The growing number of cancer survivors has created an ongoing demand for cardiologists with specialized training in the emerging field of cardio-oncology, according to authors of a review.
A recent survey of cardiology fellowship programs suggested that the number of U.S. centers providing dedicated cardio-oncology services almost doubled from 2014 to 2018. Program directors at several other centers said cardio-oncology services were planned. Still, the findings were based on responses from only 81 of 206 (39%) programs, and only nine programs offered training specific to cardio-oncology, as described in the Journal of the American College of Cardiology (JACC).
The highly specialized nature of cardio-oncology may necessitate creation of a universally recognized subspecialty, beginning with the integration of cardio-oncology competencies into general cardiology training programs, concluded a panel headed by Ana Barac, MD, PhD, of MedStar Heart and Vascular Institute in Washington, and Bonnie Ky, MD, of the University of Pennsylvania in Philadelphia.
“The number of CV [cardiovascular] specialists in cardio-oncology in the United States does not meet the healthcare needs of the rapidly expanding population of patients on cancer treatment with emerging or pre-existing CV disease and cancer survivors experiencing the long-term adverse effects of therapy,” the authors wrote. “Moreover, the vast majority of training programs provide limited exposure to the field of cancer therapeutics and its impact on CV health, exacerbating the unmet need for CV professionals in cardio-oncology.”
“In response to growing clinical demand, there is a small, but increasing number of cardio-oncology training programs located mainly in quaternary referral centers with large comprehensive cancer centers,” they added.
Almost 5,000 new cancer diagnoses occur each day in the U.S., and more than 15 million Americans alive today have a history of cancer. The number of survivors is expected to reach 20 million by 2026, about half of whom would be ages ≥70.
An aging survivor population with a history of cancer and comorbid CV disease, combined with an expanding armamentarium of cancer treatments that have complex but incompletely understood CV effects, has created a growing demand for CV specialists with a comprehensive understanding of the pathophysiology and risk factors for adverse CV events, the authors noted. Although “unparalleled growth” has occurred in the field of cardio-oncology in recent years, the need for specially trained cardiologists far exceeds availability.
The authors delineated some of the potential barriers and challenges to developing an appropriately trained cardio-oncology workforce to meet the growing need and demand for clinical services:
- Funding and logistical support
- Need for an accreditation process
- Formalized training curriculum
- Evidence regarding clinical benefit and economic feasibility of interventions
Potential solutions exist for all of the perceived barriers and challenges: increased collaboration and involvement of cardiology and oncology services; integration of cardio-oncology education into cardiology fellowship training; participation in clinical trials to generate revenue for faculty and staff involved in cardio-oncology training; increased involvement of internal medicine, cardiology, and hematology/oncology house staff in research and clinical services; and forming multidisciplinary partnerships and collaborations at every level of the specialty’s development, particularly with oncologists who form the referral base for a cardio-oncology program.
Referring a patient with cancer therapy-related cardiac dysfunction to a cardiologist without any experience in treating cancer patients is no longer ideal, said oncologist Susan Dent, MD, of Duke University in Durham, North Carolina.
“The complexity of cancer therapies today continues to grow,” she told MedPage Today. “There are unique toxicities and side effects of modern cancer therapies that the general cardiologist may not be aware of. These unique toxicities require specific management strategies to allow cancer patients to continue their cancer therapy.”
As an example, she cited a hypothetical scenario of a patient who develops hypertension during cancer therapy and may require a combination of antihypertensive drugs. To treat the hypertension appropriately, the cardiologist needs to understand how a specific cancer drug affects the CV system and recognize the importance of the patient continuing treatment with the drug.
Although the JACC article focused on the education of cardiologists, oncologists also need education in cardio-oncology, particularly an emphasis on proactive management of CV effects.
“We in the oncology community have been in more of a reactive mode, whereby if cancer patients develop CV consequences of their cancer therapy, then we refer them to a cardiologist,” said Dent. “We need to be more proactive in terms of the risk of individuals before they start cancer therapy. If those individuals are at high risk of experiencing CV consequences of the cancer therapy or if they have a number of poorly controlled CV risk factors, then ideally they would be seen by a cardiologist before they start their cancer therapy.”
As a result of the cardiology-directed article, Dent and several oncology colleagues plan to write a complementary article about preparing oncologists to take care of cancer patients with cardiovascular risks and complications.
Barac disclosed relevant relationships with Genentech and Bristol-Myers Squibb (BMS). Ky disclosed relevant relationships with Genentech. A co-author disclosed relevant relationships with Roche, Pfizer, BMS, Prothena, and Boehringer Ingelheim.