Cardio-oncology Program Research Articles

Developing Cardio-Oncology Programs in the New Era: Beyond Ventricular Dysfunction Due to Cancer Treatments.

Cardiovascular disease is a common problem in cancer patients that is becoming more widely recognized. This may be a consequence of prior cardiovascular risk factors but could also be secondary to the anticancer treatments. With the goal of offering a multidisciplinary approach to guaranteeing optimal cancer therapy and the early detection of related cardiac diseases, and in light of the recent ESC Cardio-Oncology Guideline recommendations, we developed a Cardio-Oncology unit devoted to the prevention and management of these specific complications. This document brings together important aspects to consider for the development and organization of a Cardio-Oncology program through our own experience and the current evidence.

Outcomes following implementation of a pediatric cardio-oncology program

BackgroundWith improved survival following childhood cancer, cardiovascular disease has emerged as a significant source of long-term morbidity and mortality. Oncology patients require comprehensive cardiac screening and monitoring throughout their treatment and beyond. The complexity of these patients has led to increasing numbers of pediatric cardio-oncology specialty clinics. ObjectivesTo describe the characteristics and 1-year outcomes following cardio-oncology clinic implementation at a large pediatric quaternary care institution. MethodsPatients with history of chest radiation, high-dose anthracycline, or decreased left ventricular function were referred and reviewed. Initiation of oral heart failure therapy or advanced cardiac therapies within 1 year following referral were identified, and risk factors for these were evaluated. ResultsNinety-seven patients aged 5 days to 21 yrs. old were referred from 2017 to 2021. Average age at cancer diagnosis was 8.1 ± 5.5 years, with 48 % receiving high-dose anthracycline and 36 % chest radiation. Left ventricular dysfunction was present in 28 % at presentation. Oral heart failure therapy was initiated in 31 %, and none required advanced cardiac therapies. Patients who required oral heart failure therapy were more likely to be older at the age of cancer diagnosis, 10.8 ± 5.1 vs. 7.0 ± 5.3 yrs. (p = 0.001). A higher proportion of patients who received both high-dose anthracycline and chest radiation were on oral heart failure therapy (4/8, 50 %) compared to patients with high-dose anthracycline (18/46, 39 %) or chest radiation (9/35, 26 %) exposure alone, although not statistically significant. ConclusionImplementation of a pediatric cardio-oncology clinic led to increased referrals, appropriate assessment, and initiation of oral heart failure therapy. Patients older at the time of cancer diagnosis were more likely to require treatment. However, it does remain unclear if starting a COC provides long-term benefits for this particularly high-risk patient population.

The Importance of Collaboration Elevating Cardio-Oncology Care

The Importance of Collaboration Elevating Cardio-Oncology Care

A novel cardio-oncology service line model in optimizing care access, quality and equity for large, multi-hospital health systems

BackgroundDespite the rapid growth of cardio-oncology as a subspecialty, cancer patients are still underserved from a cardiovascular perspective. A new care model is needed to integrate comprehensive cardio-oncology care with community-based facilities to improve care access, quality, and equity. Here, we present a cardio-oncology service line model for large, multi-hospital health systems to address this need.MethodsAn academic cardio-oncology program was first established using a multidisciplinary approach. Five infrastructure elements for a service line model were created, including strategic accountability, standardized care, dedicated resources, patient experience/education, and branding/identity. We then utilized these elements across our healthcare system to establish a quality-controlled and centrally governed cardio-oncology service line structure. Protocols were created to standardize care and ensure consistency and quality, including referral workflow, imaging, cardiotoxicity surveillance, and clinical management. An IRB-approved cardio-oncology registry was established for outcome tracking.ResultsThe standardized cardio-oncology services were expanded to eight hospitals and ten outpatient care centers, including rural outreach offices, resulting in increased patient access and improved clinical quality measures. The service area expanded 17-fold, and an estimated rural population of 204,133 gained access to care. Cardio-oncology office visits increased by approximately 600% three years after implementation of the service line model.ConclusionsA cardio-oncology service line with standardized care is a feasible and effective care model to improve cardio-oncology care quality, patient access, and health equity in large, multi-hospital health systems. It can be used in conjunction with academic cardio-oncology programs to improve the overall cardio-oncology healthcare efficacy in the US.

