients with CVD, including transitions of care activities	Post-rotation evaluation: • Broad cardiology experience delivering clinical services such as medication reconciliation and outpatient clinics (including CO) • Recommended to expand resident participation in CO clinics Evaluation 2-years after residency: • Expanded knowledge of cardiology • Stimulated interdisciplinarity between oncology and cardiology
Nurses within a Cardio-Oncology Multidisciplinary Team
Pareek et al., [107] 2018	Prospective cohort study of 535 cancer patients referred to CO clinic at the Royal Brompton Hospital, London, United Kingdom.	Clinic comprised of consultant cardiologists, senior clinical fellow in CO, and senior clinical nurse specialist. • Supported by specialist cardiac imaging with advanced echocardiography and CV magnetic resonance • Initial one-stop day case service model – expedite CV status assessment and provide rapid opinion to referrers • Baseline clinical assessment: cardiac biomarkers, electrocardiogram, transthoracic echocardiography • Risk of cardiotoxicity classification based on assessment • Lifestyle advice and consultation with clinical nurse specialist	• 238 patients (44.4%) deemed high risk for cardiotoxicity and referred for baseline assessment - Optimisation of cardioprotective medications including beta-blockers and ACEi/ARB - 86% of patients deemed fit for cancer treatment • Clinical activity increased from 105 patients/year to 179 patients/year • Increase in average number of new day case assessment patients seen in weekly clinic (2.3 vs. 3.6 patients/day) • High satisfaction for overall day case experience
Zhang, et al., [108] 2023	Qualitative study surveying 739 oncology nurses working in tertiary hospitals in the Shanxi Provence, China.	• Two-part questionnaire: 1) General information regarding hospital settings and nursing practice - Demographic data - Exposure to CO training within their department 2) Evaluation of nurses’ CO knowledge - Multiple choice questions divided into three domains (1) disease observation, (2) health guidance, and (3) implementation of treatment • Questions were credited with 1 point each, with a total of 10 points possible	• Low awareness rate of CO knowledge amongst surveyed nurses - 40.4% of responders could recognise potentially cardiotoxic antineoplastics, with 12.5% able to identify when cardiotoxicity would occur - Low awareness of health guidelines pertaining to oncology patients with heart disease (7.1%) - 44.7% of responders were aware of precautions for cardiotoxicity that nurses can implement • Identified greater need for precision training for nurses in CO to improve quality of care
Pharmacists and Nurses within a Cardio-Oncology Multidisciplinary Team
Liu, [109] 2023	Feasibility and acceptability study of a novel CO service line model of care for large, multi-hospital health systems in collaboration with academic cancer centres.	• CO team comprised of cardio-oncologists, vascular oncologists, specialists in advanced heart failure and infiltrative heart disease, CO pharmacists, CO administrative coordinators, and nurse practitioners • No specific description of the role of pharmacist and nurse in CO-MDT	• Feasible and effective model of care for enhancing CO care quality and accessibility • Service line can be used in conjunction with academic CO programs to enhance the efficacy of CO healthcare provision

Despite the absence of high-quality evidence, studies demonstrate the clinical utility of pharmacist-led medication reviews (PMRs) in resolving actual and potential medication-related issues, reducing medication-related harm through education, improving medication regimen concordance and enhancing communication between healthcare providers [52, 53]. There are numerous iterations of PMR programs internationally in countries such as Australia and New Zealand, the United Kingdom, the United States of America [54–57]. Whilst the medication review structure may differ, the common core aim across established comprehensive medication review services is to promote prescriber-pharmacist collaboration in the creation of a medication management plan for the patient [53]. The pharmacist provides a detailed report to the patient’s prescriber regarding any real or potential adverse drug events, such as drug-disease interactions or drug-drug interactions (DDIs), absent or inappropriate pharmacotherapies, and medication management difficulties experienced by the patient.

