How To Incorporate Cardio-Oncology As A Training Emphasis in General Cardiology Fellowship - Article

Read the abstract here.

How to cite this blog post: Brown, S. How To Incorporate Cardio-Oncology As A Training Emphasis in General Cardiology Fellowship.  http://www.cardioonctrain.com/blog; Accessed [Month, Year]. A toolkit for implementing concepts in this article is available here.  Please also read the Companion article tilted “How to Design A Preventive Cardio-Oncology Training Emphasis” available here.

View Cardio-Oncology & Preventive Cardio-Oncology Training Emphasis Toolkit Series 

View Cardio-Oncology & Preventive Cardio-Oncology Training Emphasis Article Series We all know that Cardio-Oncology is a burgeoning field, with many Cardio-Oncology programs around North America. Yet, most institutions do not have formal training in Cardio-Oncology, and numerous fellows are finishing fellowship with interest in Cardio-Oncology. Some of us have had this interest for up to 10 years (like I have), or some have recently gained this interest in being Cardio-Oncologists. How do we actually prepare to go and practice Cardio-Oncology safely and successfully, if most of our institutions do not have formal Cardio-Oncology fellowship training. Here is one model that could be considered.  How about incorporating Cardio-Oncology as a training emphasis in General Cardiology training programs? Here is a synopsis of how I achieved that goal.  MAJOR STEPS First, I turned to the Training Goals and Venues proposed by the International Cardio-Oncology Society (ICOS) (Table 1 in reference 1 below).  Second, I looked at what was available to me at my own institution, Mayo Clinic in Rochester, MN. What was available in Cardio-Oncology among the outpatient, inpatient, and consult services? What was available for research relevant to Cardio-Oncology? Third, I determined how I could practically apply the essential components of the Training Goals and Venues in the setting of my particular location.  Ultimately, I created what a sample week could look like, with a focus on Cardio-Oncology and Amyloid Clinics.  In designing this Training Emphasis, I focused on several key points.  PATIENT CARE I needed to be sure to achieve competency while seeing at least 100 unique patients (reference 1 below). I was able to achieve, monitor, and quantify that via Outpatient Clinics and Inpatient Consults during fellowship. I made sure that even if I would see several patients in their own return visits, I would count only my initial visit with each unique patient. I did not also count the myriad of patients I had previously seen on primary Oncology and Hematology inpatient services during Internal Medicine Residency Training.  Notably, I ensured that I would see patients with a variety of needs, among a variety of cancers, and at various stages of survivorship. These stages included: at diagnosis prior to therapy initiation (#SurvivorAtDiagnosis, #Day1Survivorship), during therapy before and after any evidence of cardiovascular toxicity, and following the completion of therapy with or without any evidence of cardiovascular toxicity.  Of importance, I helped coordinate our understanding and plan of care for the patients as a Cardiology-Oncology team, by communicating via phone, email, and in-person with the primary Oncologist, Cardiovascular Radiologists, and other subspecialty Cardiologists relevant to the patients’ care such as Pericardial Disease and Pericardiocentesis specialists.  EDUCATION Complementary to direct patient care, education was pursued in additional ways.  I actively participated in-person in the American College of Cardiology Course “Advancing Cardiovascular Care of the Oncology Patient” in Washington, DC in 2018 and 2019.  I also availed myself of Hematology & Oncology Core Curricula and Conferences, Hematology & Oncology Grand Rounds, Tumor Boards, and Cross-disciplinary Survivorship Group Meetings, as well as viewing any prior Cardio-Oncology Grand Rounds presentations (at least one regarding chemotherapy-induced cardiotoxicity and at least one regarding radiation-induced cardiotoxicity) at Mayo Clinic.  Of note, I presented a poster at the 2019 American College of Cardiology Course “Advancing Cardiovascular Care of the Oncology Patient” in Washington, DC. The poster was appropriately in the novel category “Training in Cardio-Oncology”.  During the poster session I described the basics of this blog post to help others get a sense of how I incorporated cardiology as a training emphasis in general cardiology fellowship, and how they may think about doing this too. One poster session attendee asked me curiously and honestly about the value (to us in Cardio-Oncology) of Hematology & Oncology Core Curricula. His thought was that the main take away from Hematology & Oncology Core Curricula would be the details of the cancer care plan from a Hematology/Oncology standpoint. I realized that that question would give even more value to posting this blog online to help us together determine value. As Cardio-Oncologists (or Cardiologists), is there value in learning the cancer care plan from a Hematology/Oncology perspective? Indeed, I would argue there is! It is only by understanding the patient’s cancer care plan from a Hematology/Oncology perspective that we can have a good overall sense of the sort, width, and breadth of cardiovascular toxicities for which patients are at risk throughout their cancer care plan and beyond. If we can get a grasp of patients’ Hematology/Oncology care plan, then we can reasonably counsel the patient, determine surveillance, and provide cardioprotective management. LEADERSHIP & TRAINING OTHERS Education in Cardio-Oncology should not be limited to only educating ourselves. We should take on the mantle of educating others as well. True to this philosophy, I helped inaugurate the Training in Cardio-Oncology Working Group for the American College of Cardiology Cardio-Oncology Section in January 2019. The Working Group is composed of leaders in Cardio-Oncology, with many members being Cardio-Oncology Fellowship Directors or Fellows who are currently training in Cardio-Oncology in formal fellowship programs or by incorporating Cardio-Oncology as a General Cardiology fellowship training emphasis.  That’s on a national level. What about also taking Education in Cardio-Oncology back to the local level? This can be done in local Cardiovascular Grand Rounds and Cardiovascular Imaging Grand Rounds, and other venues as well, such as Cardio-Hematology conferences! I had the opportunity to provide highly interactive and comprehensive presentations on The Role of Multimodality Imaging in 1) Ischemic Manifestations of Chemotherapy-Induced Cardiovascular Toxicities, and 2) Radiation-Induced Cardiovascular Toxicities, at Cardiovascular Imaging Grand Rounds. We discussed how Echocardiography, CT, MRI, SPECT, Coronary angiography, and other Imaging modalities can be informative in evaluating cardiovascular toxicities from cancer therapies such as chemotherapy, radiation, Immunotherapy, and so on. Collaborations were forged with colleagues in subspecialty areas across Cardiology and Cardiovascular Surgery to provide these teaching sessions with maximum impact. In the process, a myriad of clinical presentations, clinical decision-making, and imaging tips and pearls were reviewed.  I also presented on Translation and Implementation of Precision Cardiovascular Medicine, with a partial focus on Cardio-Oncology, at Cardiovascular Grand Rounds. This presentation focused more on research efforts - past, present, and future! A macroscopic view of precision medicine in Cardio-Oncology was proposed, to integrate findings from Genomics, Transcriptomics, Proteomics, Epigenomics/Methylomics, miRNA Regulomics, Phemonics, Computational Avatars, and so on! A highlight was to be able to present some of this work at the National Institutes of Health! 