Best Processes for Development of a Successful Cardio-Oncology Program in a Community Hospital

Best Processes for Development of a Successful Cardio-Oncology Program in a Community Hospital

Clinical experience of a cardio-oncology consultation at a tertiary university hospital in Portugal: An observational study

IntroductionHeart disease and cancer are the two leading causes of morbidity and mortality worldwide. Advances in cancer screening and management have led to longer survival and better quality of life. Despite this progress, many cancer patients experience cardiovascular complications during and after cancer treatment. This study describes the experience of a cardio-oncology program at tertiary academic hospital. MethodsIn this retrospective observational study, cancer patients referred to the CHULN cardio-oncology consultation (COC) between January 2016 and December of 2019 were included. Data collected included: patient demographics, cancer type, reason for referral, cardiovascular risk factors, cardiac and oncologic treatments and clinical outcomes. ResultsA total of 520 patients (mean age: 65 ± 14 years; 65% women) were referred to the COC. The main reasons for referral were suspected heart failure (26%), pre-high risk chemotherapy assessment (20%) and decreased LVEF (15%). Pre-existing cardiovascular risk factors were common (79%) and 309 (59%) were taking cardiac medications. The most common type of malignancy was breast cancer (216, 41%) followed by gastrointestinal (139, 27%). More than half received anthracycline-based regimens (303, 58%). Most patients (401; 77%) successfully completed cancer therapy. At the time of last data collection, the majority of patients were alive (430, 83%). Cardiac-related mortality was observed in 16%. ConclusionsThe close collaboration between cardiology and oncology teams and timely cardiac monitoring was the key to the majority of patients to completing their prescribed cancer therapy.

Practical Approaches to Build and Sustain a Cardio-Oncology Clinic.

The therapeutical advances in recent years in the field of oncology treatment have increased survival rates and improved the quality of life of oncology patients, thus turning cancer into a chronic disease. However, most of the new cancer treatments come at the expense of serious cardiovascular adverse events threatening the success story of these patients. The establishment of multidisciplinary medical teams to prevent, monitor, and treat cardiovascular diseases in cancer-treated patients is needed now more than ever. The aim of this narrative review is to demonstrate the existing knowledge and practical approaches on how to establish and maintain a cardio-oncology program for the rising number of patients who need it.

Risk Management for Radiation-Induced Cardiovascular Disease (RICVD): The 2022 Consensus Statement of the Taiwan Society for Therapeutic Radiology and Oncology (TASTRO) and Taiwan Society of Cardiology (TSOC).

Advances in cancer management have significantly improved survival in patients with cancers. Cardiovascular complications of cancer treatment are becoming significant competing causes of death in these patients. Radiotherapy is an indispensable component of cancer treatment, and irradiation of the heart and vasculature during cancer radiotherapy is now recognized as a new risk factor for cardiovascular diseases. It is important to involve multidisciplinary expertise and provide practical recommendations to promote awareness, recognize risks, and provide adequate interventions without jeopardizing cancer control. In this consensus paper, experts from the Taiwan Society for Therapeutic Radiology and Oncology and Taiwan Society of Cardiology provide a focused update on the clinical practice for risk stratification and management of radiation-induced cardiovascular disease (RICVD). We believe that implementing RICVD care under a collaborative cardio-oncology program will significantly improve cancer treatment outcomes and will facilitate high quality clinical investigations.

Initial experience of the implementation of a cardio-oncology program for breast cancer patients receiving modern radiotherapy in a tertiary institution

Background: The modern era of multimodality cancer treatment strategies has contributed to a much longer survival time of breast cancer patients. Accordingly, cardiovascular toxicity related to anticancer therapy including radiation-induced heart disease has become an issue of concern. To address this issue, it is important to develop cardio-oncology programs to provide cardiovascular assessment, surveillance and management for patients receiving cancer therapy with potential heart impairment.

