Developing Cardio-Oncology Programs in the New Era: Comparison
View Latest Version
Please note this is a comparison between Version 2 by Lindsay Dong and Version 1 by Alexandra Pons-Riverola.

Modern cancer therapies have achieved a remarkable improvement in overall survival and patients’ quality of life. However, cardiovascular toxicities are still a major concern. A specific Cardio-Oncology unit is key to offering patients with cancer the best approaches to treatment while minimizing adverse cardiac effects. Moreover, this area of medicine requires a large expertise and has limited trials on which to base decision-making. The development of structured Cardio-Oncology programs leads to better patient care and generates scientific evidence that may impact patient’s survival outcomes.

  • Cardio-Oncology
  • cardiovascular disease
  • cancer
  • cardiotoxicity
  • program

1. Introduction

There is growing evidence as to the connection between cancer and cardiovascular disease (CVD) beyond the several risk factors they share like aging, obesity, diabetes, hypertension or dyslipidemia [1]. The incidence of cancer in patients with chronic heart failure (HF) is estimated at about 19 to 34 per 1000 person-years [2], which is higher than in the general population [3]. Additionally, recent studies have shown that it is one of the main causes of death among chronic HF patients [4]. Conversely, it is well known that several cancer treatments have a deleterious effect on the cardiovascular system. Some of them are known to be toxic for the myocardium and eventually lead to ventricular dysfunction and HF. The incidence of left ventricle dysfunction and HF is estimated to be between 2 and 33% in cancer patients, depending on the cancer treatment they receive and their basal characteristics [5].
Cardio-Oncology (CO) is a new and rising field that was initially created to perform an early diagnosis and treatment of cardiotoxicity (CTOX), secondary to anthracyclines or anti-human epidermal growth factor receptor 2 (HER2) agents, which enable cancer patients to withstand their treatment and therefore increase their survival rate. HF is known as one of the most critical adverse effects of cancer treatment, as it has an important impact on cancer prognosis [3]. However, as knowledge in this field grows, modern CO goes beyond solely CTOX screening and deals with a wide spectrum of cardiovascular effects related to cancer therapies. This includes arrhythmias, valvular heart disease, pericardial disease and early atherosclerosis, among others.
CO is a challenging and growing discipline that aims to provide complete CV care for cancer patients and survivors. Evidence shows that multidisciplinary programs within Oncology, Hematology and Cardiology improve clinical outcomes in cancer patients [6[6][7],7], as they guarantee cardiac optimization and cancer treatment continuation [8]. 

2. Organization of a Cardio-Oncology Unit

2.1. Objective of the Cardio-Oncology Unit

The aim of a Cardio-Oncology Unit is to provide specialized multidisciplinary approach and consistent, continuous, coordinated and cost-effective care during the cancer process [9]. It consists of the prevention, diagnosis and treatment of cancer patients at risk of cardiotoxicity. It also involves the monitoring and treatment of cancer patients at risk or with concomitant CV diseases. The final goal of CO services is to facilitate optimal cancer treatments and prevent the unwarranted withdrawal of treatment. Barros-Gomes et al. describe the objectives in their CO practice in the Mayo Clinic as follows: (1) to facilitate the diagnosis, monitoring and therapy of cancer treatment related cardiovascular complications; (2) to evaluate the baseline cardiovascular risks prior to cancer treatment and implement strategies for reducing the risk of developing cardiovascular complications; and (3) to assist the patient with cardiovascular care through long-term follow-up [10].

2.2. Components of Cardio-Oncology Team

Cardio-Oncology is a discipline that involves different specialized professionals and demands direct communication between them to discuss shared patients. Therefore, a multidisciplinary team is crucial [9,11][9][11]. The nucleus of the CO team is composed of cardiologists (usually with a special interest and experience in the management of cardiac conditions in cancer patients), medical oncologists, radiation oncologists, hematologists and specialized nurses. Apart from the core members, the CO team also needs a close relationship with other professionals like family doctors, pathologists, radiologists, the palliative care team, pharmacists, cardiac surgeons, internists, etc. With regard to the cardiology team, Clinical Cardiology and Cardiology Imaging are usually the axis of the CO team, but multiple cardiology subspecialties may also be involved. They include the inpatient cardiology ward, cardiology critical care unit, invasive cardiology unit and heart failure specialists, among others.

