Setting up cardio-oncology services

In this article, we explain the clinical requirement for cardio-oncology services and reflect on our experiences in setting these up at Barts Heart Centre and at University College London Hospital.

Introduction

With an ageing population, the incidence of cancer is rising.¹ This, coupled with the development of newer and more effective cancer treatments, has led to an increasing number of cancer survivors. Unfortunately, many of these treatments can be cardiotoxic, and prevention, early detection, long-term monitoring and treatment of ensuing cardiac problems in these patients is a growing problem.² Cardio-oncology services aim to provide cardiac care for cancer patients and survivors.^3,4

Rationale for a cardio-oncology service

The care of cancer patients is becoming increasingly complex with a rapid increase in the number of available anticancer agents, many of which have potential cardiac side effects.⁵ A larger proportion of patients are living with cancer, often receiving a series of therapies over a number of years, aiming to maintain remission rather than achieve cure. In addition, with an ageing population, many cancer patients have a number of co-existing cardiovascular risk factors or overt cardiac disease at the time of initiation of cancer therapy. Cardiovascular disease is now very often one of the principal determinants of the outcome of many cancers, meaning that cardiovascular screening before and during therapy are essential to decrease cardiovascular complications and hence reduce mortality.⁶ In order to achieve this, patients need rapid access to cardiovascular investigations and assessment, in order to prevent detrimental delays to treatment, and cardiologists with specialist experience and interest in the management of cardiac conditions in cancer patients. Having a dedicated cardio-oncology service not only provides this, but also facilitates direct communication between oncologists and cardiologists about shared patients. A cardio-oncology service can also facilitate the nuanced management of these patients in the context of the cardiology subspecialties, e.g. coronary stenting in a patient on chemotherapy and with a low platelet count. There is now emerging evidence that the presence of a dedicated cardio-oncology service within a cancer centre will improve rates of screening for cardiotoxicity within cancer patients, and, hence, should impact on outcome in the future.⁷

Stakeholders and engagement with management

A variety of different stakeholders need to be considered when setting up a new service. Cardio-oncology is no different (figure 1).

Bringing members of all these groups together to work on the common cause of setting up and running a cardio-oncology service can be challenging. The relative lack of cardio-oncology services at other hospitals, allied with the novel nature of the specialty, can lead to a lack of awareness of the need for the service. It may be especially difficult to convince managers and key opinion leaders in the hospital of the utility of the service, given the relative lack of real-world outcome data on cardio-oncology services. In this scenario, it is important to convince senior management, e.g. medical director and chief executive officer (CEO), of the need for investment in this field. Not only will a cardio-oncology service enable optimal cardiac care for cancer patients, but resources that are currently used to provide this care in an inefficient and haphazard way can be streamlined into efficient use in the cardio-oncology service.

Publicising the service

Publicising the value of a new cardio-oncology service is very important; both to cardiologists and oncologists alike. A number of presentations may need to be given at both oncology and cardiology meetings. In addition, the wider hospital community should be made aware of the existence of and work done by the new service. Allied healthcare staff involved in the care of these patients, e.g. specialised pharmacists, clinical nurse specialists, cardiac physiologists, etc., should also understand the remit of the new service. Face-to-face contact is important, and this is very much required at the inception of the service to allow oncologists to become familiar with the concept of cardio-oncology.

It is also important to publicise the service in the primary-care centres associated with the hospital. Letters from the cardio-oncology service will be sent to patients’ oncologists, as well as their primary-care physicians. Spreading awareness of the new service among primary care would be helpful in this context, and also to allow referrals to the service for cancer survivors who may have cardiac symptoms (and are not being followed-up in ‘Late effects’ clinics).

Components

A full cardio-oncology service needs a number of components both for inpatient care, as well as the provision of outpatient services (table 1).

Clinic practicalities

For a clinic to run efficiently and effectively a number of factors need to be taken into consideration.

• Patients need to be seen in a timely fashion in order to prevent cancer treatment delays – often within a week.
• Projected patient numbers to decide on number of clinics required in a week.
• Number of clinic rooms required per clinic.
• Will it be a one-stop clinic, i.e. have echocardiography/cardiac magnetic resonance (CMR) imaging the same day?
• Timing of patient’s appointment so that tests (electrocardiogram [ECG], echocardiogram, CMR, etc.) can be done beforehand.
• Intended ratio of new to follow-up patients.
• Location of the clinic, i.e. consideration of a multi-disciplinary clinic with oncologists.
• Aim to coordinate timings of clinic with cancer clinics (even if not physically adjacent to each other).
• Advertising the service effectively (among both cardiology and oncology) to ensure appropriate referrals.
• Availability of phlebotomists, e.g. for troponin and N-terminal pro-B-type natriuretic protein (NT-proBNP) measurements.

While it is likely that patient numbers will be small at the beginning of the service, numbers would be expected to increase rapidly, and this should be factored into any projections regarding doctors required in clinic/echocardiogram slots for the clinic, etc. Flexibility is key in setting up any new service, and there needs to be a willingness to adapt quickly to meet new challenges. In addition, going forward, consideration needs to be given to the possibility of having nurse-run clinics for stable patients or even physiologist-run clinics for those patients in whom only echocardiographic monitoring is being carried out. Outlines of the clinic set-ups at our two centres are shown in tables 2 and 3.

