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Starting a Cardio-Oncology Program Our experience in the Community settingKibar Yared, MD FRCPC Director, Cardiac Imaging Medical Director, Cardio-Oncology Program Scarborough Health Network Clinical Adjunct Professor of Medicine University of Toronto

@kibaryared


@SHNcares

• Who came up with this idea and why? • How it started • Challenges • Success stories • Where are we headed?

Outline

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@SHNcares

• American Society of Echocardiography Scientific Sessions 2015 – Particularly compelling presentation by Dr. Juan Carlos Plana

• Audited our current practices and found: – All cardiac investigations ordered and followed-up by

Oncology

– If abnormal then referral sent to first-available Cardiologist – Large discrepancies in

• Time for patient to be assessed • Management • Follow-up

Who came up with this and why?


@SHNcares

• No official Cardio-Oncology Clinic – But there was established Heart Function Clinic, staffed with clerk

and nurses • Met with point person in Oncology, Dr. Orit Freedman, with same

motivation – Established what type of patient should be seen in Cardio-Oncology – Agreed that we would “take over” cardiac investigations of patients

at risk of cardiotoxicity • Included all patients on Anthracycline +/- Trastuzumab • Patients with established heart disease about to undergo

chemotherapy • Patients currently undergoing chemotherapy with cardiac

complaints or previous abnormal cardiac investigations

How it started


@SHNcares

• Met again with all Oncologists to discuss – Referral pattern – Logistics of how we would deal with referral

• Triage • Timing of investigations and consultation

– Communication (!)

How it started


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@SHNcares

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OUTPATIENT CARDIO−ONCOLOGYHISTORY

Distribution: Chart Copy

Chemotherapy #1 ________________________________ Date ___________________________________________# of Tx’s received _________________ Last Tx date_________________ Next Planned Tx date__________________Chemotherapy #2 ________________________________Date ____________________________________________# of Tx’s received _________________ Last Tx date _________________ Next Planned Tx date __________________Chemotherapy #3 ________________________________Date ____________________________________________# of Tx’s received _________________ Last Tx date _________________ Next Planned Tx date __________________Chemotherapy #4 ________________________________Date ____________________________________________# of Tx’s received _________________ Last Tx date _________________ Next Planned Tx date __________________

Previous childhood/adolescent malignancyDiagnosis ______________________ Date _________________ Treatment ___________________

Previous Cardio Toxicity: ❏ Yes ❏ No Date:__________________________Priamary Cardiologist ______________________

RN Signature ________________________________ Date____________________

Allergies/Sensitivities: Initial Weight:

History

HypertensionDyslipidemiaDiabetesPCI

❏ Yes ❏ No❏ Yes ❏ No❏ Yes ❏ No❏ Yes ❏ No

CABGCAD/MISmokerEtoh


Echo/CMR/MUGA

Date: 2D/3D % GLS %

Date: 2D/3D % GLS %

Date: 2D/3D % GLS %

Date: 2D/3D % GLS %

Date: 2D/3D % GLS %

Date: 2D/3D % GLS %

Oncologist: HER2 #of Tx:Date: Radiation Date:Date Cancer Diagnosis: Surgical Date:

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History





Echo/CMR/MUGA

Date: 2D/3D % GLS %

Date: 2D/3D % GLS %

Date: 2D/3D % GLS %

Date: 2D/3D % GLS %

Date: 2D/3D % GLS %

Date: 2D/3D % GLS %


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History





Echo/CMR/MUGA

Date: 2D/3D % GLS %

Date: 2D/3D % GLS %

Date: 2D/3D % GLS %

Date: 2D/3D % GLS %

Date: 2D/3D % GLS %

Date: 2D/3D % GLS %



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OUTPATIENT CARDIO−ONCOLOGYNURSING ASSESSMENT


OncologyOncologist ____________________________________ Cancer Diagnosis_______________________

Dyspnea at RestDyspnea on ExertionPillow Orthopnea

❏ Yes ❏ No❏ Yes ❏ No❏ 1 ❏ 2 ❏ 3 ❏ 3+ ❏ HOB Elevated ❏ Recliner/Chair

❏ Yes ❏ No ❏ Productive ❏ Non Productive Onset❏ Yes ❏ No❏ Yes ❏ No

Regular Exercise

DiagnosticsEcho EF ______________________ Date_________________ MUGA EF_________________ Date___________Cardiac MRI EF_________________ Date _________________

RN Signature ________________________________ Assessment Date____________________

❏ 1 Visit ❏ Follow−up Visitst

Symptoms

Lifestyle❏ Yes ❏ No If yes, describe:

O2 Sat______________ Pulse______________ BP Sitting______________ BP Standing______________Weight______________ Chest Auscultation______________________________________________________Peripheral Edema ❏ None ❏ Trace ❏ 1+ ❏ 2+ ❏ 3+ ❏ 4+ Location______________________

Physical Assessment

PND:

Cough

Patient Concerns:

Teaching

❏ CHF Physiology

❏ Sodium Management

❏ Medication Therapy

❏ ER/Clinic talk

❏ Symptom Recognition

❏ Fluid Management

❏ Managing CHF

❏ Weight Diary

❏ Exercise Guideline

❏ Other

PalpitationsChest Pain


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• Initial funding • Room for echo/imaging. Timely CMR. • Seeing certain patients on time

– Patients cancelling, not seeing the need in follow up. Clinic fatigue.