2.3. Cardio-Oncology Programs

Ideally, a Cardio-Oncology program should cover five different areas: clinical, research, training, innovation and quality indicator evaluation (Figure 1).
Cancers 15 05885 g001
Figure 1. Main components of a Cardio-Oncology Program. Figure shows the different areas a Cardio-Oncology program should cover and its main components. Abbreviations: CO, Cardio-Oncology.
Cardio-Oncology is a broad and complex area of knowledge which requires a multidisciplinary approach. To be successful, a comprehensive Cardio-Oncology program should comprise different sections. The clinical part takes place mainly in the outpatient clinic, but should also cover inpatient and interprofessional consultations. Easy and fast accessibility and multidisciplinary meetings are essential for the promotion of shared decision-making. As lack of evidence is frequent in some fields, creation of institutional databases, engaging in national and international societies and promoting participation in clinical trials and multicentric studies constitute important steps within the research section. An appropriate training is achieved through educational sessions, fellowship and mentorship programs. Lastly, Cardio-Oncology activity and results should be measured by thorough quality indicators.

2.3.1. Clinical Program

The CO outpatient clinic is the main activity in a CO program. Most CO consultations should be organized as a face-to-face day-case model, which reduces the number of visits to the hospital and avoids treatment delay. The aim of a day-case model is to provide clinical assessment, non-invasive investigations (blood tests with cardiac biomarkers, electrocardiogram and echocardiography) and multidisciplinary discussion on the same day. Invasive cardiac investigations, if appropriate, can be delivered in collaboration with the cardiology department (advanced cardiac imaging and interventional procedures). The virtual outpatient clinic, using a telephone call or videoconferencing, is an option to connect with patients without in person appointment, e.g., to monitor vital signs or to share test results. A CO program can be established taking advantage of existing resources, such as a specialized nursing staff and a heart failure program, thereby patients who develop significant cardiotoxicity could be transferred to HF Unit for a more specific management [12].

As for the inpatient consultation services, the CO service should also provide advice relative to oncology and hematology inpatients who develop new cardiac symptoms, as well as the cardiology inpatient with cancer. The inpatient consultation service is only possible in large CO services with more than one practicing cardio-oncologist, and ideally should be a same or next day review [13]. The CO team will also oversee organizing the patient follow-up at discharge. In some tertiary hospitals with an important number of cancer inpatients, an on-call cardiologist from the CO team should be considered.
Regarding interprofessional consults, electronic methods (e-consults) can be used as a fast and efficient way of communication between different CO specialists or with other doctors (general cardiologists, family doctors, pharmacists, etc.), particularly with regard to referral for CO consultation or recommendations and concrete advice about patient care. This method enables cardiologists to further assist oncologists and hematologists in assessing risk factors and managing existing cardiovascular disease without necessitating direct contact with the patient [10]. Polypharmacy is very frequent in elderly patients and can lead to drug–drug interaction.
Multidisciplinary team meetings are essential to facilitate shared decision-making around complex patients, as they lead to face-to-face discussions between cardiologists, oncologists and hematologists about continuation, as well as the modification or interruption of a specific cancer treatment. In a multidisciplinary team, it is imperative to have a shared electronic medical record that allows for the easy and efficient exchange of information. Both cardiology and oncology medication should also be updated in the medical history [12]. CO service organization can be quite challenging, as patients often need to be seen within a week to avoid any treatment delay. The creation of protocols for referral and specific clinical pathways adapted to the available infrastructure is mandatory to ensure that efforts and resources are dedicated to the patients who can benefit most from them. Flexibility and a self-management model in the scheduling of patient appointments is key to providing assistance in a timely fashion and to adapt to the dynamic nature of CO patients and their needs [12,14][12][14].