PD-L1 (Programmed Death Ligand 1) as a Marker of Acute Cellular Rejection After Heart Transplantation.

PD-L1 (Programmed Death Ligand 1) as a Marker of Acute Cellular Rejection After Heart Transplantation.

The impact of COVID-19 on cardio-oncology care in Taiwan

COVID-19 has not only affected the respiratory but the cardiovascular system. Taiwan has encountered a less severe COVID-19 pandemic. We reported the current situation in Taiwan. In this study, we retrospectively analyzed the data from our cardio-oncology program since October of 2019 to April of 2020 (the initial months of COVID-19 pandemic). In our cardio-oncology program, newly diagnosed breast cancer patients preparing for epirubicin therapy were included. Echocardiography, 6-min walking distance and major adverse cardiovascular events (MACEs) were recorded. To evaluate whether the social atmosphere affects cardio-oncology care, we analyzed the objective (physical) and subjective (emotional) parameters before and after January 21, 2020, when the first case of COVID-19 was confirmed in Taiwan. There was no significant decrease in patients’ return ratio and LVEFs. However, there was a trend of subjective shortness of breath reported by the patients but no decline in 6 MWT. Notably, none of the enrolled patients reported MACEs during the COVID pandemic. We observed an impact of anxiety on patients receiving epirubicin but it did not influence their return ratio.

Mending Broken Hearts

Mending Broken Hearts

Healthcare disparities in cardio oncology: patients receive same level of surveillance regardless of race at a safety net hospital

BackgroundCardiotoxicity remains a dreaded complication for patients undergoing chemotherapy with human epidermal growth factor (HER)-2 receptor antagonists and anthracyclines. Though many studies have looked at racial disparities in heart failure patients, minimal data is present for the cardio-oncology population.MethodsWe queried the echocardiogram database at a safety net hospital, defined by a high proportion of patients with Medicaid or no insurance, for patients who received HER2 receptor antagonists and/or anthracyclines from January 2016 to December 2018. Patient demographics, clinical characteristics, and treatment outcomes were collected. Based on US census data in 2019, home ZIP codes were used to group patients into quartiles based on median annual household income. The primary end point studied was referral rate to cardiology for patients undergoing chemotherapy.ResultsWe identified 149 patients who had echocardiograms and also underwent treatment with HER2 receptor antagonists and/or anthracyclines, of which 70 (47.0%) were referred to the cardio-oncology program at our institution. Basic demographics were similar, but white patients were more likely to live in ZIP codes with higher income quartiles (p < 0.00001). Comparing between racial groups, there was no statistical difference in the percentage of patients that had a reduction in ejection fraction (EF) (p = 0.75). There was no statistical difference between racial groups in the number of cardiology or oncology appointments attended, number of appointments cancelled, average number of echocardiograms received, additional cardiac imaging received. Black patients were more likely to receive ACEI/ARB post chemotherapy (p = 0.047). A logistic regression model was created using race, age, gender, insurance, income quartile by home ZIP code, comorbidities (hypertension, hyperlipidemia, coronary artery disease, arrhythmia, diabetes mellitus, smoking, family history, age > 65), procedures (coronary stents, cardiac surgery), medications pre-chemotherapy, cancer type, cancer stage, and chemotherapy. This model found that there was an increased referral rate among patients from higher income quartiles (p = 0.017 for quartile 3, p = 0.049 for quartile 4), patients with a history of hypertension (p < 0.0001), and patients with breast cancer (p = 0.02).ConclusionsThe results of this study suggest that patients of our cardio-oncology population at a safety net hospital receive the same level of surveillance and treatment, and develop drop in ejection fraction at similar rates regardless of their race. However, patients that reside in ZIP codes associated with higher income quartiles, with hypertension, and with breast cancer, are associated with increased rate of referral.

