Author + information
- ∗Cardio-Oncology Services, Rush University Medical Center, Chicago, Illinois
- †Cardio-oncology Program, Medstar Heart and Vascular Institute, Georgetown University, Washington, DC
- ↵∗Reprint requests and correspondence:
Dr. Tochi M. Okwuosa, Cardio-Oncology Services, Rush University Medical Center, 1717 West Congress Parkway, Kellogg Building, Suite 320, Chicago, Illinois 60612.
- ↵∗∗Dr. Ana Barac, Cardio-oncology Program, Medstar Heart and Vascular Institute, Georgetown University, Washington, DC.
From 1935 to 2013, cardiovascular diseases and cancer have been the 2 leading causes of death such that, in 2010, heart disease and cancer accounted for 46% of all deaths in the United States (1). Notwithstanding, owing to the success gained in finding treatments and cures for various cancers, overall cancer survival rate has skyrocketed, with about 14.5 million cancer survivors in the United States (1). Ironically, the clinical success of cancer therapy is attenuated by comorbid cardiovascular diseases as major complications (next to second malignancy) of intense oncology treatment.
To usher the patient safely through cancer therapy while tempering cardiovascular disease as a competing cause of morbidity and mortality, a clinical discipline—called cardio-oncology or onco-cardiology—has evolved. Practice in this discipline commonly involves a specialist in cardiovascular disease, often with additional expertise in heart failure and/or cardiovascular imaging, and also includes oncologists and the oncology care team, psychosocial providers, as well as primary care providers (Figure 1).
The exclusion of cancer patients from cardiovascular clinical trials and heart disease patients from oncology investigations has resulted in a paucity of data to direct clinical decision-making in many cardio-oncology patients. The oncologist may hesitate to give life-saving, potentially cardiotoxic therapy for fear of an adverse cardiac outcome, and the cardiologist may have difficulty in understanding appropriate measures on the basis of a patient’s cancer-related comorbidities and prognosis. Consequently, the cardio-oncologist plays the pivotal role of intersecting the 2 specialties, seeking to establish a comprehensive plan to address the comorbidities, while achieving necessary life-saving therapies. With the growing patient need, a number of cardio-oncology clinical programs are emerging across the United States, adding to previously established cardio-oncology services localized in a few primary cancer institutions (2). Early career cardiologists actively participate and often serve as a driving force in many of these programs. In this paper, we summarize some of the challenges that junior faculty may face and discuss opportunities for learning and growth.
Establishing a Cardio-Oncology Program
In cardio-oncology—as with any other program—institutional support is paramount to achieving success, but is not always easy to achieve. The lack of academic and administrative mentorship presents a major challenge. Its reasons include: novelty of this field, a shortage of evidence-based clinical standards, a lack of opportunities for education and training, and a limited awareness among local oncology and cardiology specialists about the need for cardio-oncology services (2). Active participation in growing cardio-oncology networks may provide critical clues on potential solutions for these challenges and open horizons for growth.
Institutional Support and Coordination of Care
Some approaches to facilitate institutional support for the junior (or any) faculty member attempting to build a cardio-oncology program are listed in Table 1. In general, an institutional administration (including cardiology) that appreciates cardio-oncology as a cardiovascular subspecialty is more inclined to disburse funds and resources to establish a cardiology service dedicated to oncology patients. Examples of needed support include:
1. Clinical staff, such as a medical assistants, clinic nurses, and physician extenders (nurse practitioners/physician assistants), for:
a. Coordination of cardio-oncology appointments and other cancer care, including chemotherapy, radiology studies, oncology and surgical appointments, and so on;
b. Timely scheduling of (serial) cardiac imaging and/or laboratory studies with prompt care on the basis of results;
c. Keeping abreast of changes in cancer treatment plans and/or changes in cardiovascular status including updates to all team members;
d. Patient education and engagement;
e. Coordinated documentation of medication adjustments and dose updates, including cancer treatments, for the purposes of cardio-oncology; and
f. Enhancing clinical flow where physician extenders could see more stable or return patients, freeing up some time for the cardio-oncologist to incorporate more complex patients into their clinic schedule.
2. Time to engage hospital staff and the community to grow a comprehensive program, which includes:
a. Participating in oncology tumor board conferences;
b. Partnering with other cardiology and oncology team members to develop population-focused approaches for subgroups of patients, such as cancer survivorship clinics or patients undergoing treatment with vascular endothelial growth factor–pathway inhibitors;
c. Training cardiology staff and technicians on newer diagnostic data and techniques, such as development of cardio-oncology–specific imaging pathways; and
d. Providing awareness about the program within and around the local health care organization through presentations, workshops, and participation in existing programs.
3. Resources to establish a cardio-oncology database for informative and research purposes.
4. Time for professional education: includes educating hospital staff and trainees, as well as attending professional conferences with specific emphasis on development of the program.
Location of Ambulatory Cardio-Oncology Clinic
Establishing the location of the clinic—in a cancer or cardiovascular center—is 1 of the key decisions to ensure the success of a cardio-oncology program and is dependent on a number of factors, including hospital administration and funding, proximity of the cardiovascular to the oncology clinics, interactions between both faculty members and staff, staffing methods, available process measures, and location of the cardiovascular imaging center(s). The pros and cons of a cardio-oncology clinic location in either a cancer or cardiovascular center are shown in Table 2. Essential to making a decision on location is the knowledge that a cardio-oncology clinic must lend itself well to interdisciplinary communication and provider accessibility for patients.