2.3.2. Research Program

Cardio-Oncology is a recently created and evolving subspecialty with limited trials on which to base decision-making. Thus, a great deal of the management of the patients relies on consensus or expert opinion. One of the main goals of creating a CO program is to participate in developing high-quality scientific evidence. A CO service should collect clinical data of patients attended in the outpatient clinic. Advanced and multidisciplinary imaging and CO biobanks are also essential to build new prediction models of cardiotoxicity. In addition to focusing in a concrete area of local research and expertise, it is crucial to participate in multicentric studies and clinical trials.

2.3.3. Training Program

Cardio-Oncology training should have an structured program that includes organized educational sessions with the Cardiology, Hematology and Oncology teams [14]. Like any other subspecialty, training medical students, cardiology residents and fellows in Cardio-Oncology is fundamental. It would also be worthwhile to regulate a fellowship in Cardio-Oncology and create mentorship programs for cardiologists interested in this field. This would help increase the visibility of CO and its program among other health care professionals and institutions. Establishing educational opportunities to provide additional experience in CO, like professional seminars and conferences, is also recommended for all CO team members. Education and support for patients also needs to be considered, so they can learn more about their disease and treatment [12].

2.3.4. Innovation in Cardio-Oncology

Despite recent advances in Cardio-Oncology and the increase in information and evidence-based approaches in the diagnosis, management and treatment of oncological patients with cardiovascular disease, there are still many gaps in knowledge and areas of uncertainty. Collaborative groups may share information and databases that increase awareness of these kind of patients and improve outcomes. Sharing experience and knowledge may create a bigger database that will make it possible to get specific and copious information and data that can extrapolated to daily clinical practice. Artificial intelligence, patient-centered data, tele-medicine and remote follow-up are several of many fields that need to be explored and exploited in the next future. Finally, individualized medicine derived from targeted treatment in specific scenarios may lead to treatments with greater efficacy and fewer secondary effects [15].

2.3.5. Quality Indicators

There is increasing interest in discovering new tools that permit a comprehensive evaluation of quality of care, including structural and process indicators and outcomes in cardiovascular disease. Geographical and social variation in medical care delivery, as well as the difficulty in the assessment of outcomes and the need to invest in closing the so called “evidence-practice gap”, has led several medical societies to try to unify and establish shared pathway goals in the management and outcomes of patients with cardiovascular disease. Currently, the use of quality indicators (QI) to evaluate medical practice is well accepted, as they may serve as a way to promote and enhance evidence-based medicine, through quality improvement, benchmarking of care providers and accountability. Specific pathways have been proposed to establish reliable QI. The most acknowledged program divides the QI development process into four steps: identifying the domain of care, constructing candidate quality indicators, selecting the final quality set and assessing feasibility [16].

2.4. Pathway of Care

Cardio-Oncology consultations are aimed at patients at considerable risk of CV complications related to anticancer treatment. Lancellotti P et al., in a report from the ESC Cardio-Oncology Council, define high risk patients as: (1) patients receiving potentially cardiotoxic treatment; (2) patients prior to cancer surgery if they have previous CV disease or are expected to receive additional cancer treatment; (3) patients who develop CV symptoms during oncological treatment; (4) patients receiving cancer treatment who develop asymptomatic newly reduced cardiac function; (5) patients with prior childhood cancer treatment; (6) those planning pregnancy or those who develop CV symptoms during pregnancy [9]. The new Cardio-Oncology guidelines also provide tools to stratify cardiovascular toxicity risk of many cancer treatments [17]. Low-risk patients can follow regular oncology monitoring without special cardiology follow-up. The main pathway of care in CO programs is the CV assessment and management of cancer patients before, during and after the cancer therapy (Figure 2).
Cancers 15 05885 g002
Figure 2. Cardio-Oncology clinical care pathway. Figure shows the management of cancer patients before, during and after cancer therapy. Abbreviations: CO, Cardio-Oncology; CV, cardiovascular; ECG, electrocardiogram; NP, natriuretic peptides; TTE, transthoracic echocardiography; Tx, treatment.
The patient journey starts before receiving cancer treatment, where a comprehensive evaluation of cardiovascular risk should be carried out. High- and very high-risk patients may benefit from primary prevention strategies. Once cancer therapy begins, proactive monitoring and early detection of cardiac toxicity is warranted. When needed, cardiovascular treatment should be prescribed as soon as possible, in order to minimize cancer therapy interruptions. Finally, patients who successfully finish their cancer treatment should be included in a long-term survivorship program, which can be done in collaboration with general practitioners.
The aim of cardiac monitoring during cancer treatment is the early detection of cardiovascular complications. It is not only cardiotoxicity related to left ventricle dysfunction and heart failure, but also arrhythmias, hypertension, vascular toxicity, ischemia, valvular heart and pericardial disease, among others [10]. The main instruments are electrocardiograms, blood tests with cardiac biomarkers (troponin and natriuretic peptides) and strain imaging echocardiography. Timing of the cardiac monitoring depends on the anticancer treatment and the patient risk profile [19][18]. Advanced cardiac imaging or invasive testing might also be necessary in some patients [20][19].

