Author + information
- Tochi M. Okwuosa, DOa,∗ (, )@RushMedical@cardio10s,
- Nicole Prabhu, MDb,
- Hena Patel, MDb,
- Timothy Kuzel, MDc,
- Parameswaran Venugopal, MDc,
- Kim A. Williams, MDa and
- Agne Paner, MDc
- aDivision of Cardiology, Rush University Medical Center, Chicago, Illinois
- bDepartment of Internal Medicine, Rush University Medical Center, Chicago, Illinois
- cDivision of Hematology/Oncology, Rush University Medical Center, Chicago, Illinois
- ↵∗Address for correspondence:
Dr. Tochi M. Okwuosa, Division of Cardiology, Cardio-Oncology Services, Rush University Medical Center, 1717 West Congress Parkway, Kellogg Building, Suite 328, Chicago, Illinois 60612.
Beginning with known problems regarding adoption of an appropriate name for this subspecialty (cardio-oncology vs. onco-cardiology), this new and promising field is beset with some rectifiable challenges. A search on PubMed reveals that the first mention of cardio-oncology was in 1996 by Cardinale (1). In reality, the subspecialty of cardio-oncology was born much earlier with the recognition of daunorubicin-induced cardiotoxicity in 1967 (2). Doxorubicin, first produced in 1969 as an improved form of daunorubicin, and used for treatment of various malignancies by the 1970s (3), is the pivotal reason for the development of cardio-oncology as a field. Recognition of its cardiotoxic effects, associated risk factors, and possible preventive strategies are all factors that eventually led to the birth of this important discipline. Since then, cardiotoxic effects of other anticancer drugs, including trastuzumab, cyclophosphamide, cisplatin, and 5-fluorouracil, and even newer so-called targeted therapies such as tyrosine kinase inhibitors, checkpoint inhibitors, and chimeric artificial T cell receptor immunotherapies, have been described (4).
As cancer patients live longer with the development of improved treatments (including chemo-, radiation, endocrine, and targeted therapies), cardiovascular disease (CVD) is a major cause of short- and long-term morbidity and mortality, next to second malignancy (5). As such, the field of cardio-oncology is critical for the development of survivorship strategies after the application of successful oncologic therapies, to assure something close to a usual life expectancy in cancer patients and survivors. The novelty of this field and its associated concepts, which unusually span 2 medical specialties, lends itself to administrative, clinical, research-related, and educational challenges that require attention in the near future as we continue to make progress in this field (Central Illustration). Herein, we discuss some of the challenges being tackled by small- to moderate-sized and some larger academic centers, particularly the cancer centers without National Cancer Institute designation.
1. Name. While a cardio-oncologist signifies an oncologist involved in care of cardiac patients (one may imagine an oncologist specializing in cardiac cancers); the name “onco-cardiologist” better defines the subspecialty in question—usually a cardiologist dedicated to managing cancer patients with heart disease. However, the name “cardio-oncology” has been attached to the field ever since it was first coined by an Italian researcher (1), and in the English language is often confusing to others encountering the term for the first time. Because the name is not self-explanatory, the typical onco-cardiologist often has to clarify the label “cardio-oncology,” with ready explanations for the terminology and the field. It is noteworthy that although cardio-oncology (with hundreds of citations in PubMed) was first mentioned in the literature in 1996, the term onco-cardiology (with only tens of citations) is not noted in PubMed until 12 years later in 2008.