• Nursing – Steep learning curve. Keeping up to date with

chemotherapeutic agents. • Oncology Patient Info System (OPIS) very useful • Ongoing education from MDs, CMEs

– Working as a team with oncology

Challenges


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• 550 patients seen to date

– 87 Discharged – 24 Died – 14 Refused follow-

up • 14 patients with LV

dysfunction – 1 death (Amyloid) – 11 complete

recovery – 2 recovery to low

normal EF

1%

1%

2%

3%

3%

9%

15%

66%

Breast CAGI/GULymphomaLung CAMultiple MyelomaLeukemiaMDSOther

Distribution of patients


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• Constantly looking to improve • Feedback from Oncology and

from patients • Participation in clinical trials

– Strain Surveillance of Chemotherapy for Improving Cardiovascular Outcomes: SUCCOUR Trial

– Evaluation of Myocardial Changes During BReast Adenocarcinoma Therapy to Detect Cardiotoxicity Earlier With MRI (EMRACE-MRI)


@SHNcares

• Relationship with Cardiac Rehab

Where are we headed?

Circulation. 2019;139:00–00. DOI: 10.1161/CIR.0000000000000679 TBD TBD, 2019 e1

Susan C. Gilchrist, MD, MS, Chair

Ana Barac, MD, PhD, Vice Chair

Philip A. Ades, MDCatherine M. Alfano, PhDBarry A. Franklin, PhD,

FAHALee W. Jones, PhDAndre La Gerche, MBBS,

PhDJennifer A. Ligibel, MDGabriel Lopez, MDKushal Madan, PhD, FAHAKevin C. Oeffinger, MDJeannine Salamone, BAJessica M. Scott, PhDRay W. Squires, PhD, FAHARandal J. Thomas, MD,

MS, FAHADiane J. Treat-Jacobson,

PhD, RN, FAHAJanet S. Wright, MDOn behalf of the Ameri-

can Heart Association Exercise, Cardiac Reha-bilitation, and Secondary Prevention Committee of the Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; and Council on Peripheral Vascular Disease

© 2019 American Heart Association, Inc.

AHA SCIENTIFIC STATEMENT

Cardio-Oncology Rehabilitation to Manage Cardiovascular Outcomes in Cancer Patients and SurvivorsA Scientific Statement From the American Heart Association Endorsed by the American Cancer Society

Circulation

https://www.ahajournals.org/journal/circ

ABSTRACT: Cardiovascular disease is a competing cause of death in patients with cancer with early-stage disease. This elevated cardiovascular disease risk is thought to derive from both the direct effects of cancer therapies and the accumulation of risk factors such as hypertension, weight gain, cigarette smoking, and loss of cardiorespiratory fitness. Effective and viable strategies are needed to mitigate cardiovascular disease risk in this population; a multimodal model such as cardiac rehabilitation may be a potential solution. This statement from the American Heart Association provides an overview of the existing knowledge and rationale for the use of cardiac rehabilitation to provide structured exercise and ancillary services to cancer patients and survivors. This document introduces the concept of cardio-oncology rehabilitation, which includes identification of patients with cancer at high risk for cardiac dysfunction and a description of the cardiac rehabilitation infrastructure needed to address the unique exposures and complications related to cancer care. In this statement, we also discuss the need for future research to fully implement a multimodal model of cardiac rehabilitation for patients with cancer and to determine whether reimbursement of these services is clinically warranted.

Advances in early detection and treatment have significantly improved the 5-year disease-specific survival rates for the 10 most common malignan-cies.1 As a result, there are >16.7 million cancer survivors in the United

States today.1–4 Many of these individuals are at increased risk of morbidity and mortality from noncancer causes, predominantly cardiovascular disease (CVD). Specifically, cancer survivors living at least 5 years beyond diagnosis have a 1.3- to 3.6-fold increased risk of cardiovascular-specific mortality and a 1.7- to 18.5-fold increased incidence of CVD risk factors such as hypertension, diabetes mellitus, and dyslipidemia compared with age-matched counterparts with no cancer his-tory.5,6 The elevated risk of CVD in cancer survivors is likely the result of normal age-related pathologies coupled with the direct (eg, radiation, chemotherapy, tar-geted therapy) and indirect (eg, deconditioning, weight gain)7 effects of cancer therapy that extend across multiple systems (ie, whole-organism cardiovascular toxicity).8 CVD is likely to become even more pervasive in the oncology setting as a result of continued improvements in cancer-specific mortality in conjunction with the rapidly aging population.9

