Click to edit Master title style Starting a Cardio-Oncology Program Our experience in the Community setting Kibar Yared, MD FRCPC Director, Cardiac Imaging Medical Director, Cardio-Oncology Program Scarborough Health Network Clinical Adjunct Professor of Medicine University of Toronto @kibaryared
Outline Click to edit Master title style • Who came up with this idea and why? • How it started • Challenges • Success stories • Where are we headed? @SHNcares @SHNcares
Who came up with this and why? Click to edit Master title style • 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 @SHNcares
How it started Click to edit Master title style • 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 @SHNcares
How it started Click to edit Master title style • Met again with all Oncologists to discuss – Referral pattern – Logistics of how we would deal with referral • Triage • Timing of investigations and consultation – Communication (!) @SHNcares
Click to edit Master title style @SHNcares
Click to edit Master title style OUTPATIENT CARDIO − ONCOLOGY HISTORY History 847474 (Rev.03/17) Page 1 of 1 Hypertension ❏ Yes ❏ No ❏ Yes ❏ No CABG 847474 OUTPATIENT CARDIO − ONCOLOGY Oncologist: HER 2 #of Tx: Dyslipidemia Date: ❏ Yes ❏ No Radiation Date: ❏ Yes ❏ No CAD/MI HISTORY Date Cancer Diagnosis: Surgical Date: Diabetes ❏ Yes ❏ No ❏ Yes ❏ No Smoker Allergies/Sensitivities: Initial Weight: PCI ❏ Yes ❏ No ❏ Yes ❏ No Etoh Echo/CMR/MUGA Chemotherapy #1 ________________________________ Date ___________________________________________ # of Tx’s received _________________ Last Tx date_________________ Next Planned Tx date__________________ 847474 Date: Oncologist: 2 D/ 3 D % GLS HER 2 % #of Tx: Chemotherapy #2 ________________________________Date ____________________________________________ Date: # of Tx’s received _________________ Last Tx date _________________ Next Planned Tx date __________________ Radiation Date: Date: 2 D/ 3 D % GLS % Chemotherapy #3 ________________________________Date ____________________________________________ Date Cancer Diagnosis: Surgical Date: # of Tx’s received _________________ Last Tx date _________________ Next Planned Tx date __________________ Chemotherapy #4 ________________________________Date ____________________________________________ Date: 2 D/ 3 D % GLS % Allergies/Sensitivities: Initial Weight: # of Tx’s received _________________ Last Tx date _________________ Next Planned Tx date __________________ Date: 2 D/ 3 D % GLS % Previous childhood/adolescent malignancy Diagnosis ______________________ Date _________________ Treatment ___________________ Date: 2 D/ 3 D % GLS % Previous Cardio Toxicity: ❏ Yes ❏ No Chemotherapy #1 ________________________________ Date ___________________________________________ Date:__________________________ Priamary Cardiologist ______________________ Date: 2 D/ 3 D % GLS % # of Tx’s received _________________ Last Tx date_________________ Next Planned Tx date__________________ Chemotherapy #2 ________________________________Date ____________________________________________ History 847474 (Rev.03/17) Page 1 of 1 # of Tx’s received _________________ Last Tx date _________________ Next Planned Tx date __________________ Hypertension ❏ Yes ❏ No ❏ Yes ❏ No CABG Chemotherapy #3 ________________________________Date ____________________________________________ Dyslipidemia ❏ Yes ❏ No ❏ Yes ❏ No CAD/MI # of Tx’s received _________________ Last Tx date _________________ Next Planned Tx date __________________ Diabetes ❏ Yes ❏ No ❏ Yes ❏ No Smoker PCI ❏ Yes ❏ No ❏ Yes ❏ No Etoh Chemotherapy #4 ________________________________Date ____________________________________________ Echo/CMR/MUGA # of Tx’s received _________________ Last Tx date _________________ Next Planned Tx date __________________ RN Signature ________________________________ Date____________________ Date: 2 D/ 3 D % GLS % Date: 2 D/ 3 D % GLS % Previous childhood/adolescent malignancy Distribution: Chart Copy Date: 2 D/ 3 D % GLS % Diagnosis ______________________ Date _________________ Treatment ___________________ Date: 2 D/ 3 D % GLS % Date: 2 D/ 3 D % GLS % Previous Cardio Toxicity: ❏ Yes ❏ No Date:__________________________ Date: 2 D/ 3 D % GLS % Priamary Cardiologist ______________________ RN Signature ________________________________ Date____________________ @SHNcares Distribution: Chart Copy
Click to edit Master title style OUTPATIENT CARDIO − ONCOLOGY NURSING ASSESSMENT ❏ 1 Visit ❏ Follow − up Visit st 847297 Oncology Oncologist ____________________________________ Cancer Diagnosis_______________________ Symptoms ❏ Yes ❏ No Dyspnea at Rest ❏ Yes ❏ No Dyspnea on Exertion Pillow Orthopnea ❏ 1 ❏ 2 ❏ 3 ❏ 3+ ❏ HOB Elevated ❏ Recliner/Chair PND: ❏ Yes ❏ No ❏ Productive ❏ Non Productive Onset Cough ❏ Yes ❏ No Chest Pain ❏ Yes ❏ No Palpitations Lifestyle ❏ Yes ❏ No If yes, describe: Regular Exercise Physical Assessment O 2 Sat______________ Pulse______________ BP Sitting______________ BP Standing______________ Weight______________ Chest Auscultation______________________________________________________ ❏ None ❏ Trace ❏ 1+ ❏ 2+ ❏ 3+ ❏ 4+ Location______________________ Peripheral Edema Diagnostics 847297 (Rev.03/17) Page 1 of 1 Echo EF ______________________ Date _________________ MUGA EF _________________ Date___________ Cardiac MRI EF _________________ Date _________________ Teaching ❏ CHF Physiology ❏ Symptom Recognition ❏ Exercise Guideline ❏ Fluid Management ❏ Other ❏ Sodium Management ❏ Medication Therapy ❏ Managing CHF ❏ Weight Diary ❏ ER/Clinic talk Patient Concerns : @SHNcares RN Signature ________________________________ Assessment Date____________________ Distribution: Chart Copy
Challenges Click to edit Master title style • 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 @SHNcares
Distribution of patients Click to edit Master title style Breast CA • 550 patients seen to GI/GU 1% Lymphoma date 1% Lung CA 2% – 87 Discharged Multiple Myeloma Leukemia 3% – 24 Died MDS 3% Other – 14 Refused follow- 9% up • 14 patients with LV dysfunction 15% – 1 death (Amyloid) – 11 complete 66% recovery – 2 recovery to low normal EF @SHNcares
Click to edit Master title style • 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
Where are we headed? Click to edit Master title style • Relationship with Cardiac Rehab Circulation AHA SCIENTIFIC STATEMENT Cardio-Oncology Rehabilitation to Manage Cardiovascular Outcomes in Cancer Patients and Survivors A Scientific Statement From the American Heart Association Endorsed by the American Cancer Society Circulation. 2019;139:00–00. DOI: 10.1161/CIR.0000000000000679 @SHNcares
Where are we headed? Click to edit Master title style • 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. @SHNcares
Where are we headed? Click to edit Master title style Telemedicine Patient Alternative access to care, reduced travel costs SHN Program efficiencies, reduced wait times and no shows Clinicians Improved patient care and family/patient satisfaction @SHNcares
Click to edit Master title style Image courtesy of Duke Cancer Institute 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 @SHNcares
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