Transcript Attitudes and practice patterns in cardiac oncology: the

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Developing a Cardiac Oncology
Fellowship Program
ASCO June 2014
Susan Dent
Medical Oncologist
The Ottawa Hospital Cancer Center
Ottawa, Canada
The problem
Cancer Survivors (Million) 2012 - 2018
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20
15
10
Cancer Survivors (Million) 2012 - 2018
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2
1
0
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Brigham,
MGH
MSK
U Penn
Medstar Washington
Louisville
Duke
Stanford
Vanderbilt
MD Anderson
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Why do we need Cardiac Oncologists?
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• N = 63 with LVSD (LVEF < / = 45%) post chemo
• 67% symptomatic HF: 54% had Cardiology input (black)
• Survival 71% vs 41% in no Cardiology input
Cardiology input = black
No Cardiology = white
All = grey
Cardiovascular Management of Cancer Patients With
Chemotherapy-Associated Left Ventricular Systolic
Dysfunction in Real-World Clinical Practice
Journal of Cardiac Failure, Volume 19, Issue 9,
2013, 629 - 634
Why do we need cardiac oncologists ?
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Yoon , Telli , Kao , Matsuda , Carlson , Witteles
Left Ventricular Dysfunction in Patients Receiving Cardiotoxic Cancer Therapies : Are Clinicians Responding Optimally?
Journal of the American College of Cardiology, Volume 56, Issue 20, 2010, 1644 - 1650
What is Needed !
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Network / Collaboration
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Facilitate networking: ICOS NA , CCON
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Create WG and TFs – link
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Publicize Cardio-Oncology: websites, social media
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Facilitate Research Collaborations: invite participation – group efforts
Clinical
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Centralize existing resources, create white papers and guidelines
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Create a learning pathway
Training
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Develop a Fellowship program
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Standardized Curriculum
Fellowship Training – what’s out there
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• 7 Fellows in US / Canada
• No accreditation
• No internal funding
• No recognized structure to follow
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Cardiology
Oncology
Consults
Clinics
HF
Imaging
Research
Cardiac Oncologist?
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Should we develop a curriculum
for cardiac oncology ?
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GOALS
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Master
CURRICULUM
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 Convey a knowledge base. Stimulate research.
 Integrate into mainstream cardiology and oncology
training programs
 Reshape the mindset about traditional roles of
cardiologists and oncologists .
 Graduates expand best practices outside the
cloistered “cardio oncology centers”, improve
practice, lessen disparities in practice.
Richard M. Steingart MD
Chief, Cardiology Service
Memorial Sloan-Kettering Cancer Center
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cardiac tumors
use of chemotherapeutic drugs, biologic products, and growth factors;
their mechanisms of action, pharmacokinetics, clinical indications, and
limitations, including their effects, toxicity, and interactions
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Level
1 (Internal
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Medicine
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• basic knowledge of cancer agents and their
potential to cause cardiac damage
• Imaging strategies – basic knowledge on
cardiac imaging in oncology patients
• Basic understanding of treatment strategies
for cancer patients experiencing cardiac
toxicities
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Level
2 (Medical/Cardiology
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• For residents who wish to broaden their
exposure to cardiac oncology patients
• More detailed assessment of patients
• Intermediate knowledge base
• More exposure to advanced cardiac imaging
eg. advanced echocardiography (strain/3D)
• Understanding of the role of biomarkers in
early detection of cardiac toxicity
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Level
3 (Cardiac
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Oncology
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Fellow)
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• 12-24 months of dedicated fellowship
training
• advanced knowledge of cancer agents and
potential toxicities
• broad exposure to in- and out- patients
• training in biomarkers, advanced imaging
• actively involved in research
Level
3
Cardiac
Oncology
Fellow
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(12-24 months)
• Cardiologist stream
• Oncologist stream
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Principles of oncology care
Advanced knowledge of cancer
agents and potential toxicities
Training in biomarkers, advanced
cardiac imaging
Appropriate cardiac imaging
techniques
cardiotoxicity surveillancewhen/how long?
Evidence based treatment with
cardioprotective drugs
Actively involved in research
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Understanding cardiac imaging:
limitations and common techniques
Familiarity with principles of heart
failure, arrhythmias and
hypertension
Familiarity with principles of
echocardiography , cardiac MRI and
biomarkers
Techniques of cardiac surveillance
Evidence based treatment with
cardioprotective drugs
Actively involved in research
HOW TO ACCOMPLISH THE ESSENTIAL
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INSTRUCTION?
Cancer therapies taught by cardiologists to cardiology trainees
as life saving interventions with manageable toxicity.
Longitudinal Outpatient Cardio-Oncology Clinic
• Adults currently receiving anthracyclines/trastuzumab.
– Continuum of benefit and risk.
• Surgical clearance of the cancer patient.
• Childhood cancer survivors.
• Adults receiving VSPI.
– Blood pressure, CHF and ischemia management.
Inpatient Consultation Service
• Antiplatelet/anticoagulant risks and benefits.