How To Start A Cardio- Oncology Program

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How To Start A CardioOncology ProgramMonika Leja, MD, FACC, Joerg Herrmann, MD, FACCAnecita Fadol PhD, RN, FNP, FAANP

Audience Poll How many audience members are from thecommunity? How many already have cardio-oncologypractices? How many have teamed with an academiccenter?

History of Onco-cardiology First adult cardiology departments in cancer centers in US emergedapproximately 15-20 years ago with the advent of HER and TKIcardiotoxicity Initial Needs were supportiveKara Kennedy's Heart May Have Taken'Direct Hit' by Cancer Cure – Sept 20, 2011

From Cancer Patient to Cancer Survivor:SurvivorLOST IN TRANSITIONCommittee on Cancer Survivorship: ImprovingCare and Quality of LifeNational Cancer Policy BoardMaria Hewitt, Sheldon Greenfield, and Ellen Stovall,EditorsINSTITUTE OF MEDICINE AND NATIONALRESEARCH COUNCIL OF THE NATIONALACADEMIES, 2006THE NATIONAL ACADEMIES PRESSWashington, D.C. www.nap.eduOne of fastest and growing patient populationsAt risk for premature CV diseaseMore than 15.5 Million Cancer Survivors in US

What is Cardio-Oncology?-Learn to Live with Cancer with bestquality of life“A Continuum Of Care For The Cancer Patient. “Achieving complentation with oncology”Localized Disease - Disease Recurrence - Metastatic DiseaseCancer PatientPrecancer TherapyCardiac Assessment-Functional Capacity-Evaluate cardiac risksand modify-Mitigating Factors-Assessing safety oftreatmentCancer Therapy-Helping with acutecardiotoxicity-Getting Patientsthrough their therapysafelySurvivorship-Treat Radiation andChemotherapy relatedcomplications-Resuming functionalcapacity-Early Recognition of LongTerm Side Effects-Developing Long TermHealth Goals

Umass MemorialAdvocate Christ Medical CenterWorchester, MAOak Lawn, ILEdward-Elmhurst HealthUniversity ofBrigham andElmhurst, ILRochesterMayo ClinicWomen’s HospitalAurora Health CareRochester, NYBoston, MARochester, MNMilwaukee, WIScottsdale, AZNorthwestern UniversityBethIsrael DeaconessJacksonville, FLChicago, ILU of MCVI Boston, MAMinneapolis, MN University ofCommunity Heart andMass GeneralVascular HospitalWisconsinBoston, MAIndianapolis, INMadison, WIUConnHealthUniversity ofFarmington, CTMichiganAnn Arbor, MIYale Cancer CenterNew Haven, CTMt. Sinai HospitalNew York City, NYMemorial Sloan-KetteringCancer CenterNew York City, NYLankenau Medical CenterWynnewood, PAMedStar Heart InstituteBaltimore- WashingtonUCLAWashington Hospital CenterWashington, DCCedars-SinaiVCU Massey Cancer CenterLos Angeles, CARichmond, VAUniversity of KansasBon Secours Cancer InstituteCancer CenterRichmond, VAKansas City, KSDuke Radiation OncologyCovenant Heart andVanderbiltDurham, NCVascular InstituteU of L Nashville, TNLubbock, TXOrlando Health Heart Institute and UFLouisville, KYHealth Cancer Center Orlando, FLEmory UniversityMethodist HealthcareAtlanta,GAUniversitySouth FloridaSan Antonio, TXTampa, FLSt. Mary’s Health Care System andMoffitt Cancer CenterOconee Heart and Vascular CenterMD AndersonTampa, FLAthens, GAHouston, TX

Radiation ogyTeamRiskPredictionPreventionCV rdioOncologyTeam

Centers of ExcellencePotential practice models of a CardioCardio-Oncology ClinicCardiologist-staffedwith oncologistcommunicationPros:- defined set-up- one focus group- easierstandardization- faciliated expertinputCons:- usually confined tolarger practices- on-demand practice- emphasis on CVCardiologist- andOncologist- staffed(alternating or simultaneous)Pros:- truly joint approach- suitable platform for multipledisciplines in one clinic setting(e.g. inclusion of nephrooncology)- fostered interactions- increased patient satisfactionCons:- resource intensive- inefficient meeting of demand(different individualrequirements)- confined to large centersSnipelisky D. et. al. Heart Failure Clinics 2017, in pressOncologist-staffedwith cardiologistcommunicationPros:- defined set-up- community appeal(tele-medicine withcardiology services)- Integration of otherdisciplines (e.g.nephrology) with onemain gatekeeper- Suitable forsurvivorship clinicsCons:- emphasis ononcology- vulnerability to lackof CV input