The perspectives of transition-of-care patients and their experiences with pharmacist-led post-discharge medication management and reviews has been previously explored [58]. Perceived benefits included improved health literacy and education provision that lead to a reduction in anxiety associated with medication changes, along with enhancing communication between members of the patient’s healthcare team, such as primary care physicians [58]. Whilst the study population were hospitalized due to a primary diagnosis of CVD rather than cancer, the results can be extrapolated to those with cancer who frequently transition between hospital and home. PMRs could therefore present a useful initiative as part of a cancer patient’s treatment plan and would be a vital component of a specialized CO pharmacist’s role.

Significance of drug interactions for the cardio-oncology patient

Interactions are highly prevalent in the context of anticancer treatments, with one study demonstrating that nearly 80% of patients being treated for cancer have at least one potential DDI [59]. This presents a considerable issue in CO. In a recent statement from the American Heart Association (AHA), pharmacists are identified as an essential component of the CO-MDT in addressing the pharmacodynamic and pharmacokinetic interactions that exist between pharmacological therapies for cancer and CVD [60].

Pharmacokinetic interactions involving cytochrome P450 (CYP) enzymes and P-glycoprotein (P-gp) efflux pumps are touted as the most common interactions within oncology [61]. Many anticancer agents themselves are inhibitors or inducers of metabolic enzymes that impact the concentrations of not only anticancer therapies, but other pharmacological agents concomitantly administered for the management of comorbidities [62]. Several anticancer agents and CV drugs interact via CYP metabolic pathways, either through direct hepatic drug metabolism or its influence over CYP enzyme activity [63]. A common and important clinical scenario relevant to CO is the prescribing of anticoagulants in cancer patients. For example, the concurrent use of apixaban with idelalisib — a potent inhibitor of CYP3A4 — may lead to a drastic increase in apixaban serum concentration and subsequent increase in bleeding risk. Hence combination should be avoided and an alternative treatment investigated [60].

The importance of monitoring for pharmacodynamic DDIs can be illustrated by potential interactions between tyrosine kinase inhibitors (TKIs), such as alectinib — indicated for anaplastic lymphoma kinase (ALK)-positive non-small cell lung cancer — or dasatinib — indicated for chronic myeloid leukemia — and CV medications. Coadministration of lorlatinib with other bradycardic agents such as beta-blockers increases the risk of severe symptomatic bradycardia, hence combination should be avoided [64]. Similarly, combining dasatinib with antiarrhythmic drugs such as sotalol, flecainide, or amiodarone may prolong the QTc interval and increase the risk of torsades de pointes and sudden cardiac death [65]. Identification of DDIs is therefore critical in maintaining appropriate cancer treatment efficacy, whilst minimising the risk of toxicity of both cancer treatment and CV pharmacotherapies [48, 49].

Pharmacist provision of telemedicine: an area of expansion??

The healthcare’s response to limited physical interaction with patients amongst the height of the COVID-19 pandemic has consequentially paved the way for new models of care. The use of telehealth as a solution demonstrates the feasibility of remote care provision for patients with CVD and cancer [66–70]. However, the concept of telepharmacy predates the rapid growth of telehealth due to the recent pandemic. In 2014, Sankaranarayanan and colleagues [71] performed a retrospective cross-sectional study evaluating a telepharmacy service model by comparing documented pharmacist interventions across eight hospital sites. The study compared the interventions and outcomes between sites with or without an onsite rural hospital pharmacist. Results demonstrated that the introduction of telepharmacy services significantly increased the spectrum of proposed interventions, patient-centered interventions, and health system-centered interventions from baseline. Interventions with both an on-site and off-site (remote) pharmacist were significantly more patient-centric, actionable, and corresponded with transcribing and prescribing of medicines [71].

The more recent demand for telemedicine has encouraged the expansion of pharmacy services delivered remotely. Crilly and Kayyali [72] reviewed randomised controlled trials involving telehealth and digital technology-assisted community pharmacist services to better understand how these services are being utilized. Most studies assessed an improvement in public health outcomes such as medication adherence, medication counselling, HTN management, vaccination uptake, and smoking cessation. The most common telehealth service provided by community pharmacists was telephone calls or automated telephonic prompts, however the authors acknowledged the limited use of novel technologies, such as mobile phone applications, and the limited public health topics addressed through telehealth interventions [72]. Provision of telehealth services may enable greater delivery of medication-related services to oncology patients for the management of their CV complications.

