Cardio -o ncology Fellowship Training What Does the Future Hold? Joseph R. Carver, MD, FACC Bernard Fishman Professor of Clinical Medicine Abramson Cancer Center 30 September 2016
Disclosure I am a cardio-oncologist in the United States ¡ ¡
Cardio-oncology: A Human “ Tsunami ” More Cancer R x Options Better Survival More “Double- Hits” Increasing potential for cardiac toxicity
Cardio-oncology: A Human “ Tsunami ” More Cancer R x Options Better Survival More “Double- Hits” Increasing potential for cardiac toxicity Our goal is to improve care and outcomes
What ’ s The Problem ?
Cardio-oncology Landscape In a 2015 nationwide survey of 444 adult and pediatric cardiology division chiefs and cardiovascular fellowship program training directors we recognized a growing trend toward establishment of cardio- oncology services and a gap in training and perceived competency Barac A et al. JACC 2015;65: 2739
Cardio-oncology Landscape II • 27% reported having no established, specialized cardio-oncology program • 39% did not feel confident handling cardiac care specific to patients with cancer • 65% thought access to consultants with specialized training in cardio- oncology would provide an advantage in cancer patient care Barac A et al. JACC 2015;65: 2739
Cardio-oncology Landscape III • 43% of programs offered no formal training in cardio-oncology • 25% expressed need for training, curriculum, educational materials and dedicated meetings Barac A et al. JACC 2015;65: 2739
What ’ s The Solution?
Cardio-oncology: A Human “ Tsunami ” More Cancer R x Options Better Survival More “Double- Hits” Increasing potential for cardiac toxicity Our goal is to improve outcomes TRAINING & EDUCATION
What I Am Not Talking About Today • Definitions • Numbers • Specifics of core competencies • Level I, II, III training, goals and curriculum ¡
How Do We Get There?
What Can We Learn From History? Heart Failure Training: A Call for an Integrative Patient-Focused Approach to an Emerging Cardiology Subspecialty Marvin A. Konstam for the Executive Council of the HFSA J of Cardiac Failure 2004;10 (5): 366
“ Heart failure [CANCER] is a growing epidemic in the United States, owing to the aging of our population and the increasing survival of patients presenting with large myocardial infarction [MALIGNANCY] … Over the past decade, we have seen an explosion of new treatment options for patients with heart failure [CANCER], with documented benefit on clinical outcome …
Numerous new approaches are being explored and are likely to markedly increase the complexity of optimal care during the coming decade … The subspecialty of heart failure [CARDIO- ONCOLOGY] should focus on the patient and the disease, incorporating a deep and broad understanding of all available diagnostic and treatment modalities …
The expanding patient population, coupled with rapid growth in information and treatment options demands the recognition of heart failure [CARDIO- ONCOLOGY] as an essential and well-defined sub- specialty of cardiology. A highly specialized clinician will be needed to master the care of the heart failure patient [CANCER PATIENT WITH CARDIAC COMORBIDITY].
The U.S. Heart Failure Experience 1990s Cardiologists Focused on Heart Failure 2001 HFSA Established 2004 HFSA Training: Call For Subspecialty 2008 ¡ ABIM ¡ Approves ¡ Subspecialty ¡
The U.S. C ardio-Oncology Experience 1990s 1990s Heart Failure Cardiologists Cardiologists Focused on Cancer 2005-2006 Cardiology- Oncology 2001 Partnership, ICOS HFSA CCON (2111) Established 2004 2014-15 HFSA Training: ACC C-O Working Group Call For Approves C-O Council Subspecialty 20?? 2008 ¡ ABIM Approves ABIM ¡ Approves ¡ Subspecialty Subspecialty ¡ of C-O
The U.S. C ardio-Oncology Experience 1990s 1990s Heart Failure Cardiologists Cardiologists Focused on Cancer 2005-2006 Cardiology- Oncology 2001 Partnership, ICOS HFSA CCON (2111) Established 2004 2014-15 HFSA Training: ACC C-O Working Group Call For Approves C-O Council Subspecialty Crit itical ical Steps eps: : 20?? 2008 ¡ ABIM Approves ABIM ¡ Tact actics ics & Strategy Approves ¡ Subspecialty Subspecialty ¡ of C-O
How They Did It: Tactics & Strategies • HFSA advocacy • Critical partnership with ACC • Debated and defined core competencies • Established criteria and began training program s