Depending on its goals and objectives, some cardio-oncology programs have dedicated inpatient consultative services. These services are possible in institutions with 2 or more practicing cardio-oncologists, particularly with support staff. Conversely, an institution with only 1 practicing cardio-oncologist and not much support staff could adopt an approach where the general cardiology service sees and consults on the cancer inpatient, with/without some input from the cardio-oncologist, with subsequent cardio-oncology outpatient follow-up.
Research and Mentorship
Another key component of establishing a successful cardio-oncology program is conduction of meaningful research, which consequently enhances recognition and growth of the program. Finding a cardio-oncology research mentor is a major difficulty faced by the young faculty, but can be overcome by a motivated junior investigator. One could find a mentor in oncology and another in cardiology (e.g., in cardiovascular imaging or heart failure) and then generate project ideas with potential for growth through the collaboration. Another possibility is to identify a mentor in 1 of the few major cancer centers in the country with an already established cardio-oncology program (2), which raises the concern of a long-distance mentor-mentee relationship with less contact and therefore fewer accomplished work. However, this plan could offer an advantage with fostering interinstitutional collaborations and growth of this fascinating field.
Limited data in this nascent field leave a myriad of unanswered questions about the relationship among cancer, cancer therapies, and the heart, with a wide-open field of research. At the same time, funding in less-established fields such as this one can pose specific challenges. A recent publication summarizing the recommendations of the 2013 National Heart, Lung, and Blood Institute and National Cancer Institute workshop on cancer treatment–related cardiotoxicity provides valuable insight into current scientific priorities and an important resource for person(s) considering development of a cardio-oncology research project (3).
Future Opportunities for Cardio-Oncology Programs and Career Growth
Many cardio-oncology programs are being developed across the United States by relatively young junior cardiologists who take on the task of engaging hospital/institutional administration for time and resources to facilitate program success. In response to the challenges, some of which are summarized in the previous text, there has been a call for platforms that allow for knowledge exchange and interdisciplinary education within the field of cardio-oncology. The American College of Cardiology’s Cardio-Oncology Working Group organized the first Cardio-Oncology Intensive at the 64th Annual Scientific Sessions (ACC.15), which brought specialists and subspecialists from across a number of disciplines to discuss advances in diverse aspects of clinical care, research, and cardio-oncology program development. A survey noted in a recent publication by this group demonstrated a widespread appreciation of cardiovascular concerns in cancer patients and survivors, identifying at the same time a number of critical barriers for the development of specialized services (2). The newly formed ACC Cardio-Oncology Member Section aims to serve as a professional home for the growing number of specialists in this field. Its success and the ability to advance the future of cardio-oncology programs will critically depend on the contribution of all, and in particular, of early career members focused on advancing this field within their institutions and nationally.
- Edward T.H. Yeh, MD ()
RESPONSE: Cancer and the Heart: A Fortuitous Union Between Oncology and Cardiology
When I was asked to build a department of cardiology in a major cancer center 15 years ago, I was often asked whether my department specialized in caring for “cancer of the heart,” and why there is a need for a cardiologist in a cancer center. For decades, cardiologists and oncologists have worked in different spheres, attending to their favorite maladies. However, it has become increasingly apparent that cancer patients would benefit from the expert care of both cardiologists and oncologists, because heart disease and cancer often coexist in the same patient. Furthermore, cancer therapy frequently causes either short- or long-term cardiovascular complications. Many chemotherapy drugs are known to cause cardiomyopathy, thromboembolic disease, ischemic heart disease, blood pressure alterations, and rhythm disorders (1). Radiation therapy accelerates atherosclerosis and causes valvular and pericardial heart diseases (2). Thus, cardiovascular consultations are often needed during active cancer therapy or in cancer survivors. In MD Anderson Cancer Center, the department of cardiology employs 12 full-time cardiologists to provide comprehensive cardiac care to our cancer patients. However, in the majority of noncancer hospitals, cardiac consultation for cancer patients is often given by a single provider or by referral to outside institutions. Given the success of modern cancer therapy and the sheer increase in the number of cancer survivors, there is a tremendous opportunity for cardiologist to enter this burgeoning field called “onco-cardiology” or “cardio-oncology.”
Drs. Okwuosa and Barac have written a thoughtful piece on the challenges and opportunities for early career cardiologists to enter into this new subspecialty. They carefully outline the need to obtain institutional support and the strategy for growing a comprehensive program. Many of these recommendations are excellent, but need to be individualized. Clearly, the most important ingredient for success is persistence and the willingness to provide prompt and high-quality advice to our oncologic colleagues. Another hurdle for the young cardiologists is the lack of knowledge base in this new field, because cancer has been an exclusion criterion for most of the cardiology trials. We have organized 3 international conferences in cancer and the heart with the mission to educate our next-generation onco-cardiologists. In addition, we have developed algorithms based on the practice patterns of cardiologists in our department, called the MD Anderson Practice, from which 11 video modules are available (3). These resources should serve as a good starting point for the burgeoning onco-cardiologist.
Finally, the interface between cardiology and oncology also provides an excellent opportunity for basic and clinical research. A good example is the discovery of a new paradigm for anthracycline-induced cardiomyopathy that may lead to new strategy for prevention (4). Multiple clinical trials are currently in progress to determine whether chemotherapy-induced cardiotoxicity can be predicted by biomarkers and ameliorated with cardiac medications. Furthermore, with the increasing number of targeted therapies that interfere with prosurvival signaling in the heart, we also can learn valuable lessons from our patients about cardiovascular biology. In summary, the future success of onco-cardiology is only limited by our imagination.
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- ↵MD Anderson Cancer Center. Cancer and the heart programs. Available at: www.cancerandtheheart.org. Accessed July 18, 2015.
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