Nursing in cardio-oncology: contribution to the multidisciplinary team

The need for ongoing CV care in cancer patients is articulated in consensus statements and within the literature [9, 12, 73]. However, given the challenges of local availability of staff, differing geography, funding arrangements and different health systems, a “one size fits all approach” remains a challenge.

The role of nursing as a part of a team-based approach in the early identification and management of diseases in many specialties is widely acknowledged [74–76]. Nursing has established efficacy in models of care ingrained in CV patient management including cardiac rehabilitation, chest pain clinics, HF, AF, and HTN [77–81].  A nurse specialist with highly developed clinical skills, commitment to patient education, and management across the full spectrum of the disease process underpins this model of care.

In cardiology settings the improvement in access to care, guideline adherence, treatment outcomes, improved medication adherence, and improved health outcomes have been consistently demonstrated. Furthermore, this multidisciplinary approach is now embedded in international guidelines and consensus statements [82–84]. Importantly, this can be in a variety of settings including hospital settings, outpatient clinics, home based care and now the emergence of telehealth options has increased post discharge follow up support. Similarly, nurse practitioner (NP) models of care in cardiology have demonstrated the potential for similar benefits including reductions in 30-day hospital readmission rates [85, 86] and high patient satisfaction; [87] although most studies assessing NP involvement in cardiology have been of poor quality [88].

NPs have played a vital role in oncology MDTs for several decades, with the first oncology NP competencies established in 2007 by the Oncology Nursing Society [89]. These competencies were updated in 2019 to reflect the expanding clinical, education, administration, and policy advancement roles of NPs in cancer care [90]. Oncology NPs are often viewed as care coordinators and patient advocates for people receiving cancer therapy or palliative care [91]. The inclusion of oncology NPs in emergency cancer care services has demonstrated reductions in emergency department presentations and hospital admissions [92–94]. Oncology NPs also provide ongoing cancer surveillance, symptom monitoring and managing and health promotion education as part of post-treatment survivorship programs [95].

However, the role of NPs within the CO-MDT has not yet fully been recapitulated, though the acknowledgement of their importance has been described [19, 37, 96, 97]. The instigation of primary prevention strategies can be potentially a challenging time for health professionals in ensuring adherence and patient acceptability, a coordinated systematic multidisciplinary approach can enhance patient care and improve patient outcomes [85, 86, 98].

One of the cornerstones of these models is the team-based approach where care co-ordination, patient education, and multidisciplinary collaboration are all features of a strong multidisciplinary care program. The emergence of CO can allow the same principles involved in the assessment, clinical management and patient empowerment of this group of patients to be translated into this subspecialty to enhance patient care (see Table 2). As cancer treatments continue to improve prognosis of cancer patients and enhance outcomes, long term vigilance and support will remain of the upmost importance to this population [99].

Nursing models of care remain an evidenced based option and have a focus on: [100]

Clinical Assessment — Blood pressure, pulse, electrocardiogram, non-invasive evaluation, identification of underlying risk factors, care coordination, titration of medications. This includes before and during treatment, and in a survivorship capacity.

Lifestyle Advice — Nutritional advice, exercise advice, smoking cessation, weight loss education and the establishment of referral pathways to allied health providers.

Education — Providing education on disease process and management, sign and symptom recognition, potential complications, and medication use and self-management support.

Whilst this model has been demonstrated to be effective, there is evidence that there are positive economic benefits to nursing-led models of care. Nurse-led models of care have been shown to be associated with fewer hospital days per year and reflected cost savings [79]. Importantly when combined with the multidisciplinary team, including pharmacists, the results have demonstrated important positive outcomes for chronic disease management in a variety of settings [101, 102]. The early experience of the specialised CO nursing services is extremely positive [103, 104]. Translating this to be accepted internationally, utilizing current models of care remains of upmost importance in delivery care for the cancer patient.

