AHA Issues First Cardio-Oncology Rehabilitation Statement

Patrice Wendling

April 12, 2019

A new scientific statement from the American Heart Association (AHA) lays out the rationale and specifics for multimodal cardiac rehabilitation (CR) for patients with cancer, with a clear eye toward gaining equal footing for these services among third-party payers.

"This really sets the stage as a 'how-to' for interested people in the cardiac rehabilitation space to help cancer patients, but for this to take hold on a national level, it needs to be a reimbursable service," Susan Gilchrist, MD, MS, writing group chair and cardiologist at M.D. Anderson Cancer Center, Houston, said in an interview with theheart.org | Medscape Cardiology.

Although CR reimbursement was established in the 1980s for patients who experience a myocardial infarction, coronary artery bypass graft surgery, or stable angina, no reimbursement strategy is currently available to provide access to a multimodal CR program for patients with cancer.

"This scientific statement is a first step to pave the way for reimbursement for patients with cancer within the CR model," the authors write. "Further work is needed to establish the science base for CR in the cancer population and to generate guidelines and accompanying policy metrics to shape referrals and reimbursement."

Although randomized clinical trial data are lacking, a growing number of observational studies report cardio-oncology rehabilitation (CORE) is associated with improved cardiorespiratory fitness (CRF), muscular strength, and quality of life in patients with active cancer and survivors.

Cardiovascular disease (CVD) risk is elevated in this population as a result of shared risk factors between CVD and cancer, such as obesity, hypertension, and diabetes, coupled with the direct effects of anticancer therapies and indirect effects, such as weight gain and deconditioning. One study estimates that each 5 kg weight gain after a breast cancer diagnosis is associated with a 19% increase in CVD mortality, the authors report in the report study, published online April 8 in Circulation.

Referral to CORE

The document follows the well-established American Society of Clinical Oncology (ASCO) guideline for select cancer therapies that predispose patients to increased risk for cardiac dysfunction. Those recommendations include:

  • High-dose anthracycline or high-dose radiotherapy.

  • Lower-dose anthracycline or trastuzumab alone plus at least two risk factors, age at least 60 years at cancer treatment, or compromised cardiac function (history of MI, ejection fraction 50%–55%, moderate valvular disease).

  • Lower-dose anthracycline followed by trastuzumab.

A solid evidence base supports those recommendations but the writing committee wrestled over inclusion of other at-risk groups, such as patients with prostate cancer on androgen therapy, and ultimately noted in the document that the decision of whether a patient is at risk lies with the cardiologist or oncologist, Gilchrist said.

Although some models advocate for initiation of exercise referral at the time of diagnosis and treatment, the CORE algorithm is very lenient on this point because the logistics of starting rehabilitation at diagnosis or active treatment can be very challenging because of competing interests, she noted.

"That being said, a beautiful model to keep in mind is that lifestyle change and exercise in general should be part of the treatment plan when one is thinking about what needs to be done to improve quality of life and get through treatment," Gilchrist said. "It's not just a pharmacological approach."

The statement proposes that patients with cancer should meet an initial set of exercise performance metrics to assess overall safety for CORE and includes a chart detailing those metrics.

Given that exercise may be limited or unsafe as a result of treatment-related frailty, musculoskeletal, neurological, or cognitive issues, bone loss, and ongoing treatment, it also recommends that cancer rehabilitation (physical and occupational therapy) be initiated before CORE to address these impairments.

Although CORE leverages the existing CR infrastructure, the document acknowledges the nuances in this setting through a series of cancer-specific considerations for overall patient assessment, nutritional counseling, tobacco cessation, and management of weight, diabetes, blood pressure, and lipids.

For example, blood pressure should be checked in both arms unless contraindicated by lymphedema or other impairments, because unilateral subclavian steal can be seen in patients treated with mediastinal or neck irradiation. Chart review is also needed for chemotherapeutic agents and targeted drugs, such as vascular endothelial growth-factor inhibitors, that cause hypertension, the authors note.

The document is a call to action for cardiologists who have traditionally worked with oncology teams after cardiotoxicities have occurred or in survivorship, Gilchrist said. At the same time, cardiologists rely on oncologists to refer patients in order to do their jobs.

"We're trying to reset the tone," she said. "This framework that we present is more proactive and interactive with the oncology team."

Research Gaps

To move toward referral and reimbursement for CORE, the AHA statement highlights several research gaps that need to be addressed including:

  • Developing and conveying the evidence base for CORE to patients, families, clinicians, health systems, payers, and employers.

  • Demonstrating which patients are most likely to benefit, and when possible, showing improved economic outcomes.

  • Identifying the most effective, efficient, and patient-centric delivery practices in varied settings.

  • Testing the impact of CORE on cardiac-specific outcomes in patients with cancer.

  • Creating automatic or opt-out referral systems and stratifying participation data by cancer type, stage, and cardiac risk.

  • Defining and testing the effects of adding a small set of metrics to quality reporting and performance programs.

Although much work needs to be done, Gilchrist remains optimistic about breaking down silos between cardiology and oncology and streamlining the delivery of CORE to patients with cancer and the more than 16.7 million cancer survivors in the United States.

"I think this statement is so important because it gets the issue into Circulation, which is one of our best cardiology journals, and lets the workforce of cardiology and cardiac rehab know this is something you can grab onto and create change for a new population you may not have thought of before," she said. "So I'm hopeful. This is so new but it's also the exciting time because then you can shape it in a way where you can really create change for cancer patients at risk for cardiovascular disease."

Gilchrist reports no relevant financial interests. Disclosures for the writing committee are listed in the paper.

Circulation. Published online April 8, 2019. Full text

Follow Patrice Wendling on Twitter: @pwendl. For more from theheart.org | Medscape Cardiology, follow us on Twitter and Facebook.

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