Step #2Outline the scopeof cardiooncology practiceStep #3Organize a clinicmodel that meetsthe envisionedscope of practiceStep #1Step #1Seek institutionalsupportImplement thepracticeStep #2Develop aninstitutionalinfrastructureStep #3InstituteinstitutionalcommunicationSnipelisky D. et. al. Heart Failure Clinics 2017, in pressMilestone #2: Institutional SupportDefine the needfor a cardiooncologyprogramMilestone #1: Cardio-Oncology Clinic VisionStep #1Step #2Support andeducate staffand patientsStep #3Commit tocontinuous bestcareMilestone #3: Thriving Cardio-OncologyServiceCardio-Oncology Clinic Milestones

Umass MemorialAdvocate Christ Medical CenterWorchester, MAOak Lawn, ILEdward-Elmhurst HealthUniversity ofBrigham andElmhurst, ILRochesterMayo ClinicWomen’s HospitalAurora Health CareRochester, NYBoston, MARochester, MNMilwaukee, WIScottsdale, AZNorthwestern UniversityBethIsrael DeaconessJacksonville, FLChicago, ILU of MCVI Boston, MAMinneapolis, MN University ofCommunity Heart andMass GeneralVascular HospitalWisconsinBoston, MAIndianapolis, INMadison, WIUConnHealthUniversity ofFarmington, CTMichiganAnn Arbor, MIYale Cancer CenterNew Haven, CTMt. Sinai HospitalNew York City, NYMemorial Sloan-KetteringCancer CenterNew York City, NYLankenau Medical CenterWynnewood, PAMedStar Heart InstituteBaltimore- WashingtonUCLAWashington Hospital CenterWashington, DCCedars-SinaiVCU Massey Cancer CenterLos Angeles, CARichmond, VAUniversity of KansasBon Secours Cancer InstituteCancer CenterRichmond, VAKansas City, KSDuke Radiation OncologyCovenant Heart andVanderbiltDurham, NCVascular InstituteU of L Nashville, TNLubbock, TXOrlando Health Heart Institute and UFLouisville, KYHealth Cancer Center Orlando, FLEmory UniversityMethodist HealthcareAtlanta,GAUniversitySouth FloridaSan Antonio, TXTampa, FLSt. Mary’s Health Care System andMoffitt Cancer CenterOconee Heart and Vascular CenterMD AndersonTampa, FLAthens, GAHouston, TXCardio-Oncology ClinicsUS 2016

Mayo Clinic, Rochester, MN

Mayo Cardio-Oncology TimelinePresentations toCardiology andHematologydepartmentPresentationto Oncologydepartment20122010Presentationto OncologydepartmentPresentationto Cardiologydepartment201520132012Start ofCardio-OncologyE-consults2013Start t ofCardio-OncologyWednesdayafternoon clinic

Cardio-Oncology Clinic Visits[n]

Cardio-Oncology E-Consultations[%]

Cardio-Oncology Referral GroupsBeforeAfter“Physical” Cardio Oncology Clinic

Mayo Cardio-Oncology Triage ModelOncology/Hematology patientRequest for Cardio-OncologyLimited review, no major managementdecisions, no initiation of new treatmentsTriageE-consultationProvider or patient preference,major management decisions,first CV survivorship visitFull consultationCardio-OncologyE-consult consultant of the dayCardio-OncologyClinic appointmentTriage orCurbsideQuestions

Mayo Cardio-Oncology Team ModelCardiacimagingHeart nVascularbiology andcoronaryphysiologyHeartRhythm

University of Michigan CardioOncology Program Start Date 2011 Housed in the Cardiovascular Center

Establishing Relationships – All Cancers Are Not Created Equally and Have More CardiacProblems than Others and Understand the Needs of the InstitutionTop 5 cancers diagnosed andtreated at the University ofMichigan: Melanoma Breast cancer Prostate Cancer Blood Cancers Lung CancersU-M recognized as Blue Distinction Center for Complex andRare Cancers: Acute Leukemia Bladder Bone - Primary Brain - Primary Esophageal Gastric Head and Neck Liver - Primary Pancreatic Ocular Melanoma Rectal Soft Tissue Sarcomas Thyroid - Medullary and/or Anaplastic

Outline New Services You Can Offer Dedicated Cardio-oncology clinics – Fast Track ThesePatients Imaging Focusing on Cardio-oncology problems-Echocardiography with strain imaging-Cardiac MRI – EF and fibrosis, Cardiac Masses, Amyloid-Becoming active members of tumor boards-Educate your community physicians – Primary Care

Understand the Cardiac Problems of Each Cancer and Its Therapy and DevelopRelationships Each cancer is unique Team Up With Other CardiologySpecialties Understand the oncologists fears andmyths:-Patients will die from their cancerfirst-If they have heart disease, theycan’t get their cancer treatment-You’re going to stop mychemotherapy

UM Cardio-oncology Program-2 ½ full day dedicated cardio-oncology clinics-Dedicated cardio-oncology nurse-Subspecialty Programs:Sarcoma Survivorship,Cardiac Tumors-Diverse Group of Patients: Cardiotoxicity, Cardiac Tumors,Carcinoid, Cardiac Amyloid, XRT, Pericardial Disease,Arrhythmia

The Community Establish dedicated time slots Understand what to screen for? Establish good relationships with your localoncologists! Team up for the weird!