Abstract 12919: Quantitative Assessment of Cardiovascular Autonomic Impairment in Cancer Survivors: A Single Center Experience

Background: Cardiovascular autonomic dysfunction in cancer survivors is poorly understood. Objectives: To better characterize the clinical characteristics and types of autonomic dysfunction in this population. Methods: A retrospective analysis of cancer survivors within an academic cardio-oncology program referred for suspected autonomic dysfunction was performed. Autonomic reflex testing of adrenergic, cardiovagal, and sudomotor function was done. Patients with pre-existing autonomic dysfunction prior to their cancer diagnosis were excluded. Results: Of approximately 282 patients in the UCLA Cardio-Oncology program, twenty-four patients met the inclusion criteria. Twenty-two had autonomic impairment on autonomic reflex testing. Eight patients were female, and the mean age at time of autonomic testing was 51.3 years. The average duration from cancer diagnosis to autonomic testing was 10.3 years. The reasons for referral included dizziness, tachycardia, palpitations, and syncope. The majority of patients (75%) had hematologic disorders. The most common chemotherapies administered were vinca alkaloids (54.2%), alkylating agents (66.7%), and anthracyclines (54.2%). Most patients received radiation to the thorax (66.7%) and neck (53.3%). Eleven patients had mild autonomic impairment, seven had moderate, and four had severe autonomic impairment. Dysfunction was commonly present in the sympathetic and parasympathetic branches, but most pronounced in the sympathetic system. The majority of patients were diagnosed with orthostatic hypotension (50%), inappropriate sinus tachycardia (20.8%), and postural orthostatic tachycardia syndrome (12.5%) and had subjective improvement with treatment. Conclusion: Cardiovascular autonomic dysfunction occurs in cancer survivors, and commonly affects both the sympathetic and parasympathetic systems. Symptom recognition in patients should prompt autonomic testing and treatment where appropriate.

Quantitative assessment of cardiovascular autonomic impairment in cancer survivors: a single center case series

BackgroundCardiovascular autonomic dysfunction in cancer survivors is poorly understood.ObjectivesTo better characterize the clinical characteristics and types of autonomic dysfunction in this population.MethodsA retrospective analysis of cancer survivors within an academic cardio-oncology program referred for suspected autonomic dysfunction was performed. Autonomic reflex testing of adrenergic, cardiovagal, and sudomotor function was done. Autonomic impairment was graded on severity based on the Composite Autonomic Severity Score system. Patients with pre-existing autonomic dysfunction prior to their cancer diagnosis were excluded.ResultsOf approximately 282 total patients in the UCLA Cardio-Oncology program, 24 were referred for suspected autonomic dysfunction and met the inclusion criteria. 22 had autonomic impairment on autonomic reflex testing. Eight patients were female, and the mean age at time of autonomic testing was 51.3 years. The average duration from cancer diagnosis to autonomic testing was 10.3 years. The reasons for referral included dizziness, tachycardia, palpitations, and syncope. The majority of patients (75%) had hematologic disorders. The most common chemotherapies administered were vinca alkaloids (54.2%), alkylating agents (66.7%), and anthracyclines (54.2%). Most patients received radiation to the thorax (66.7%) and neck (53.3%). Eleven patients had mild autonomic impairment, 7 had moderate, and 4 had severe autonomic impairment. Dysfunction was commonly present in the sympathetic and parasympathetic branches, but most pronounced in the sympathetic system. The majority of patients were diagnosed with orthostatic hypotension (50%), inappropriate sinus tachycardia (20.8%), and postural orthostatic tachycardia syndrome (12.5%) and had subjective improvement with treatment.ConclusionCardiovascular autonomic dysfunction occurs in cancer survivors, and commonly affects both the sympathetic and parasympathetic systems. Symptom recognition in patients should prompt autonomic testing and treatment where appropriate.

