Cardio-Oncology Offers Fellows the Opportunity to Venture Into the ‘Wild West’

For the large number of patients facing both cancer and heart disease, finding a specialist to simultaneously treat the nuances of both conditions has until recently been challenging, with comprehensive training programs few and far between. The relatively new field, deemed cardio-oncology, is increasingly attracting early-career physicians interested in building from the ground up.   

“When you have cancer and a heart attack, it’s like a double jeopardy,” said Nirmanmoh Bhatia, MD, who became interested in the integration of cardiology and oncology as a resident at MD Anderson Cancer Center (Houston, TX). “The patient population was so interesting, and no one seemed to have any idea what to do with these patients,” Bhatia told TCTMD, adding that key cardiology trials typically exclude those with cancer, leaving researchers unable to track outcomes—or discover how best to improve them—in this population. 

Now in his second year of a general cardiology fellowship focusing on cardio-oncology at Vanderbilt University Medical Center (Nashville, TN), he is planning an “academic career geared toward optimizing all aspects of interventional care, including what we have to do in the cath lab.”

According to Bhatia, TAVR will be an area of cardiology where cancer carries particular weight. “Many cancer patients are living for many years after their diagnosis and developing aortic stenosis for which they need valve replacement. The cancer may disqualify them for surgery, . . . but TAVR may allow them to have a meaningful life,” he said, noting that he hopes to add to the literature on how best to manage this patient subset.

 While being an interventional cardiologist with training in cardio-oncology is relatively unique right now, it is likely to become much more commonplace in the near future, Bhatia said, given the many different cancer patient populations who are living longer and needing cardiac care. In many cases, there is uncertainty about how well these patients will tolerate PCI and antiplatelet therapies. In prostate cancer patients, for example, research is showing that they may be predisposed to heart attack and stroke as a result of hormone replacement therapies, he added. 

Lack of Formal Training, Standards

Cardio-oncology stems from both the potential for anticancer therapies to cause cardiovascular side effects and the improvements in cancer care that are allowing patients to live longer, said Ana Barac, MD, PhD, of Medstar Heart and Vascular Institute (Washington, DC). Barac told TCTMD that cardiologists need to be familiar with an ever-increasing number of cancer therapies as well as the importance of primary prevention of cardiac issues prior to and during chemotherapy.

While the number of training programs and fellowships in cardio-oncology is limited, Barac pointed out that the same was once true of training in advanced heart failure and interventional cardiology. For the most part, she said, cardio-oncology fellowships are still in the “home grown” stages with no uniform standards, although that may soon change.

Last summer, Barac was named chair of the American College of Cardiology (ACC)’s cardio-oncology member section. Her goal is to bring together cardio-oncology practitioners so that they can investigate ways to share best practices and develop educational materials and tools that will move the specialty forward.

In a 2015 nationwide survey of cardiology division chiefs and cardiovascular fellowship program training directors conducted by the ACC group, they reported that 43% of programs offered no formal training in cardio-oncology. Additionally, nearly 40% of those surveyed said they did not feel confident handling cardiac care specific to patients with cancer, and a whopping 70% said they would welcome the chance to use educational material for their fellows and staff, if available. 

Another member of the ACC’s cardio-oncology group, Daniel J. Lenihan, MD, also of Vanderbilt, observed that interest in the field has exploded in the last 5 to 7 years. “But when you have an area that is rapidly developing, it’s kind of like the Wild West,” he said. “People do whatever they feel like doing, and there are some common features, but where we are at right now is in trying to rein everyone in.”  

As president of the North American chapter of the International CardiOncology Society, Lenihan holds monthly webinars geared toward unique cardio-oncology cases and facilitating discussion among those interested in the field. “We have tried to discuss at length what the elements of a fellowship would be, what the educational principals would be, and how we go about making sure that each place delivers on those educational principles,” he said.

A major hurdle, however, has been creating a uniform set of guidelines for practitioners from several areas of medicine including general cardiology, heart failure, epidemiology, basic science, oncology, imaging, and interventional cardiology. Lenihan said the ACC member section has submitted a proposal for fellowship guidelines that is currently under review for publication in a cardiology journal. “That would be the first formal representation of what we think a cardio-oncology fellowship should look like,” he added.

Barac said she is confident that standards for training will happen and that cardio-oncology will emerge from its niche. “Even general cardiology fellows should be exposed to and be comfortable to a certain level in managing patients with cancer and heart problems,” she commented. “We are all concerned that training is being prolonged . . . and the mere fear of that has blocked some efforts to go forward with formalized training.” 

There is also a need, she said, for continuing medical education geared toward physicians further along in their careers who are not in a position to do a fellowship.

In addition to the paucity of training standards, lack of structured data on cancer survivors means no definitive guidelines exist for treatment either, Barac noted, adding that multi-society involvement is crucial and is slowly happening. The 2015 ACC meeting, for example, had a half-day cardio-oncology intensive that Barac said was extremely well attended. Likewise, Lenihan noted that the 2015 European Society of Cardiology Congress held sessions relevant to cardio-oncology nearly every day of the meeting. More recently, the Society for Cardiovascular Angiography and Interventions (SCAI) published an expert consensus on considerations for PCI, CABG, and TAVR in cancer patients.

“The problem is that to make definite recommendations we need some solid, randomized controlled trials with good quality data,” Bhatia observed, calling the SCAI document a good first step. “As we get more quality research done, the guidelines are going to be very helpful and I see a role for a separate society of cardio-oncology.” If such a society were created, he added, it would likely champion for national and international databases where data on patients with cancer and heart disease could be collected.

A Field for Problem-Solvers

The enormous potential for growth in the field also has led to changes in who is applying for cardio-oncology fellowships.

Michelle N. Johnson, MD, MPH, who directs the cardio-oncology fellowship program at Memorial Sloan Kettering Cancer Center (New York, NY), said many applicants in the early years of their program were residents looking to enhance their ability to secure a cardiology fellowship. Over the last few years, however, more and more fellows coming through the program are board-certified cardiologists planning careers in cardio-oncology. Graduates of their fellowship program have gone on to help set up cardio-oncology programs at centers across the country, Johnson noted.   

This year, she said, Memorial Sloan Kettering has 2 cardio-oncology fellows. One holds a PhD, has completed a cardiology fellowship, and is spending 2 years doing a combination of clinical work, higher-level imaging training, and collaborative basic science work in stem cell therapies for anthracycline-induced cardiomyopathies. The other fellow also is a board-certified cardiologist who has an interest in preventive medicine and heart failure. He is planning to go into private practice with the goal of offering cardio-oncology services in an outpatient setting.

“There are ample opportunities to build out a career in [cardio-oncology],” Johnson said. “The reality is a lot of these patients are not seen in academic centers until people in private practice see them first and find themselves in a quandary as to what to do with them.” Specialists well versed in cardio-oncology are in a good position to distinguish themselves in a competitive job market on both the clinical and research sides of the fence, she added.

Institutions that want to establish their own cardio-oncology programs need experts who not only know how to structure clinics but also how to collaborate with multiple disciplines on complicated patient issues that are typically out of the range of general cardiology or general oncology practitioners, Johnson noted.

Due to the lack of treatment guidelines, much of the work that a cardio-oncologist will do involves “working it out,” she observed. “[I]f you’re the type of person for whom that resonates and generates excitement, then this might be for you. But if you are looking for a more scripted existence it’s probably not the place to be because 10 years in, this field is still in its genesis.”