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Establishing a Cardio-Oncology Program at an Academic Institution – A recipe for success!

Susan Dent, BSc, FRCPCMedical Oncologist, DCICo-Director Duke Cardio-Oncology ProgramAssociate Director Breast Cancer ResearchProfessor of Medicine, Duke UniversityApril 26th, 2019

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• I have received financial support from Hoffman-La Roche, Amgen, Novartis in the form of unrestricted educational grants, speaker honorarium and fellowship funding.

Disclosures

Click to edit Master title styleObjectives

• To discuss how to establish a successful cardio-

oncology program at an academic institution

• To discuss the benefits of a establishing a cardio-

oncology program at an academic institution

• To discuss how to engage health care providers in

this multidisciplinary approach

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1. Establish the need for a cardio-oncology clinic/program

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Click to edit Master title styleCardiovascular Side Effects of

Modern Cancer Therapy

Arrhythmia

HypertensionAP / MI

Cardiac DysfunctionHeart Failure Thromboembolism

Click to edit Master title styleCardiovascular Disease: Important cause of mortality in early breast cancer

Years from diagnosis

Perc

ent

Mo

rtal

ity

Other causes

Patnaik et al. Breast Ca Res, 2011

CVD

Breast cancer

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VSP Inhibitors

Hypertension

Heart Failure Thrombosis

Her2 Targeted

Therapies

Cardiomyopathy

Anthracyclines

Radiation

Heart Failure

CAD

Anti-metabolites (5FU)

Ischemia

Vasospasm

Adapted from Moslehi, Cheng. Science Translational Medicine, 2013. Moslehi, NEJM. 2016.

PI3K Inhibitors

Hyperglycemia

Metabolic

?Myocardial/

Arrhythmia

BTK Inhibitors

Ibrututinib:

Arrhythmia/

Atrial Fibrillation

MEK/RAF TKI

Cardiomyopathy

Drugs Affecting UPS

Immunomodulators

(IMiDs): thrombosis

Proteasome inhibitors

(e.g. bortezomib,

carfilzomib): vascular

HDAC inhibitors

Arrhythmia

Cancer

Immunotherapies

Myocarditis

Cancer Survivorship

CML TKIs

Imatinib

Dasatinib/Nilotinib/

Ponatinib:

PAH/Vascular/

Atherosclerosis

Significant Impact of new cancer drugs on Cardiovascular Health

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Oncologist

Cardiologist

The cardiologist!

The patient developed

cardiac disease !

The oncologist!

The patient has

a cancer!

Who is responsible for patient care?

Courtesy, Dr.Cardinale

Click to edit Master title styleThe cardio-oncologist

Courtesy, Dr. Cardinale

Health care providers focused on the prevention, early detection,

management and recovery of cardiovascular function potentially

resulting from cancer therapies

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2. Seek Institutional Support for your Cardio-Oncology Clinic

Click to edit Master title style• Logistics

• Resources

• Expertise

• Allied Health Support

• Collaboration

• Location of clinic, close interaction between oncologists and cardiologists

• Access to space, imaging, $$

• Cardiologist with imaging experience and knowledge of cancer therapies

• Support from other health care providers (nursing, pharmacy)

• Consistent communication between health care providers

Institutional Support for Cardio-Oncology Clinic

Sulpher et. al Cancer Report Card 2014-2015

Click to edit Master title style• lack of Institutional support from administration/university

• lack of academic and administrative mentorship – novelty of field, a shortage of evidence-based clinical standards

• few “champions” in your institution

• lack of opportunities for education and training

• limited awareness among oncology and cardiology specialists about the need for cardio-oncology services

Barriers and Obstacles

Okwuosa and Barac JACC, 2015

Click to edit Master title styleA Successful Cardio-Oncology Program

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3. Define the structure of the Cardio-Oncology Clinic

Click to edit Master title style0rganization of Cardio-Oncology Program

Okwuosa and Barac, JACC 2015

Click to edit Master title styleEducation

Multidisciplinary RoundsFellowship

Medical education of health care providers

patients

Components of a Cardio-Oncology Program

ResearchClinical outcomes

Translational Optimal imaging strategies

BiomarkersDatabase

Clinical CareMedical and radiation

Oncologists/hematologistsCardiologistsPharmacists

Nursing

Cardio-Oncology Survivorship

Cardio-Oncology Clinic

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Tumor biology andCV health,Immuno-

cardiology

Retrospective observational

studies

Prospective patient registries

Role of clinical assessments

(cardiac imaging, exercise testing, etc.) in CV risk stratification

Blood biomarkers, -omics,

Biorepository core

Clinical trials (CV endpoints of novel therapies)

Health Outcomes / Epidemiology

Biostatistics / Bioinformatics

Clinical Outcomes

Basic / Translati

onal

Research

Primary prevention of

CTRCD in patients with

early CV signal

CV risk stratification for cancer therapy,

SCT, surgery (treatment-related & pre-existing CV risks)