2. Billing. Patients receiving high doses of chest radiation or chemotherapies with cardiotoxic effects have an increased lifetime risk of CVD, including coronary artery disease, heart failure, valvular heart disease, pericardial disease, and arrhythmias. The presentation and mechanism by which cancer therapies increase the risk of CVD in cancer patients differs from that of the general population, and is multifactorial. Thus, to prevent potential cardiovascular events, it is recommended that such patients be referred to cardio-oncology for specialized monitoring (6). Because chest radiotherapy (and some chemotherapy, such as paclitaxel) can cause neuropathy, these patients may experience very atypical or nonidentifiable symptoms of CVD that may portend impending cardiovascular events (7). As such, regular interval monitoring is recommended to identify CVD in these patients before they occur (6). The difficulty lies in fathoming a billing code to use in, for example, the asymptomatic patient post-radiotherapy that requires coronary evaluation. Furthermore, data show that cancer survivors are still at risk for cardiovascular events, even with normal stress tests (8). As such, a coronary computed tomography angiography (without invasive cardiac catheterization) would seem an appropriate tool for coronary screening in these patients, except that many insurance companies deny coverage of such a test without symptoms or prior stress testing. Even the need for serial echocardiograms in the patient receiving cardiotoxic chemotherapy can sometimes present challenges for coverage. Additionally, Medicare would cover screening tests such as B-type natriuretic peptide and troponin I—with very good data to support their use in screening for cardiomyopathy in patients receiving cardiotoxic chemotherapy—only if there is an associated heart failure diagnosis. The utility of these tests for screening are not recognized. Likewise, myocardial strain imaging by speckle tracking echocardiography (STE) has proven to be a valuable tool in screening for chemotherapy-associated cardiomyopathy, and predicts a decrease in left ventricular ejection fraction early in the process, thus allowing for early institution of appropriate cardiovascular therapy. Notably, acquisition of STE takes time and skill. Nonetheless, as valuable as it is, acquisition of STE imaging is not covered by most insurance companies. Therefore, most echo labs have to image with STE using their own time and resources.
Regarding compensation for services rendered, it is of note that the relative value units used as a time-value measure for physician services in most American institutions does not come close to assessing the amount of work input by the typical onco-cardiologist in the care of this complicated patient population.
3. Ownership of Cardio-Oncology. In most institutions, the onco-cardiologist is a cardiologist. In a few other places, an oncologist has served in this role. The location of the clinic in the cancer center versus the cardiology clinic each presents both benefits and drawbacks (9). The fact that these are oncology patients that require oncology health care providers—including nurses, advanced practice providers, and ancillary staff—but are managed by a cardiologist begs the question as to ownership of this medical subspecialty. This often places the onco-cardiologist in the difficult position of being “stuck in the middle” of the 2 medical sections and divisions, particularly regarding funding of clinical, administrative, and sometimes educational and research-related needs.
4. Nursing Staff. There is no doubt that a nurse is required in the cardio-oncology clinic, as the typical cardio-oncology patient is complicated as a result of cancer, cancer therapies, and associated cardiovascular complications. The ultimate question of skill sets required for the nursing staff to be successful has proved debatable. Although the cardiology nurse is well versed in CVDs and testing, the oncology nurse understands cancer patients and their medical, social, and psychological needs, particularly while undergoing cancer treatment. One is hard pressed to find the ideal nurse that spans both specialties.
5. Patient Population. The typical oncology patient receiving active cancer treatment can be quite ill, with complicated medical and emotional needs. Some may be demoralized, and depending on their stage of cancer, may want to engage their health care provider in end-of-life and other difficult discussions. The onco-cardiologist understands the oncologic needs of this patient population to some extent, and is sometimes the first health care provider with whom this issue presents itself. He or she is therefore forced to decide how best to navigate this complex process and appropriately involve the primary oncologist without seeming insensitive to the needs of this vulnerable population.
6. Varied Responsibilities of the Onco-Cardiologist. Owing to the novelty and exploratory period of this specialty that is yet to be fully defined, most institutions that have a cardio-oncology service employ only 1 onco-cardiologist. The onco-cardiologist is therefore one among a myriad of oncologists spanning various organ systems, with duties that include interacting with oncologists regularly to resolve curbside questions, attending tumor board conferences and providing cardiovascular input, reviewing and interpreting cardiac studies to provide perspective to the oncologist, and helping manage acute cardiovascular needs in the oncology clinic and inpatient setting. The onco-cardiologist therefore has to determine approaches to streamline these multiple responsibilities while still thoroughly attending his or her complicated patient population.
7. Finding Other Onco-Cardiologist(s) to Join the Practice. As the onco-cardiologist acquires recognition and the need for the service is appreciated and engaged, the task of acquiring more than 1 onco-cardiologist within a given institution presents its own challenges. Many cardiology fellows-in-training aspire to practice cardiology alone, and therefore reject the seemingly complicated picture of acquiring training in cardiology, with some features of oncology. As such, few make that decision to acquire extra training (no matter how short) to practice cardio-oncology, and even fewer want to be burdened with the job of managing this complex patient population. Consequently, in the programs with expanding cardio-oncology needs, finding a second or third onco-cardiologist is often a problematic undertaking.