How They Did It: Tactics & Strategies • Developed educational programs • Grew a dedicated journal & annual meeting • Metrics that they improved care & outcomes • ACGME/ABMS recognition • Perseverance, self-assessment, remodeling
Basic Principles • Build on basic fellowship skills with subsequent dedicated “ experience ” • Multiple levels of initial and ongoing training • Metrics (e.g., COCAT ’ s 6 competencies & proficiencies) • Patients to know that when referred to a cardio- oncologist that the specialist has been rigorously trained and is proficient in the field * medical knowledge/pt care and procedure skills/practice based learning and improvement/systems based practice/interpersonal and communication skills/professionalism
Roadmap and Detours • Short Term • The three “ Fs ” (faculty, facility, funding) • The two “ Cs ” (competencies, curriculum) • Multiple “ Ns ” ¡
• “ This is general cardiology ” • “ This is Advanced Heart Failure and Transplant ” • “ All the arrhythmias and QT prolongation belong to EP ” • “ There are already too many cardiology subspecialties ”
Roadmap and Detours • Long Term • Metrics and program standardization • The three “ Rs ” (COCATS ACGME ABIM) • Work force training and access • Disease management strategies for non- cardio-oncologists to use • Systems for referral • Oncologist to cardio-oncologist • General Cardiologist to cardio-oncologist • Primary care to cardio-oncologist ¡
How WE are Doing It: Tactics & Strategies • HFSA advocacy CCON & ICOS ADVOCACY
How WE are Doing It: Tactics & Strategies • HFSA advocacy CCON & ICOS ADVOCACY • Partnered with ACC ACC ASCO and AHA
How WE are Doing It: Tactics & Strategies • HFSA advocacy CCON & ICOS ADVOCACY • Partnered with ACC ACC ASCO and AHA • Debated and defined core competencies ONGOING
How WE are Doing It: Tactics & Strategies • HFSA advocacy CCON & ICOS ADVOCACY • Partnered with ACC ACC ASCO and AHA • Debated and defined core competencies ONGOING • Established criteria for training programs ONGOING
How WE are Doing It: Tactics & Strategies • Educational programs WE ARE HERE
How WE are Doing It: Tactics & Strategies • Educational programs WE ARE HERE • Dedicated journal http:// cardiooncologyjournal.biomedcentral.com
How WE are Doing It: Tactics & Strategies • Educational programs WE ARE HERE • Dedicated journal CARDIO-ONCOLOGY JOURNAL • ACGME/ABMS recognition EARLY DIALOGUE WITH COCATS 5 LEADERSHIP
How WE are Doing It: Tactics & Strategies • Educational programs WE ARE HERE • Dedicated journal CARDIO-ONCOLOGY JOURNAL • ACGME/ABMS recognition EARLY DIALOGUE WITH COCATS 5 LEADERSHIP • Perseverance, self-assessment, remodeling THE CORE OF OUR COMPETENCIES
Existing Non-accredited Fellowships • Dana Farber • London • MD Anderson • MSKCC • Ottawa • Penn • Rush • Tampa • Vanderbilt • ??
Back To The Future (Modified from Konstam 2008) “ In health care, as in industry, demand should define change. Based on the growing patient population and the growing complexity of diagnostic and treatment options, the time has come for establishing clear criteria for cardio oncology training; for codifying cardio onoclogy as a patient-focused subspecialty of cardiology and oncology; and for encouraging cardiology and oncology trainees in this direction. ”
Back To The Future “ In health care, as in industry, demand should define change. Based on the growing patient population and the growing complexity of diagnostic and treatment options, the time has come for establishing clear criteria for cardio oncology training; for codifying cardio onoclogy as a patient-focused subspecialty of cardiology and oncology; and for encouraging Cardiology and oncology trainees in this direction. ” The future is now, it is time for world-wide collaboration for us to continue and complete the steps toward achieving these goals
The Future The future is now, it is time for world-wide Collaboration and for us to continue and complete the steps toward achieving these goals If you are interested in being part of a working task group-give me your name and contact info after this talk
The Cardio-oncologist After Training
Take Home Message • Without training and education, our goals of improving care and patient access will not be achieved • Without formal and official recognition of cardio-oncology by the “ governing boards ” there will be no formal training/fellowship • There is a workforce gap and we intend to fill it
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