RESEARCH

Of course, the work presented was also published as novel landmark manuscripts synthesizing Precision Cardio-Oncology information in high impact journals, and ensuring scholarship as a tangible outcome of the experiences in research, patient care, and education (references 2 and 3 below. I also published a Letter to the Editor (reference 4 below) with formative thoughts on Training itself, as well as a poem related to Cardio-Oncology (reference 5 below)! SOCIAL MEDIA Along with accomplishing all of this, my goal was and is to be an ambassador for Cardio-Oncology not only on a local, regional, and national scale, but internationally as well! From early on, I partnered with the American College of Cardiology/Mayo Clinic FITs-on-the-go video blog on YouTube (www.youtube.com/fitsonthego). In the video blogs, I personally interviewed Dr. Ana Barac (https://youtu.be/2qLeA5fPaWo) and Dr. Joe Carver (https://youtu.be/bw2dVYJIbyk) to give everyone around the world a chance to hear from them about emerging trends and future directions in Cardio-Oncology, in terms of patient care, research, and education! It didn’t stop there! YouTube also became host to my 3-minute poster presentation describing the essence of this outline at the 2019 American College of Cardiology Course “Advancing Cardiovascular Care of the Oncology Patient” in Washington, DC (https://youtu.be/7tgejhwi65M)! I must give credit to Dr. Giselle Suero Abreu for being an incredible cameraperson, anchor, friend, and dynamite physician scientist charting her course in Cardio-Oncology and Preventive Cardio-Oncology currently in residency (after her PhD) and in her future fellowship! Dr. Suero Abreu and I emblazened #CardioOnc on Twitter at the 2019 American College of Cardiology Course “Advancing Cardiovascular Care of the Oncology Patient” in Washington, DC, a tradition I carried on from the 2018 course as well! So much so that I was the number one tweeter of #CardioOnc that 2019 weekend and the number two Mention as a runner-up to @ACCInTouch, who of course we mention in everything! The American College of Cardiology (ACC) has been such an incredible supporter, pioneer, and proponent of Cardio-Oncology for several years now and decades to come!  FUTURE Now for the future...We have achieved so much in the past and present, and there is limitless potential for the future! For example, Mayo Clinic in Rochester, MN is planning a formal Cardio-Oncology fellowship. I have had this on my #heart since I was an MD/PhD student (pun intended), as you can imagine. I even wrote a Letter to the Editor about it! However, it will be some time yet before that is ready at Mayo Clinic and a myriad of other places, in addition to a handful of already existing programs (ref my paper and ACC website)! There are so many of us in Cardio-Oncology, but there are limited opportunities for formal Cardio-Oncology training. Consequently, until additional formal Cardio-Oncology fellowship programs are available, the outline I have provided here may be a useful model. This potentially replicable model could be practically applied in any local institution with a strong Cardio-Oncology clinical and research program. This of course would be optimal at institutions with a tradition of excellent education in other Cardiology subspecialty fields.  CONTACT We have covered a lot together in this outline. Perhaps you have a lot to say about this topic too, or perhaps you would like to become engaged in someway. Feel free to contact me at anytime. I would be happy to have these discussions with you or your fellows or program directors. I’ll be more than happy to come and talk with your fellows or with your program about how to incorporate Cardio-Oncology as a General Cardiology fellowship training emphasis.  Of course, when we say “Cardio-Oncology”, we really in some sense mean “Cardio-Hem-Oncology” (#CardioHemOnc)! #PrevCardioOnc #SurvivorAtDiagnosis (c/o @GiselleSA_MDPhD) #Day1Survivorship (c/o a survivor on Twitter) #TogetherWeCan (c/o Twitter!) @drbrowncares @PrevCardioOnc drbrowncares@gmail.com

References

1. Lenihan et al. Cardio-Oncology Training: …. J Card Fail, 2016;22(6):465-71.

2. Brown S, Sandhu N, Herrmann J. Systems biology approaches to adverse drug effects: the example of cardio-oncology. Nat Rev Clin Oncol, 2015; 12:718–731.

3. Brown S, Nhola L, Herrmann J. Cardiovascular Toxicities of Small Molecule TKIs: An Opportunity for Systems-Based Approaches. Clin Pharm & Ther, 2017; 101(1):65-80.

4. Brown S, Sandhu N. Proposing and meeting the need for interdisciplinary cardio-oncology subspecialty training. J Card Fail, 2016;22(11):934-935.

5. Brown S. Somebody Tell Me. The Oncologist, 2019;23:1.