Inpatient cover

A cardio-oncology service should provide timely advice for inpatients, as required. The range of potential referral indications is wide and may include assessment of new pericardial effusions or heart failure in cancer inpatients, advice regarding rhythm abnormalities or coronary events during inpatient chemotherapy, or even advice regarding management of patients with implantable cardiac devices (pacemakers and defibrillators) receiving thoracic radiotherapy. To enable same or next day review, a sufficient number of doctors need to be involved in the service. Referrals may be received via email to an account monitored by the cardio-oncology specialist nurse, or could come via the cardiology registrar on-call. Close liaison between the cardio-oncology service and other cardiology colleagues is essential if specialised investigations, e.g. advanced imaging or interventions, such as pericardial fluid drainage, are required.

Multi-disciplinary team (MDT) meetings

MDT meetings are an invaluable way to achieve buy-in of a new cardio-oncology service from oncologists. They allow a platform through which cardiologists can be educated about cancer care, and oncologists can better understand the rationale behind the management of cardiac issues in cancer patients. The multi-disciplinary model has worked well in other cardiology subspecialties, like heart failure, and is a European Society of Cardiology (ESC)-recommended approach for appropriate patient groups, e.g. heart failure, infective endocarditis, etc. Face-to-face discussion on complex patients are especially beneficial in cardio-oncology given the relative lack of experience of cardiologists with state-of-the-art oncology and vice versa. The presence of cardio-oncology and oncology specialist nurses, as well as specialised oncology pharmacists, in MDTs is very helpful, as their input allows a variety of viewpoints to be taken into consideration.

Protocols

There are a few cardio-oncology guidelines currently published,^8-14 although more are currently being written. As such, it is useful to have departmental protocols to guide local cardio-oncology practice. Such protocols can include the following.

• Basic cardiovascular risk assessment to determine those patients that need cardio-oncology review.
• Cardiovascular monitoring of cardio-oncology patients – a. anthracyclines; b. trastuzumab; c. tyrosine kinase inhibitors; d. vascular endothelial growth factor (VEGF) inhibitors.
• Coronary intervention in cancer patients.
• Arrhythmias and pacing in cancer patients.
• Echocardiography in the monitoring of patients on cardiotoxic cancer therapy.
• New oral anticoagulants in cancer patients.

Data collection, research and audit

A very important component of any new service is being able to audit practice to determine if patient outcomes are changing for the better. A research nurse or specialist cardio-oncology nurse is invaluable in this regard. Being a new specialty, cardio-oncology is an area ripe for research. A number of research areas can be considered, ranging from determining the benefit gained with early cardioprotection (e.g. with beta blockers and angiotensin-converting enzyme [ACE] inhibitors) in patients seen in the cardio-oncology clinic to assessing cardiovascular complications in patients on trial oncology drugs. Research collaboration with other cardio-oncology centres is beneficial and will allow multi-centre trials to run to increase the evidence base in cardio-oncology. We would also advocate involvement from cardiology in clinical trials of new cancer treatments with potential cardiotoxic side effects, to ensure that adverse events are detected and treated early.

Professional education, development and training

Attending cardio-oncology conferences and meetings is important for service members’ continuing professional development. In addition, they need to educate other hospital departments about the service and about new developments in the field. Training junior doctors is an important part of any specialty; fellowships in cardio-oncology, both within training and potentially post-certification, should be set up to allow specialisation in cardio-oncology. In the future, we would hope that such fellowships would attract applicants both from within cardiology and oncology training programmes, and a formal curriculum and syllabus will need to be formulated to cater for these.

Communication

Communication is a key component of running a smooth service, more so when it is a new and unestablished service for a new specialty. Clear communication with all stakeholders and clear goals will help to clarify the purpose of the service to all, and allow the service to grow and fulfil its potential. Buy-in from different stakeholders is key, and needs a lot of time and effort. Good communication skills, unsurprisingly, significantly aid this process.

Conclusion

Cardio-oncology, as a specialty, is in its infancy. However, it is likely that coordinated and specialised care for the cardiac needs of cancer patients will improve the care received by these patients. In addition, an answer to an oncologist’s question regarding continuing or suspending life-saving cancer treatment can be provided more rapidly through the framework of a cardio-oncology service. Further experience and research is required to determine if cardio-oncology services can improve patient outcomes and provide efficiency savings to the health service as a whole.

Conflicts of interest

None declared.

Key messages

• Increasing numbers of cancer patients are surviving longer, many of whom have been exposed to therapy with potential cardiac side effects
• Dedicated Cardio-Oncology services can help optimise the care of these patients
• A variety of stakeholders need to be fully engaged and involved in setting the service up and helping it grow
• Audit, research and training are key components
• Multi-disciplinary team meetings are very helpful to facilitate decision making across Cardiology and Oncology and their subspecialties

References

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