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The cardio-oncology clinic: Goals, scope, and focus of practice


KEY POINTS

  • The cardio-oncology clinic covers all cardiovascular aspects of patients with cancer, including tumors that involve the heart and vasculature, cancer therapies that affect the heart and vasculature, and cardiovascular diseases in patients with cancer.

  • The key goal of the clinic is to enable patients with cancer to receive the best possible cancer therapy at the lowest possible cardiovascular risk (to uncouple risk and benefit).

  • A multidisciplinary team forms the core of the clinic. It is composed of professionals specialized in providing cardiovascular evaluations and treatments for patients across their continuum of cancer care.

  • Three milestones can be distinguished toward establishing a cardio-oncology clinic: (1) goals and vision, (2) institutional support and organization, and (3) implementation and operation.

  • The structure and scope of the cardio-oncology clinic, which needs to be individualized for the specific practice environment, requires reevaluation and readjustment based on outcome measures and developments in the field.

Over the past three decades cancer treatment has evolved dramatically from the availability of cytotoxic chemotherapy, radiation therapy, and surgery to the addition of a plethora of targeted and immune-based therapies. , The latter two modes (or pillars) of therapy have transformed the practice radically and never in the history have there been more cancer survivors than presently (in excess of 15 million in the United States alone). Adverse effects and toxicities of cancer therapies have gained increasing significance with the improved survival outcomes, and some of the most important toxicities of cancer therapy in terms of morbidity and mortality are cardiovascular in nature. On the other hand, cardiovascular diseases can be present even before a diagnosis of cancer is made and can complicate and terminate cancer therapy (especially if not managed appropriately) with grave implications for clinical outcomes. These dynamics are expected only to increase in the future in view of the general aging of the population.

The recognition of these trends and interactions between cardiovascular disease (CVD) and cancer and the need to optimize the cardiovascular care of patients with cancer has given rise to a new discipline referred to as “Cardio-Oncology” or “Onco-Cardiology.” As the field involves hematology as well, the terminology “Cardio-Onco-Hematology” has also been used at times, but for simplicity and consistency we will use the term “Cardio-Oncology” throughout this book. Clinics providing such services have started to emerge in the mid first decade of the 21st century, and since then, there has been an exponential growth in their number across all continents. , Milestones and steps toward the successful implementation of a cardio-oncology service line are outlined in prior reviews and the central illustration. , The very starting point is defined by the needs of the patients, and meeting the needs of the patients defines the success of the cardio-oncology clinic.

Milestone #1: Goals and vision

Defining the cardiovascular needs and demands of patients who have cancer at a given practice location will inform about the goals of the cardio-oncology clinic (i.e., what is to be accomplished, which impact one would like to have, which improved outcomes one would like to see). Commonly aspired goals are outlined in Table 1-1. , A clear vision is absolutely critical and needs to be shaped in cross-disciplinary communications. The perspectives of both, cardiology and oncology/hematology groups, should be taken into account when plans for the clinic are being made, and this should furthermore be in the context of the unique individual practice environment of these groups (private office, group practice, community/regional hospitals, tertiary referral center, cancer center) and the cancer population referred to the cardio-oncology clinic. Based on these foundations, it is possible to summarize and update the vision for the scope and shape of the program:

TABLE 1.1
Goals of the Cardio-Onco-Hematology (COH) Clinic
STAGE IN THE CANCER CONTINUUM COH CLINIC GOALS
Before Recognition and Mitigation of CV Risk

  • Identification of potential risk factors for cancer therapy-related CV toxicity

  • Optimization of CV health and preexisting CVD (guideline-directed therapies)

  • Discussion of the most efficacious cancer therapy without substantial CV harm

  • Definition of optimal surveillance and preventive efforts for CV complications/toxicities

  • Facilitation of safe administration of anticancer therapies

During Early Recognition and Treatment of CVD and CV Toxicities

  • Implementation of safety measures to avoid cancer therapy interruptions

  • Surveillance, early identification, and treatment of CV complications

  • Defining and prioritizing risks of CVD/CV toxicity vs. cancer therapies

  • Discussions on continuation vs. interruption of cancer therapy

After Surveillance and Mitigation of Late CV Complications and CVD

  • Optimization of preventive strategies

  • Screening for late-onset complications

  • Setup of routine follow-up protocols

  • Enabling health lifestyle measures

  • Referral to cardio-oncology rehabilitation if not done earlier in the continuum

CV, Cardiovascular; CVD, cardiovascular diseases.

The cardio-oncology clinic will see ... (type of patients) by ... (cardiologists/oncologists/hematologists) in the .... (heart/cancer center, clinic, hospital). The appointment types might include virtual (e-)consultations as well as in-person, out-patient, and in-patient visits. It should moreover be defined if curbside and on-call options will be made available. Last but not least, based on the defined demand, it can be projected that .... (number of) patients will be seen in the cardio-oncology clinic every month.

Although accomplishing these goals is a team effort, a cardio-oncology clinic champion (director) should be identified who will take ownership and will be the main point of contact, integration, and implementation.

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