Clark Robyn A, Marin Tania S, McCarthy Alexandra L, Bradley Julie, Grover Suchi, Peters Robyn, Karapetis Christos S, Atherton John J, Koczwara Bogda
1College of Nursing and Health Sciences, Flinders University, Adelaide, SA Australia.
2Acute Care & Cardiovascular Research, College of Nursing and Health Sciences, Flinders University, Adelaide, SA Australia.
Cardiooncology. 2019 Aug 22;5:14. doi: 10.1186/s40959-019-0046-5. eCollection 2019.
BACKGROUND/AIM: Cardiotoxicity is a potential complication of anticancer therapy. While guidelines have been developed to assist practitioners, an effective, evidence based clinical pathway for the treatment of cardiotoxicity has not yet been developed. The aim of this study was to describe the journey of patients who developed cardiotoxicity through the healthcare system in order to establish baseline data to inform the development and implementation of a patient-centred, evidence-based clinical pathway.
Mixed-methods design with quantitative and qualitative components using process mapping at 3 large medical centres in 2 states between 2010 and 2015.
Fifty (50) confirmed cases of cardiotoxicity were reviewed (39 medical record reviews, 7 medical record review and interviews and 4 internview only). The mean age at cancer diagnosis of this group was 53.3 years (range 6-89 years); 50% female; 30% breast cancer, 23% non-Hodgkin's lymphoma; mean chemotherapy cycles 5.2 (median 6; range 1-18); 49 (89%) presented to chemotherapy with pre-existing cardiovascular risk factors; 39 (85%) had at least one modifiable risk factor and 11 (24%) had more than 4; 44 (96%) were diagnosed by echocardiogram and 27 (57%) were referred to a cardiologist (only 7 (15%) before chemotherapy). Post chemotherapy, 22 (48%) patients were referred to a multidisciplinary heart failure clinic; 8 (17%) to cardiac rehabilitation; 1 (2%) to cancer survivorship clinic and 10 (22%) to a palliative care service. There were 16 (34%) deaths during the timeframe of the study; 4 (25%) cardiac-related, 6 (38%) cancer-related, 4 (25%) due to sepsis and 2 (12%) other causes not recorded. The main concerns participants raised during the interviews were cancer professionals not discussing the potential for cardiotoxicity with them prior to treatment, nor risk modification strategies; a need for health education, particularly regarding risks for developing heart failure related to cancer treatment; and a lack of collaboration between oncologists and cardiologists.
Our results demonstrate that the clinical management of cancer patients with cardiotoxicity was variable and fragmented and not patient centered. This audit establishes practice gaps that can be addressed through the design of an evidence-based clinical pathway for cancer patients with, or at risk, of cardiotoxicity.
背景/目的：心脏毒性是抗癌治疗的一种潜在并发症。虽然已经制定了相关指南来帮助从业者，但尚未制定出一种有效、基于证据的心脏毒性治疗临床路径。本研究的目的是描述发生心脏毒性的患者在医疗系统中的就医过程，以便建立基线数据，为制定和实施以患者为中心、基于证据的临床路径提供参考。
采用混合方法设计，在2010年至2015年期间，对两个州的3家大型医疗中心进行定量和定性分析，并使用流程映射。
对50例确诊的心脏毒性病例进行了回顾（39例病历回顾，7例病历回顾加访谈，4例仅访谈）。该组患者癌症诊断时的平均年龄为53.3岁（范围6 - 89岁）；50%为女性；30%为乳腺癌，23%为非霍奇金淋巴瘤；平均化疗周期为5.2个（中位数6；范围1 - 18）；49例（89%）在接受化疗时已有心血管危险因素；39例（85%）至少有一个可改变的危险因素，11例（24%）有4个以上；44例（96%）通过超声心动图确诊，27例（57%）被转诊至心脏病专家处（化疗前仅7例（15%））。化疗后，22例（48%）患者被转诊至多学科心力衰竭诊所；8例（17%）至心脏康复科；1例（约2%）至癌症幸存者诊所，10例（22%）至姑息治疗服务机构。在研究期间有16例（34%）死亡；4例（25%）与心脏相关，6例（38%）与癌症相关，4例（25%）因败血症，2例（12%）为其他未记录原因。参与者在访谈中提出的主要担忧是癌症专业人员在治疗前未与他们讨论心脏毒性的可能性，也未提及风险调整策略；需要进行健康教育，特别是关于癌症治疗相关心力衰竭风险的教育；以及肿瘤学家和心脏病专家之间缺乏合作。
我们的结果表明，癌症合并心脏毒性患者的临床管理存在差异且不连贯，并非以患者为中心。本次审计确定了一些实践差距，可通过为有心脏毒性或有心脏毒性风险的癌症患者设计基于证据的临床路径来加以解决。