8. Lack of Guidelines. As new as this subspecialty is, there are no actual societal guidelines to help standardize clinical practice, despite a few consensus statements. Even then, these limited statements deal mostly with older (and better understood) cancer drugs such as anthracyclines, although there are insufficient data on the newer cancer drugs, and there are a good number approved per year. Furthermore, there is very sparse or limited information to guide the onco-cardiologist concerning the number of other issues that daily present themselves, such as anticoagulation or dual antiplatelet therapy in the setting of low platelet counts, management of arrhythmias in the setting of cancer therapy and associated systemic complications, management of ischemic heart disease and heart failure through radiotherapy and cardiotoxic chemotherapy, and a plethora of other intricate issues that often need to be addressed.
9. Ever-Evolving Cancer Therapies With Cardiovascular Side Effects. This involves both the newer cancer drugs recently developed, and the evolution of cancer therapy for each patient based on disease response. The former requires keeping abreast of the ever-evolving cancer literature with regular ongoing discussions with oncologists to appropriately address cardiovascular questions or issues on referrals, while the latter involves keeping informed on cancer therapies of each cardio-oncology patient on active treatment. This last issue usually requires reliance on cardio-oncology ancillary staff, and keeping open the lines of communication with the oncologists, advanced practice providers, and other cardio-oncology health care providers.
10. Creating a Balance Between the Degree of Cancer Illness and CVD Prevention. In most cases, the focus for care of the typical oncology patient is the cancer, while other not-so-active disease processes—particularly those involving prevention—recede to the background. However, cancer and heart disease have common risk factors such as cigarette smoking, alcohol use, obesity, and some diets (e.g., red meat consumption) to the extent that growing data now also support the fact that some of these same risk factors (including dyslipidemia) are associated with cancer progression and recurrence, while treatment of these risk factors improves survival in the cancer patient (10). This creates the need to achieve a balance between finding a healthy diet that the typical cancer patient can eat and enjoy, while maintaining his or her caloric needs during cancer therapy. Such a balance is often difficult to achieve in the cancer patient suffering from anorexia and gastrointestinal complications of cancer therapy (nausea, vomiting, and even diarrhea), and requires close collaborations between the onco-cardiologist and the cancer center nutritionist or dietician. Likewise, the case has been made for use of cardiovascular preventive drugs such as statins, beta-blockers, aspirin, and others to improve overall survival in the cancer patient on active therapy (10). The untoward side effects of these drugs (myalgias, myositis, and transaminitis in the case of statins; and aspirin-associated increase in bleeding risk in the setting of possible cytopenia from cancer therapy) also has to be put in perspective.
11. Training and Education. The diversity and lack of standardization in training and practice within the pockets of training institutions in cardio-oncology throughout the United States, calls for formalized (Accreditation Council for Graduate Medical Education accredited) training in this new subspecialty. Such formal training would aid in recruiting much-needed cardiology fellows to the field of cardio-oncology, and also create a network for exchange of information and growth in knowledge, as well as help facilitate recruitment of faculty to the field. The standardization would streamline and therefore positively influence overall care of the cardio-oncology patient. Furthermore, funding for said training programs remains a challenge.
12. Research Funding. The oncology research funding sources do not involve the heart, and vice versa. Consequently, there are very limited funding sources encompassing both fields, although the evolving recognition of the importance of survivorship may provide one avenue for such funding. However, in more recent times, the recognition of cardio-oncology as a burgeoning field within cardiology is opening new waves of funding from both national cardiology societies and the National Institutes of Health. Institutional and foundational funding sources within cardio-oncology are yet in the making. Overarching funding sources related to specific cancers, disease prevention, or specific cancer therapies within oncology could sometimes prove to be innovational funding sources for specific cardio-oncology projects.
The demand for onco-cardiologists will only increase as expanding treatment options for cancer patients are leading to more cures and longer survival measured in years. As the growing population of cancer survivors age, the cardiac side effects of therapy can be expected to compile with common comorbidities. Attention to the issues described herein will ensure the stability and readiness of this important specialty of cardio-oncology to tackle the needs of this distinctive population.
Dr. Kuzel has recevied speaking honoraria from Sanofi; has served as a member of data monitoring committees for international clinical trials for Merck; has served as chair of the data monitoring committee for an international clinical trial for Amgen; has recevied clinical trial funding from Bristol-Myers Squibb, Eisai, and Seattle Genetics; and has served on advisory boards for Bristol-Myers Squibb, Eisai, Seattle Genetics, Pfizer and AbVie. Dr. Paner has served as a consultant for Celgene, Amgen, Janssen, and Takeda. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
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