Experts Call on Training Programs to Incorporate Cardio-Oncology to Meet Growing Need

Cardio-oncology is a relatively new concept, but the surge in its popularity over just a few short years attests to the fact that more and more physicians from the cardiology and oncology communities want to learn and be involved in growing the specialty, a new review paper suggests.

The review included a nationwide survey of Accreditation Council for Graduate Medical Education (ACGME)-accredited general cardiology fellowships. Overall, 51% of respondents report working at centers that have an established, specialized cardio-oncology service. A similar survey conducted in the 2014 had put that figure at just 27%.

“The need for cardio-oncology services is clearly appreciated,” lead author Salim S. Hayek, MD (University of Michigan, Ann Arbor), said in an interview with TCTMD. “I expect that in the next 5 to 10 years most centers will have these dedicated services.” He added that centers that do offer cardio-oncology report that patients are happy with their care, but training the cardiovascular workforce to meet the growing needs of these patients is no easy task.

“There has been a lot of progress over the last 4 years . . . but there also have been calls for increasing awareness, education, and training,” noted Ana Barac, MD, PhD (MedStar Heart and Vascular Institute, Washington, DC), a senior author of the paper, which was published online April 29, 2019, ahead of print in Journal of the American College of Cardiology.

Lack of clinical practice guidelines has been identified as a consistent limitation with regard to growth of cardio-oncology. While some individual medical societies have released their own position papers and other documents, the authors say a critical next step will be to develop guidelines for cardiovascular care with specific cancer regimens.

“With increasing numbers of older patients with cancer, and the rise and incidence of adverse cardiovascular events of chemotherapy, we're seeing more and more cancer patients presenting with atypical presentations of cardiovascular disease,” Hayek said.

Another important factor, however, is the lack of cost-effectiveness studies to demonstrate the financial benefits of offering cardio-oncology programs. “Until these studies come out it’s difficult to incentivize having funding to train and essentially provide these services,” Hayek added. “We don’t have good data [but] this is an area that is primed to boom.” Doing those studies, will be challenging, he acknowledged but testing specific strategies in a randomized fashion may be the best way to identify groups of patients most likely to benefit from having cardio-oncology available to them.

Education Barriers

The survey also shows that while cardio-oncology services exist in centers across the United States, approximately 40% of those currently offering or planning to offer such programs are clustered in the Northeast. Less than half of the general cardiology fellowships reported incorporating educational topics pertaining to oncology patients, including cancer therapy-related cardiotoxicity, complications of radiation therapy, risk stratification, thromboembolism, and care of cancer survivors.

“Inclusion of cardio-oncology as a component of general cardiology training programs is the first step at establishing a workforce capable of recognizing and managing the complex cardiovascular burdens associated with cancer in every community,” Hayek and colleagues write.

They also note that cardio-oncology fellowship programs “can only effectively exist and thrive in conjunction with well-established cardio-oncology services with robust patient and imaging volume as well as ongoing clinical and basic science research activities.” An additional challenge, Hayek said, is that among established cardio-oncology fellowship programs, training seems to vary dramatically, raising important questions about how to provide uniform training that meets everyone’s needs.

Perhaps most important of all, collaboration with oncologists and oncology societies is the only way to ensure that not only will cardio-oncology have a future as a discipline and possibly as a subspecialty, but also that policymakers and payers will grasp its value in patient care, Hayek and colleagues observe. Among the things they would like to see are grand rounds attendance and presentations with feedback from hematology/oncology and cardiology colleagues regarding shared patients, and development of billing codes relevant to cardio-oncology services.

To TCTMD, Barac said multispecialty collaboration in clinical trials also is especially crucial for filling gaps in knowledge and prioritizing the cardio-oncology research agenda.

“This is an exciting time for cardio-oncology,” Hayek observed. “I feel our cancer patients have derived reassurance from having cardiovascular specialists shepherd them in their care. For their sakes, it is our duty to generate the evidence and strategies that we need to optimize their care.”