The potential importance of specialized models of care for Cardio-Oncology patients in rural areas

Rural patients experience CVD rates at 20% higher compared to metropolitan patients and have worse clinical outcomes [110]. This health outcome disparity is additionally reflected in rural cancer outcomes, with mortality rates 7% higher compared to metropolitan cancer patients; a concern that remains largely unchanged [111]. In addition, given the challenges of access to care and specialty care for rural patients, further clinical pathways involving the multidisciplinary team are needed to guide improvement in risk stratification, management and treatment pathways for all rural cardiology patients [112, 113]. Nursing-led clinics have been shown to enhance access to healthcare in diverse settings [114–116]. Pharmacist involvement in the healthcare provision for rural communities have also been demonstrated to lead to improved patient outcomes across a myriad of disciplines within medicine [117–119]. Improvement in the management of CV care, by strengthening clinical pathways, utilising multidisciplinary teams of cancer patients may have the potential for improved care of rural cancer patients.

The next steps: developing Cardio-Oncology pharmacists and nurses

There is limited literature pertaining to education and training for pharmacists and nurses in the field of CO. Whilst there is a general acknowledgement of the need for formalized training to enhance the delivery of CO care to people with cancer [120, 121], there has yet to be the proper translation of these education initiatives into practice. Greater intentional training of pharmacists and nurses within a CO-MDT will help improve communication between the two traditionally siloed disciplines of cardiology and oncology, improving cancer outcomes and survivorship programs, and growing future leaders within CO.

Most training models focus on bridging the knowledge gaps between cardiology, oncology and haematology for physicians, which includes clinical rotations and fellowships [120–122]. However, there is a growing need for structured programs that bridge this gap for other healthcare providers to create a true CO-MDT. Brown and colleagues [123] describe the core components required for training and career development in CO applicable to pharmacists, nurses, and physicians. Included in their proposition are four key components: (i) adequate infrastructure to support learning, (ii) fellowship opportunities in CO, (iii) output demonstrating the results and impact from different training models, and (iv) specialty development, such as through continuing education targeting the broader CO-MDT.

An ideal model of training and education for pharmacists and nurses would include a combination of formal education through structured CO coursework, providing fundamental knowledge, and fellowships to work as part of a CO-MDT within developed CO clinics [123]. IC-OS provides health professionals access to a myriad of CO-related educational resources and guidelines, which includes a cardio-oncology nursing education program tailored to the specific needs of nurses providing CO services [124]. The nursing program involves a series of modules covering cardiovascular care, cancer therapeutics, cardiotoxicities and their management, and cancer survivorship. Adaption of this education program for other members of a CO-MDT, including pharmacists, may be a feasible mechanism to help further their education in CO.

Providing nurses and pharmacists with opportunities to pursue a six-to-twelve-month fellowship in CO, mirroring programs established for medical practitioners [121, 122], would help develop core clinical and leadership skills as members of the CO-MDT. Pharmacists and nurses undertaking a fellowship would need to be integrated into established CO centers under the supervision and mentorship of experienced CO clinicians; a collaborative engagement that would further strengthen the quality of CO care delivery.

The challenges, however, of implementing such education programs or fellowships in CO are duly expected. Appropriate funding, infrastructure, support from accredited CO clinicians, and strong partnerships with societal organizations are essential to feasibly integrate pharmacist and nurse training into existing CO programs. Adequate role definition for both pharmacists and nurses would also be required to ensure all members of the MDT are working within their expected scope of practice.

The expanding cardio-oncology multidisciplinary team

The continual evolution of CO-MDTs illustrates the greater need for holistic supportive care provided by social workers, dieticians, and other allied health professionals [125]. A CO rehabilitation program for cancer survivors with high CV risk was recently established and demonstrated the positive effects of improving cardiorespiratory fitness and physical function on risk factor control and quality of life [126]. Bi-weekly exercise training sessions were conducted by a physiotherapist and supervised by a psychiatrist that incorporated both aerobic and resistance-based training [126]. Nutritional counselling from dieticians, psychologist support, and CV risk assessment have been acknowledged as key extensions for CO rehabilitation programs to further enhance cancer survivor quality of life [127]. These highlight key additions to any CO-MDT to provide more complete management of cancer survivors during and after treatment.