Practical and cost-effective model to build and sustain a cardio-oncology program

BackgroundCardio-Oncology (CO) is a new subspecialty that thrives mostly in large academic quaternary centers. This study describes how to establish a successful cardio-oncology program, with limited resources, in order to effectively manage the unique care required by this patient population.MethodsClinical data was collected from 25 consecutive months. There were four foundational elements to establish a CO program: 1. Clinical program: integrating staff and resources from the Heart and Vascular, and Cancer Centers; 2. Education Program: establishing a platform to educate/advocate with respect to CO; 3. Engagement with professional societies: active engagement allowed for the successful establishment of the proposed CO program; and 4. Research program: establishing data collection modalities/cooperation with other institutions.Results474 consecutive patients were treated by our CO program during the first 25 months of operation. Clinical data, information about cancer treatment, cardiovascular co morbidities, cardiac testing and impact of CO management are reported.ConclusionsA successful CO program can be established utilizing existing resources without the need for significant additional assets. Integration with professional societies, advocacy, education and research, provide a platform for learning and growth. This model improves access to care and can be reproduced in a variety of settings.

First phase implementation of cardio-oncology program in the middle-income country of Costa Rica at Hospital Metropolitano healthcare system.

e24091 Background: Developing a cardio-oncology program in a middle-income country like Costa Rica can present unique opportunities and challenges. Hospital Metropolitano is a health care system in Costa Rica with a network of two hospitals, 36 clinics, and over 150,000 patients enrolled in its health plan, Medismart. Here we summarize our program, and the initial results of the implementation phase, hoping that institutions with similar resources in low-and-middle-income countries will use this as guidance to develop their own cardio-oncology program. Methods: A cardio-oncology committee was established in May 2019 and includes medical providers, clinical coordinators, administrative workers, and nursing and laboratory staff. A 4-month pre-launch period was established to create an institutional protocol after we reviewed guidelines and literature from similar programs in the United States and Europe. The protocol targets both active cancer patients undergoing treatment and cancer survivors. The program was launched in September 2019 and is currently in the first phase of implementation. Results: During the first phase of implementation, the program was limited to the outpatient setting and patients were referred exclusively by the medical oncology providers from our health care system. In this period, 28 patients met criteria for referral and all enrolled according to our protocol. The median age of our patients was 49 (range 16-77). 25 patients (89%) were female and 20 (71%) had a diagnosis of breast cancer. At the time of enrollment, 21 (75%) were receiving active cancer treatment and 7 (25%) were identified as cancer survivors. All patients are being followed prospectively. A committee review at the end of the first phase of implementation revealed that the most important challenges that the program needs to address for the second phase of implementation include the following: 1) patient education and outreach, 2) cost of care associated with the interventions recommended by the protocol, and 3) data tracking/registry given the lack of an electronic medical record. Conclusions: Our program represents a real-life experience of the challenges and opportunities that institutions in middle-income countries need to consider when launching such initiatives. To our knowledge, this is the first cardio-oncology program formally established in Central America and we are committed to continue to measure our outcomes prospectively and share these with the global oncology community.

Implementing a Cardio-oncology Center of Excellence: Nuts and Bolts, Including Coding and Billing.

Cardio-oncology is rapidly expanding as part of cancer therapy in both the acute phase and later stages after treatment. The shifting paradigm of cancer becoming a chronic disease requires long-term follow-up for ongoing cardiac toxicity. As more cancer patients enter the survivorship phase, there needs to be identification of those at risk and strategies for how best to monitor long-term cancer therapy-related cardiac disease. This article serves as a template decide if a cardio-oncology program should be started and expanded as a center of excellence for the discipline as well as to help in implementing and financially sustaining a program.

P1569The Impact of Multidisciplinary Cardio-Oncology Program on the Cardiovascular Outcomes in Breast Cancer Patients