Cardiac Tumor Program Collaborative program ofoncologists, cardiologists,radiologists, surgeons,targeted therapy Monthly tumor board Multi-institutional Referrals from all states Both primary andmetastatic tumors to theheartRight Atrial Sarcoma Resection

The Heart Success Program

Heart Success Program Interdisciplinary patient-centered program for themanagement of heart failure in patients with cancer Early identification of risk factors for cardiotoxicity,prevention of exacerbation and readmissions Ensure provision of appropriate care and education

Barriers Lack of guidelines Lack of funding – NCI is providing new dedicated grants– FOA - PA-16-035– Funding Opportunity title - Improving Outcomes in Cancer TreatmentRelated Cardiotoxicity (R01) Limited Educational Opportunities Limited Infrastructure Perception of necessity

Why Manage Heart Failure in Cancer Patients? Several chemotherapeutic agents are known to cause cardiotoxicity Heart failure as a comorbid condition can affect choice of cancer therapy Severity of heart failure has direct impact on the care, prognosis, clinicaloutcomes and patient’s quality of life Cancer patients typically have cardiovascular disease and vice versa,demanding a team approach

Patients with Cancer and HF at MDACCFYTotal HospitalDischargesHF 01023,9851199 (4.9%)456 (38%)1001 (83%)201125, 1681258 (4.9%)427 (34%)887 (71%)2009 - The US Center for Medicare and Medicaid Services (CMS) began public reportingof all-cause readmissions rates after HF hospitalization2010 – Patient Protection and Affordable Care Act establish financial penalties forhospitals with the highest readmission rates during the first 30 days after discharge National database for Medicare patients showed HF readmission within 30 days isapproximately 19.1% Comprehensive discharge planning and planned follow –up may reduce earlyreadmission rates by as much as 25%

Cancerof Pts. withCancer Diagnosisof DxPatientswithHF*Heart Failure**HF incidence 4%

Heart Success tationServicesPatient/FamilyContinuum of sEmergency Center/InpatientOutpatient/Cardiomyopathy ClinicHome/HospiceHeart Failure Order SetHeart 2 Heart Support GroupHome Care

Heart Success Program Tools Education component– Nursing and interdisciplinary staff Cardiac Complications of Cancer Therapy symposium– Patient/Family Education Clinical component–––– Identification of patients with LVDInterdisciplinary clinical roundsClinical In-services (case conferences)Clinical Nurse Leaders (CNL) as clinical championsOutcomes measurement– Hospital readmission– Patient experience

Heart Success ProgramTeam Education

Patient Education

Teach Back: Closing the LoopSchillinger D, Piette J, Grumbach K, Wang F, Wilson C, Daher C, Leong-Grotz K, Castro C, Bindman A.Closing the Loop Physician Communication With Diabetic Patients Who Have Low Health Literacy.Arch Intern Med/Vol 163, Jan 13, 2003

Transition from Hospital to Home Review discharge instructions egular weight monitoringToss the salt shaker Schedule outpatient follow-up with HCP Review instructions with clinic visit

Provision of discharge instructionsFadol, A. et al. Heart success program. Progress in Pediatric Cardiology. 2015. 39. 99-105.

Patient Satisfaction(HCAHPS)Fadol, A. et al. Heart success program. Progress in Pediatric Cardiology. 2015. 39. 99-105.

Management of HF In Cancer Patients Integrated interdisciplinary approach necessary toimprove outcomes Organized program across the continuum of care Improve patient experience and satisfaction

Summary of how to start a Cardio-oncology Practice Develop Individual Relationships and Understandthe Needs Work as a Team Understand What you Can Offer and Deliver

How to Build a Clinical Cardio-Oncology Practice Communication Collaboration Coffee

Resources Herrmann, Joerg et al. How To Develop A Cardio-oncology Clinic. HeartFailure Clinic Dec 26, 2016 Fadol, A. et al. Heart success program: An interdisciplinary patient-centerdapproach to cancer patients with concurrent heart failure. Progress inPediatric Cardiology. 2015. 39. 99-105. ACC.org cardio-oncology section and webpage Canadian Cardiac Oncology Network International Cardio-Oncology Society

UM Cardio-oncology Program-2 ½ full day dedicated cardio-oncology clinics-Dedicated cardio-oncology nurse-Subspecialty Programs: Sarcoma Survivorship,Cardiac Tumors -Diverse Group of Patients: Cardiotoxicity, Cardiac Tumors, Carcinoid, Cardiac Amyloid, XRT, Pericardial Disease, Arrhythmia

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