3. Conclusions

Cardio-Oncology now goes far beyond ventricular dysfunction screening and treatment. Cardiotoxicity comprises a wide spectrum of myocardial, pericardial, coronary and arrhythmic complications. Cardio-Oncology units should perform thorough cardiovascular management of cancer patients to enhance their quality of life, avoid unnecessary withdrawal from cancer therapies and improve their prognosis. This is a complex and challenging job that requires a multidisciplinary approach and continuous communication among all parties involved, including the patients. A comprehensive and structured program is the key to success. The Cardio-Oncology team should be patient-centered, but should also focus on research, training and innovation.

References

  1. Koene, R.J.; Prizment, A.E.; Blaes, A.; Konety, S.H. Shared Risk Factors in Cardiovascular Disease and Cancer. Circulation 2016, 133, 1104–1114.
  2. Ameri, P.; Canepa, M.; Anker, M.S.; Belenkov, Y.; Bergler-Klein, J.; Cohen-Solal, A.; Farmakis, D.; López-Fernández, T.; Lainscak, M.; Pudil, R.; et al. Cancer diagnosis in patients with heart failure: Epidemiology, clinical implications and gaps in knowledge. Eur. J. Heart Fail. 2018, 20, 879–887.
  3. Banke, A.; Schou, M.; Videbaek, L.; Møller, J.E.; Torp-Pedersen, C.; Gustafsson, F.; Dahl, J.S.; Kober, L.; Hildebrandt, P.R.; Gislason, G.H. Incidence of cancer in patients with chronic heart failure: A long-term follow-up study. Eur. J. Heart Fail. 2016, 18, 260–266.
  4. Moliner, P.; Lupón, J.; de Antonio, M.; Domingo, M.; Santiago-Vacas, E.; Zamora, E.; Cediel, G.; Santesmases, J.; Díez-Quevedo, C.; Isabel, M.; et al. Trends in modes of death in heart failure over the last two decades: Less sudden death but cancer deaths on the rise. Eur. J. Heart Fail. 2019, 21, 1259–1266.
  5. Nhola, L.F.; Villarraga, H.R. Fundamentos de las unidades de cardio-oncología. Rev. Española Cardiol. 2017, 70, 583–589.
  6. Ammon, M.; Arenja, N.; Leibundgut, G.; Buechel, R.R.; Kuster, G.M.; Kaufmann, B.A.; Pfister, O. Cardiovascular management of cancer patients with chemotherapy-associated left ventricular systolic dysfunction in real-world clinical practice. J. Card. Fail. 2013, 19, 629–634.
  7. Parent, S.; Pituskin, E.; Paterson, D.I. The Cardio-oncology Program: A Multidisciplinary Approach to the Care of Cancer Patients With Cardiovascular Disease. Can. J. Cardiol. 2016, 32, 847–851.
  8. Pareek, N.; Cevallos, J.; Moliner, P.; Shah, M.; Tan, L.L.; Chambers, V.; Baksi, A.J.; Khattar, R.S.; Sharma, R.; Rosen, S.D.; et al. Activity and outcomes of a cardio-oncology service in the United Kingdom-a five-year experience. Eur. J. Heart Fail. 2018, 20, 1721–1731.