Abstract Background Chemo- and target therapies may induce myocardial dysfunction and lead to poor prognoses. Early detection of minor myocardial dysfunction is important for the prevention of subsequent cardiotoxicity. Cardio-oncology is a multidisciplinary field focusing on managing and preventing cardiovascular complications in cancer patients. However, whether Cardio-oncology program truly makes difference in cardiovascular outcomes remains unknown. Herein, we are sharing our experiences in our Medical Center. Methods Since 2014 till 2017, we recruited 154 patients with newly diagnosed breast cancer preparing for Epirubicin therapy. Echocardiography, biomarkers, six minute walking distance and cardiovascular adverse events including new onset of hypertension, stroke, myocardial infarction (MI) and mortality were recorded at baseline, three months, six months and one year. Any functional decline was reported to oncologists for the consideration of changing regimens. Otherwise, cardiologists would be consulted for cardiovascular educations and therapies. The echocardiographic and clinical records of 450 breast patients receiving Epirubicin therapy during 2010 to 2013 were also collected as comparison. Results Compared with the ratio of 20% patients receiving echocardiography prior to 2014, the ratio increased to 100% since Cardio-Oncology program started. Also, the drop of left ventricular ejection fraction (LVEF) from 25% attenuated to 5%. Before Cardio-Oncology Program, there were 1.7% of new onset hypertension, 0.8% of MI, 0.8% of stroke and 16.8% of mortality. Conversely, after the program, there were only 0.6% of new onset hypertension while no other cardiovascular complications were reported. Furthermore, compared with previous reports of the effectiveness of Cardio-Oncology Program, our result also displayed a superior impact on the cardiovascular outcomes. Conclusions Collectively, through a comprehensive monitoring and an early intervention of myocardial dysfunction post chemotherapies, Cardio-Oncology Program truly decreased the cardiovascular complications in breast cancer patients. Acknowledgement/Funding Chi-Mei Medical Center

Cardiac Monitoring for Thoracic Radiotherapy: Survey of Practice Patterns in the United States

American Society of Clinical Oncology (ASCO)'s 2017 Guideline on Prevention and Monitoring of Cardiac Dysfunction in Survivors of Adult Cancers identified patients receiving thoracic radiation (TRT) ≥ 30 Gy (heart in field) at increased risk for developing radiation induced heart disease (RIHD). ASCO encouraged clinicians to actively screen and monitor for baseline modifiable cardiac risk factors and therapy-induced cardiotoxicity in this high-risk population, which would include a majority of lung and esophageal patients obtaining definitive TRT. Further, coronary artery calcium (CAC) is an independent risk factor for adverse cardiac events that can be mitigated with preventative medical therapy. CAC is easily identified on non-contrast thoracic CT simulation scans, yet it is unclear whether ROs are aware of the clinical implications of CAC seen on simulation scans. We sought to assess ROs practice patterns, experiences, and perceptions of cardiac screening and monitoring for TRT patients. A 28-question survey was emailed to United States ROs 3 times from September 2018 to January 2019. Responses were collected on Survey Monkey and descriptive statistics were used to report results. Of the 162 respondents from 42 states, 94% treat non-breast thoracic cancers to doses ≥ 45 Gy with heart in the field, 51% practice in academic settings, and 62% have an average of 1-5 thoracic cancer patients actively on treatment. While 22% have access to a Cardio-Oncology program, 81% were not aware of the ASCO cardiac monitoring guidelines. Only 24% agreed with these guidelines, whereas 41% thought they should be more specific and 35% were not sure. The most significant reported barrier to cardiac monitoring in asymptomatic patients was lack of strong evidence for type and timing of cardiac monitoring tests (69%). The majority (56%) did not monitor cardiac changes after RT. When monitoring, 38% prefer ECHO, yet 72% were unsure or had no preference as to which type of ECHO to order. While 62% agreed that RIHD could occur in any section of the heart in the RT field and that the earliest expected time-point that cancer survivors would be symptomatic from RIHD was <2years (27%), 2-5 years (41%) or 5-10 yrs (26%), 72% would NOT reduce tumor coverage and 67% would NOT reduce RT dose in order to minimize RT heart dose since the priority was cancer control. If CAC was evident on CT sim scans, 68% had never thought about what actions to take or did not take any actions, whereas 38% would refer to internist or cardiologist. Only 7% reported having ongoing clinical trials for cardiac monitoring at their centers. This survey highlights a critical gap in knowledge about cardiac monitoring and potentially missed opportunities for preventive medical management in a high risk population that may have competing life-threatening cardiac risks. Future studies focusing on timing and detection of RIHD may elucidate the utility of cardiac monitoring for TRT patients.