Effective and viable strategies are needed to mitigate CVD risk in patients with cancer. The use of a delivery model similar to that used in cardiac rehabilitation

Key Words: AHA Scientific Statements ◼ cancer ◼ cardiac rehabilitation ◼ cardiovascular diseases

Dow

nloaded from http://ahajournals.org by on A

pril 18, 2019

Circulation. 2019;139:00–00. DOI: 10.1161/CIR.0000000000000679 TBD TBD, 2019 e1

Susan C. Gilchrist, MD, MS, Chair

Ana Barac, MD, PhD, Vice Chair

Philip A. Ades, MDCatherine M. Alfano, PhDBarry A. Franklin, PhD,

FAHALee W. Jones, PhDAndre La Gerche, MBBS,

PhDJennifer A. Ligibel, MDGabriel Lopez, MDKushal Madan, PhD, FAHAKevin C. Oeffinger, MDJeannine Salamone, BAJessica M. Scott, PhDRay W. Squires, PhD, FAHARandal J. Thomas, MD,

MS, FAHADiane J. Treat-Jacobson,

PhD, RN, FAHAJanet S. Wright, MDOn behalf of the Ameri-

can Heart Association Exercise, Cardiac Reha-bilitation, and Secondary Prevention Committee of the Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; and Council on Peripheral Vascular Disease

© 2019 American Heart Association, Inc.

AHA SCIENTIFIC STATEMENT

Cardio-Oncology Rehabilitation to Manage Cardiovascular Outcomes in Cancer Patients and SurvivorsA Scientific Statement From the American Heart Association Endorsed by the American Cancer Society

Circulation

https://www.ahajournals.org/journal/circ

ABSTRACT: Cardiovascular disease is a competing cause of death in patients with cancer with early-stage disease. This elevated cardiovascular disease risk is thought to derive from both the direct effects of cancer therapies and the accumulation of risk factors such as hypertension, weight gain, cigarette smoking, and loss of cardiorespiratory fitness. Effective and viable strategies are needed to mitigate cardiovascular disease risk in this population; a multimodal model such as cardiac rehabilitation may be a potential solution. This statement from the American Heart Association provides an overview of the existing knowledge and rationale for the use of cardiac rehabilitation to provide structured exercise and ancillary services to cancer patients and survivors. This document introduces the concept of cardio-oncology rehabilitation, which includes identification of patients with cancer at high risk for cardiac dysfunction and a description of the cardiac rehabilitation infrastructure needed to address the unique exposures and complications related to cancer care. In this statement, we also discuss the need for future research to fully implement a multimodal model of cardiac rehabilitation for patients with cancer and to determine whether reimbursement of these services is clinically warranted.

Advances in early detection and treatment have significantly improved the 5-year disease-specific survival rates for the 10 most common malignan-cies.1 As a result, there are >16.7 million cancer survivors in the United

States today.1–4 Many of these individuals are at increased risk of morbidity and mortality from noncancer causes, predominantly cardiovascular disease (CVD). Specifically, cancer survivors living at least 5 years beyond diagnosis have a 1.3- to 3.6-fold increased risk of cardiovascular-specific mortality and a 1.7- to 18.5-fold increased incidence of CVD risk factors such as hypertension, diabetes mellitus, and dyslipidemia compared with age-matched counterparts with no cancer his-tory.5,6 The elevated risk of CVD in cancer survivors is likely the result of normal age-related pathologies coupled with the direct (eg, radiation, chemotherapy, tar-geted therapy) and indirect (eg, deconditioning, weight gain)7 effects of cancer therapy that extend across multiple systems (ie, whole-organism cardiovascular toxicity).8 CVD is likely to become even more pervasive in the oncology setting as a result of continued improvements in cancer-specific mortality in conjunction with the rapidly aging population.9

Effective and viable strategies are needed to mitigate CVD risk in patients with cancer. The use of a delivery model similar to that used in cardiac rehabilitation

Key Words: AHA Scientific Statements ◼ cancer ◼ cardiac rehabilitation ◼ cardiovascular diseases

Dow

nloaded from http://ahajournals.org by on A

pril 18, 2019


@SHNcares

• Further participation in clinical trials – Statins for the Primary Prevention of Heart

Failure in Patients Receiving Anthracycline Pilot Study (SPARE-HF)

– Characterizing Heart And Mind health Post-chemotherapy In wOmeN with Breast Cancer (CHAMPION)

• Expansion across sites and regionally.



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Telemedicine


PatientAlternative access to care, reduced

travel costs

CliniciansImproved patient care and family/patient

satisfaction

SHNProgram efficiencies, reduced wait

times and no shows


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THANKS to

Patricia Osgood Sarah Aiken, RN

Margo Wells, RN Siva Punniasingam, RN

MaryAnn Quilang Saul Miller, MD

Nisha D’Mello, MD Andrea Rosenbloom, MD

ImagecourtesyofD

ukeCancerInstitu

te

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