Conclusion

Dedicated cardio-oncology programs are becoming widespread in the United States and Europe, mainly in academic centers, yet they are not mandated in all cancer centers. Whilst the need for comprehensive cardiac care at all stages of the cancer journey has been articulated, limited guidance has been given as to how this should be conducted. The introduction of a multidisciplinary, team-based approach offers a potential solution. CV complications of cancer treatment are heterogeneous in nature and are impacted by the presence and exacerbated by underlying risk factors and co-morbidities. Multidisciplinary and team-based strategies that promote adherence to guideline-based therapy, clinical assessment and surveillance, guideline adherence, diagnosis, patient education and empowerment may offer improvements to patient care.

Pharmacists and Nursing are well positioned to provide essential monitoring for, and management of, CTR-CVT. Increasing the utilisation of pharmacists and their repertoire of clinical skills in medication management and PMRs would be a positive contribution to a patient’s CO-MDT. It is evident that increased cooperation between cardiology and oncology teams is imperative for a true CO-MDT. Continuing education, research, and training in the space of CO would promote collaboration between healthcare professionals leading to significantly better prognoses for the patients in terms of longevity and quality of life.

Abbreviations

ACEi/ARB

Angiotensin converting enzyme inhibitor/angiotensin receptor blocker

AF

Atrial fibrillation

AHA

American Heart Association

ALK

Anaplastic lymphoma kinase

ASCO

American Society of Clinical Oncology

CO

Cardio-oncology

CO-MDT

Cardio-oncology multidisciplinary team

CTR-CVT

Cancer therapy-related cardiovascular toxicity

CV

Cardiovascular

CVD

Cardiovascular disease

CYP

Cytochrome P450

DDI

Drug-drug interaction

DM

Diabetes mellitus

ESC

European Society of Cardiology

ESMO

European Society of Medical Oncology

HF

Heart failure

HTM

Hypertension

iCOP-pharm

Iraqi Cardio-Oncology Program-Pharmacist program

IC-OS

International Society of Cardio-Oncology

LV

left ventricle

NP

Nurse practitioner

P-gp

P-glycoprotein

PMR

Pharmacist-led medication review

TITAN

Team IntervenTion in cArdio-oNcology trial

Author contributions

Joshua D Bennetts: Conceptualization, writing–original draft, and writing–review and editing. Trent D Williams: Conceptualization, writing—review and editing, and supervision. Craig J Beavers: writing–review and editing. Heather N Moore: writing–review and editing. Cameron Robson: writing–review and editing. Thomas Warner: writing–review and editing. Susan Dent: writing–review and editing. Aaron L Sverdlov: Conceptualization, writing—review and editing, and supervision. Doan TM Ngo: Conceptualization, writing—review and editing, and supervision.

Funding

JDB is the recipient of an Australian Government Research Training Programme Scholarship (University of Newcastle Vice- Chancellor’s Scholarship) and would like to thank the Commonwealth of Australia for their financial contribution to this research (Award ID not assigned). ALS is supported by Heart Foundation of Australia Future Leader Fellowships (Award IDs 101918 & 106025); DTN is supported by NSW Ministry of Health EMC Fellowship, Australia (Grant ID G1701368) and Heart Foundation of Australia Future Leader Fellowship (Award ID 104814). This work is supported in part by Medical Research Future Fund: Cardiovascular Health Mission, Australian Government National Health and Medical Research Council (Award ID G2200136) and Cameron Family Health & Medical Research Grant from the Hunter Medical Research Institute (JDB, DTN; Grant ID G2100856); Royal Australasian College of Physicians (RACP) Foundation Research Establishment Award (ALS; Grant ID G1801367); NSW Ministry of Health Translational Research Grant (ALS; Grant ID G1901542).

Data availability

No datasets were generated or analysed during the current study.

Declarations

Précis

Integration of pharmacists and nurses into a cardio-oncology multidisciplinary team can contribute to positive patient outcomes. Further role clarification and education for pharmacists and nurses may be required to develop a true cardio-oncology multidisciplinary team.

Competing interests

The authors declare no competing interests.