  9. Lancellotti, P.; Suter, T.M.; López-Fernández, T.; Galderisi, M.; Lyon, A.R.; Van der Meer, P.; Cohen, A.; Zamorano, J.L.; Jerusalem, G.; Moonen, M.; et al. Cardio-Oncology Services: Rationale, organization, and implementation. Eur. Heart J. 2019, 40, 1756–1763.
  10. Barros-Gomes, S.; Herrmann, J.; Mulvagh, S.L.; Lerman, A.; Lin, G.; Villarraga, H.R. Rationale for setting up a cardio-oncology unit: Our experience at Mayo Clinic. Cardiooncology 2016, 2, 5.
  11. Arjun KGhosh Charlotte Manisty Simon Woldman Tom Crake Mark Westwood, J.M.W. Setting up cardio-oncology services. Br. J. Cardiol. 2017, 24, 1.
  12. Snipelisky, D.; Park, J.Y.; Lerman, A.; Mulvagh, S.; Lin, G.; Pereira, N.; Rodríguez-Porcel, M.; Villarraga, H.R.; Herrmann, J. How to Develop a Cardio-Oncology Clinic. Heart Fail. Clin. 2017, 13, 347–359.
  13. Okwuosa, T.M.; Barac, A. Burgeoning Cardio-Oncology Programs: Challenges and Opportunities for Early Career Cardiologists/Faculty Directors. J. Am. Coll. Cardiol. 2015, 66, 1193–1197.
  14. Sadler, D.; Chaulagain, C.; Alvarado, B.; Cubeddu, R.; Stone, E.; Samuel, T.; Bastos, B.; Grossman, D.; Fu, C.L.; Alley, E.; et al. Practical and cost-effective model to build and sustain a cardio-oncology program. Cardiooncology 2020, 6, 9.
  15. Brown, S.-A.; Rhee, J.-W.; Guha, A.; Rao, V.U. Innovation in Precision Cardio-Oncology during the Coronavirus Pandemic and Into a Post-pandemic World. Front. Cardiovasc. Med. 2020, 7, 145.
  16. Aktaa, S.; Batra, G.; Wallentin, L.; Baigent, C.; Erlinge, D.; James, S.; Ludman, P.; Maggioni, A.P.; Price, S.; Weston, C.; et al. European Society of Cardiology methodology for the development of quality indicators for the quantification of cardiovascular care and outcomes. Eur. Heart J. Qual. Care Clin. Outcomes 2022, 8, 4–13.
  17. Lyon, A.R.; López-Fernández, T.; Couch, L.S.; Asteggiano, R.; Aznar, M.C.; Bergler-Klein, J.; Boriani, G.; Cardinale, D.; Córdoba, R.; Cosyns, B.; et al. 2022 ESC Guidelines on cardio-oncology developed in collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO) and the International Cardio-Oncology Society (IC-OS). Eur Heart J 2022, 43, 4229–4361.
  18. McDonagh, T.A.; Metra, M.; Adamo, M.; Gardner, R.S.; Baumbach, A.; Böhm, M.; Burri, H.; Butler, J.; Čelutkienė, J.; Chioncel, O.; et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur. Heart J. 2021, 42, 3599–3726.
  19. Zamorano, J.L.; Lancellotti, P.; Rodriguez Muñoz, D.; Aboyans, V.; Asteggiano, R.; Galderisi, M.; Habib, G.; Lenihan, D.J.; Lip, G.Y.; Lyon, A.R.; et al. 2016 ESC Position Paper on cancer treatments and cardiovascular toxicity developed under the auspices of the ESC Committee for Practice Guidelines: The Task Force for cancer treatments and cardiovascular toxicity of the European Society of Cardiology (ESC). Eur. Heart J. 2016, 37, 2768–2801.
More
© Text is available under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/)
Video Production Service
Feedback