Click to edit Master title style Developing a Cardiac Oncology Fellowship Program ASCO June 2014 Susan Dent Medical Oncologist The Ottawa Hospital Cancer Center Ottawa, Canada

Click to edit Master title style The problem

Click to edit Master title style Cancer Survivors (Million)

Click to edit Master title style Brigham, MGH MSK U Penn Medstar Washington Louisville Duke Vanderbilt MD Anderson Stanford

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Treatable? Cardinale 2010 N = 201 LVEF >= 45%; ACEi +/or BB – early rx J Am Coll Cardiol Jan 19;55(3): Anthracycline-induced cardiomyopathy: clinical relevance and response to pharmacologic therapy.

Click to edit Master title style Preventable? OVERCOME Trial N = 90 acute leukemia / SCT randomized to enalapril + carvedilol or control Echo and CMR were performed before and at 6 months after randomization J Am Coll Cardiol.J Am Coll Cardiol Jun 11;61(23): Enalapril and carvedilol for preventing chemotherapy- induced left ventricular systolic dysfunction in patients with malignant hemopathies: the OVERCOME Bosch X 1 et alBosch X

Click to edit Master title style Why do we need Cardiac Oncologists? N = 63 with LVSD (LVEF < / = 45%) post chemo 67% symptomatic HF: 54% had Cardiology input (black) Survival 71% vs 41% in no Cardiology input Cardiovascular Management of Cancer Patients With Chemotherapy-Associated Left Ventricular Systolic Dysfunction in Real-World Clinical Practice Journal of Cardiac Failure, Volume 19, Issue 9, 2013, Cardiology input = black No Cardiology = white All = grey

Click to edit Master title style Yoon, Telli, Kao, Matsuda, Carlson, Witteles Left Ventricular Dysfunction in Patients Receiving Cardiotoxic Cancer Therapies : Are Clinicians Responding Optimally? Journal of the American College of Cardiology, Volume 56, Issue 20, 2010, Why do we need cardiac oncologists ?

Click to edit Master title style What is Needed ! Network / Collaboration Facilitate networking: ICOS NA, CCON Create WG and TFs – link Publicize Cardio-Oncology: websites, social media Facilitate Research Collaborations: invite participation – group efforts Clinical Centralize existing resources, create white papers and guidelines Create a learning pathway Training Develop a Fellowship program Standardized Curriculum

Click to edit Master title style Need: Local level – program Network / Collaboration Create WG between Cardiology, Oncology: MDs, Nurses, Allied Health Facilitate networking: list Publicize Cardio-Oncology: reciprocal presentations Facilitate Research Collaborations: invite participations Clinical: Pathway Before: prevention (RFs) + early detection During: monitor during anticancer therapy; imaging/biomarkers After: develops a plan to monitor long-term as needed Training Adopt standardized curriculum

Click to edit Master title style Fellowship Training – what’s out there 7 Fellows in US / Canada No accreditation No internal funding No recognized structure to follow

Click to edit Master title style Cardiac Oncologist? HF Imaging Research Consults Clinics Cardiology Oncology

Click to edit Master title style Should we develop a curriculum for cardiac oncology ?

Click to edit Master title styleGOALS OF THE CURRICULUM  Convey a knowledge base. Stimulate research.  Integrate into mainstream cardiology and oncology training programs  Reshape the mindset about traditional roles of cardiologists and oncologists.  Graduates expand best practices outside the cloistered “cardio oncology centers”, improve practice, lessen disparities in practice. Richard M. Steingart MD Chief, Cardiology Service Memorial Sloan-Kettering Cancer Center

Click to edit Master title style use of chemotherapeutic drugs, biologic products, and growth factors; their mechanisms of action, pharmacokinetics, clinical indications, and limitations, including their effects, toxicity, and interactions cardiac tumors

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basic knowledge of cancer agents and their potential to cause cardiac damage Imaging strategies – basic knowledge on cardiac imaging in oncology patients Basic understanding of treatment strategies for cancer patients experiencing cardiac toxicities Level 1 (Internal Medicine Residents)

Click to edit Master title style For residents who wish to broaden their exposure to cardiac oncology patients More detailed assessment of patients Intermediate knowledge base More exposure to advanced cardiac imaging eg. advanced echocardiography (strain/3D) Understanding of the role of biomarkers in early detection of cardiac toxicity Level 2 (Medical/Cardiology Resident)

Click to edit Master title style months of dedicated fellowship training advanced knowledge of cancer agents and potential toxicities broad exposure to in- and out-patients training in biomarkers, advanced imaging actively involved in research Level 3 (Cardiac Oncology Fellow)

Click to edit Master title style Cardiologist stream Principles of oncology care Advanced knowledge of cancer agents and potential toxicities Training in biomarkers, advanced cardiac imaging Appropriate cardiac imaging techniques cardiotoxicity surveillance- when/how long? Evidence based treatment with cardioprotective drugs Actively involved in research Oncologist stream Understanding cardiac imaging: limitations and common techniques Familiarity with principles of heart failure, arrhythmias and hypertension Familiarity with principles of echocardiography, cardiac MRI and biomarkers Techniques of cardiac surveillance Evidence based treatment with cardioprotective drugs Actively involved in research Level 3 Cardiac Oncology Fellow (12-24 months)

Click to edit Master title style HOW TO ACCOMPLISH THE ESSENTIAL INSTRUCTION? Cancer therapies taught by cardiologists to cardiology trainees as life saving interventions with manageable toxicity. Longitudinal Outpatient Cardio-Oncology Clinic Adults currently receiving anthracyclines/trastuzumab. – Continuum of benefit and risk. Surgical clearance of the cancer patient. Childhood cancer survivors. Adults receiving VSPI. – Blood pressure, CHF and ischemia management. Inpatient Consultation Service Antiplatelet/anticoagulant risks and benefits.