Organisation & models of cardio-oncology clinics

Organisation & models of cardio-oncology clinics

International Journal of Cardiology 214 (2016) 381–382 Contents lists available at ScienceDirect International Journal of Cardiology journal homepag...

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International Journal of Cardiology 214 (2016) 381–382

Contents lists available at ScienceDirect

International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard

Correspondence

Organisation & models of cardio-oncology clinics Dorothy M. Gujral a, Charlotte Manisty b, Guy Lloyd b,c, Sanjeev Bhattacharyya b,c,⁎ a b c

Department of Clinical Oncology, Imperial College Healthcare NHS Trust, London, UK Bart's Heart Centre, St Bartholomew's Hospital, London, UK Echocardiography Laboratory, Bart's Heart Centre, St Bartholomew's Hospital, London, UK

a r t i c l e

i n f o

Article history: Received 25 March 2016 Accepted 27 March 2016 Available online 6 April 2016

The management of cancer often involves multiple treatment modalities and different combinations of cytotoxic therapies and targeted agents. Several of these agents are potentially cardiotoxic and may cause heart failure, hypertension or arrhythmia [1]. The concept of specialised cardiovascular clinics for cancer patients being treated with potentially cardiotoxic therapies stems from the need to provide timely and expert pre-therapy assessment, monitoring and treatment that facilitates and does not delay cancer therapy [2]. Organisation of these services may be complicated by separate geographical locations of cardiovascular and oncology centres, requirement of multiple hospital visits for investigations/procedures and co-ordination of care including multi-disciplinary discussion of complex cases. We previously reported approximately half of international comprehensive cancer centres operated a cardio-oncology clinic [3]. We sought to investigate the organisation and models of cardio-oncology clinics in an international survey of cancer centres. A list of cancer centres in the United Kingdom was compiled from the National Health Service website (www.nhs.uk), European comprehensive cancer centres were obtained from the Organisation Of European Cancer Institute's website (http://www.oeci.eu) and the United States comprehensive cancer centres were obtained from the National Comprehensive Cancer Network website (http://www. nccn.org). An electronic survey was designed to identify the frequency, location of clinics (cancer centre, cardiac centre, general hospital), specialists within the clinic (cardiologist, oncologist, specialist nurse), type of patient seen in the clinic and the presence of dedicated tumour board/multi-disciplinary team meetings for cardio-oncology patients. The study period ran from May to July 2015.

⁎ Corresponding author at: Echocardiography Laboratory, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom. E-mail address: [email protected] (S. Bhattacharyya).

http://dx.doi.org/10.1016/j.ijcard.2016.03.237 0167-5273/© 2016 Elsevier Ireland Ltd. All rights reserved.

A total of 113 out of 156 (72%) oncology centres responded. Cardiooncology clinics were run in 39 out of 113 (35%) centres. Cardio-oncology clinics were held daily in 7 centres (18%) and weekly in 32 centres (82%). The cardio-oncology clinics were located within the cancer centre in 21 centres (54%), within the associated hospital cardiovascular centre in 10 (26%) and within main hospital out-patient facilities in 8 (21%). All cardio-oncology clinic staff included a cardiologist. An oncologist also saw patients in 8 clinics (21%). Specialist nurses saw patients in 6 clinics (15%). All cardio-oncology clinics would see all patients referred by their associated cancer centre. Reasons for referral included: trastuzumab- or anthracycline-induced left ventricular dysfunction, management of heart failure patients prior to chemotherapy, chest pain related to 5-/fluoropyrimidines or arrhythmia. Additionally, 6 (15%) clinics would routinely see all patients undergoing adjuvant trastuzumab therapy and 3 (7.5%) would routinely see all patients undergoing adjuvant trastuzumab therapy with reduced ejection fraction. Only one (3.6%) cardio-oncology clinic had a specific multi-disciplinary team meeting to discuss complex cardio-oncology patients. The other 38 (97%) clinics would discuss these patients within appropriate tumour site or cardiac board meetings. The optimal organisation of cardio-oncology service will vary depending on the scale of service, availability of cardiovascular imaging and the type of patient referred. The majority of clinics saw patients with cardiovascular abnormalities detected by oncologists and referred for further evaluation of heart failure/left ventricular dysfunction, coronary disease or cardiac rhythm disturbance. A small proportion of cardio-oncology clinics (15%) provided the initial evaluation and monitoring of all patients undergoing adjuvant trastuzumab therapy. A key consideration is whether cardiologists should provide a complete evaluation of all patients undergoing potentially cardiotoxic therapy or focus primarily on patients where abnormalities have been identified by oncologists. Emerging evidence suggests that myocardial strain echocardiography is able to identify sub-clinical changes in left ventricular systolic function before changes in left ventricular ejection fraction and these changes may predict future risk of cardiotoxicity [4]. Therefore, early cardiovascular input may be beneficial, although whether earlier detection of cardiac toxicity leads to better outcomes or is cost effective is unclear at present. The majority of cardio-oncology clinics were located within cancer centres. The advantages of this approach include easy access for patients who already require multiple visits to the cancer centre. Furthermore, co-location with oncologists may lower the threshold for referral to cardio-oncology services and promote greater integration of services.

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However, this approach requires adequate infra-structure incorporating advanced cardiac imaging. Providing multi-disciplinary discussion which incorporates a cardiovascular opinion for cancer patients may be a logistical challenge given the multiple different cancer specialities each with their own tumour board/multi-disciplinary meeting. Possible solutions include a cardiooncology multi-disciplinary meeting for complex cases; however only one centre achieved this. Cardio-oncology is a relatively new cardiovascular sub-speciality. Models of care vary significantly between institutions. A single model is unlikely to provide an ideal solution for all institutions and therefore needs to be individualised to local healthcare systems. However, consensus on standards of care needs to be developed. Funding None.

Conflict of interest None. References [1] A. Albini, G. Pennesi, F. Donatelli, R. Cammarota, S. De Flora, D.M. Noonan, Cardiotoxicity of anticancer drugs: the need for cardio-oncology and cardiooncological prevention, J Natl Cancer Inst 102 (2010) 14–25. [2] A. Barac, G. Murtagh, J.R. Carver, M.H. Chen, A.M. Freeman, J. Herrmann, et al., Cardiovascular health of patients with cancer and cancer survivors: a roadmap to the next level, J Am Coll Cardiol 65 (2015) 2739–2746. [3] D.M. Gujral, G. Lloyd, S. Bhattacharyya, Provision & Clinical Utility of Cardio-Oncology Services for Detection of Cardiac Toxicity in Cancer Patients, J Am Coll Cardiol 67 (2016) 1499–1500. [4] H. Sawaya, I.A. Sebag, J.C. Plana, J.L. Januzzi, B. Ky, T.C. Tan, et al., Assessment of echocardiography and biomarkers for the extended prediction of cardiotoxicity in patients treated with anthracyclines, taxanes, and trastuzumab, Circ Cardiovasc Imaging 5 (2012) 596–603.