Monitoring for early CTRCD

Secondary prevention of cardiovascular

events

Management of other CV toxicity

(e.g., HTN, ischemia,

arrhythmias)

Primordial prevention of CTRCD in high risk patients

Cancer rehab

(exercise program)

Onco-primary care for CV co-

morbidity, lifestyle

management

Active TherapySurvivorship

Clinical Care

DukeCardio-

Oncology Program

Multidisciplinary Cardio-Onc

Board

Cardio-OncologyFellowship

Pharmacology(CV risks of

emerging cancer therapies)

Grand Rounds

Symposia & Conferences

Education

AwarenessTraining

Hematology / Bone Marrow

Transplant

Medical Oncology /

Solid Tumor

Radiation-Oncology

Pediatric Oncology

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4. Define the goals of the Cardio-Oncology Clinic

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Rapid access to cardiologists with an

understanding of systemic /targeted

therapies.

What does a clinic offer ?

Education of patients and health care providers

Resident/fellowship training

Preceptorship

Multidisciplinary rounds

Development of a collaborative research environment: basic/translational research and

clinical/health outcomes research.

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PATIENT

CARDIAC RISK FACTORS

PREVENTION STRATEGIES

EARLY DETECTION

PREDICTION

IMPROVE CLINICAL OUTCOMES

COMPLETION OF CANCER TREATMENT

Define patient population – e.ghematology, oncology, surgery

All patients vs high risk Frequency of clinics Streamline referrals:

urgent vs elective Survivorship?

Clinical Care

Click to edit Master title style• Health care providers/patients

• Multidisciplinary rounds (accredited)

• CME presentations (allied HCP’s)

• Preceptorship programs

• Training- Residency/Fellowships

• Cardio-Oncology Meetings (ICOS, CCON,GCOS)

• Special education sessions – ASCO, SABCS

• Courses (ACC workshop)

Education

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Onco logist

HCP

Cardiologist

Optimization of cardiac

monitoring

Biomarkers + imaging

Early detection of

cardiotoxicity using markers of apoptosisSAFE study

Cardiac protection

during cancer treatment

International cardio-

oncology registry

Risk prediction of

cardiotoxicity

RESEARCH

198 registered CT on diagnosis and treatment of cardiotoxicityclinical trials.gov

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5. Measure Outcomes of the Cardio-Oncology Clinic

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• Completion of cancer therapy

• Improved cancer outcomes

• Improved cardiovascular outcomes

• Prevention of long term cardiovascular sequelae of cancer therapies

Benefits of a cardio-oncology clinic

Limited Supporting Data

Click to edit Master title styleOttawa Cardio-Oncology Clinic

Progress in Pediatric Cardiology, 2015

Click to edit Master title styleThe SURVIVE (cardiovaScUlaR toxicity in cancer and improVement In recoVEry) Registry.

• cancer patients who have received or are receiving CT, targeted agents, immunotherapy +/-radiation

• Collect serum, plasma, saliva at baseline, 6 months, 12 months then yearly for at least 3 years

• Cardiac imaging collected and analyzed by a core lab

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6. Promote your Cardio-Oncology Clinic

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7. Develop Collaborations and Partnerships

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England

Italy

Israel

Poland

Japan

Brazil

Argentina

Mexico

Australia

China

Spain

India

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ICOS

BCOSChina

Argentina

Brazil

Poland

India

International Collaboration

Italy

IsraelSwitzerl

andl

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Optimize Cardiac Health Best Cancer Care

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Journal of Clinical Oncology, on line December 2016

NCCN Clinical Practice Guidelines in Oncology: Survivorship-Anthracycline-induced cardiotoxicity (2015)

Click to edit Master title style• Establishment of cardio-oncology clinics/programs provides

the framework for optimizing clinical care delivery, education and research.

• Development of cardio-oncology registries/data bases are needed to establish the benefits of this multi-disciplinary approach

• Cardio-oncology collaborations will continue to define best practices for cancer patients exposed to potential cardiotoxic cancer therapies and establish surveillance strategies for cancer survivors

Key Messages

Click to edit Master title style• Dent S, Law A, Aseyev O, Ghosh N, Johnson C. Co-ordinating

Cardio-Oncology Care. Chapter 15 pg. 221-236. Cardio-Oncology: Principles, Prevention and Management. Elsevier publications, 2017.

• Okwuosa T and Barac A. Burgeoning Cardio-Oncology Programs. JACC Vol 66 No. 10 2015 pg 1193-1196

• Barros-Gomes S et.al Rationale for setting up a cardio-oncology unit: our experience at Mayo Clinic. Cardio-Oncology Journal April 2016 2:5

• Lenihan D, Cardio-Oncology Training: A Proposal from the International CardiOncology Society and Canadian Cardiac Oncology Network for a new multidisciplinary specialty. Journal of Cardiac Failure, 2016 March 30.

Cardio-oncology resources

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Questions ?