Participants
Individual and Focus Group Interviews. A total of 9 providers and 4 administrators participated in focus group or individual interviews. Nine clinicians participated in the provider focus group, representing medical oncology, radiology, hematology, cardiology, and cardio-oncology. Four cancer service line, cardiovascular service line, and/or college of medicine administrators (leadership and operations) participated in individual interviews.
Survey. Due to the use of partners’ listservs to disseminate the survey invitation, we do not have a denominator for the number of individuals who ultimately received an invitation to participate; as a result, we cannot calculate a response rate. Ultimately, 48 survey responses were received. After omitting 14 surveys due to incompleteness, 33 were analyzed. Participants included cardiologists (14, 42.4%), oncologists (12, 36.4%), and primary care or other (7, 21.2%). The majority of respondents practiced at an AMC (21, 63.6%); most were attending physicians (27, 93.1%) (Table 1).
Table 1
Demographics of study respondents.
Specialty | N | Percent |
---|
Cardiology | 14 | 42.4 |
Oncology | 12 | 36.4 |
Primary care or other | 7 | 21.2 |
Practice Location | | |
Academic Medical Center | 21 | 63.6 |
Community Teaching Hospital | 5 | 15.2 |
Community Non-Teaching Hospital | 2 | 6.1 |
Community Clinic/Practice | 4 | 12.1 |
Other | 1 | 3.0 |
Position | | |
Attending physician | 27 | 93.1 |
Clinical fellow | 2 | 6.9 |
Innovation
Cardio-Oncology services involve risk stratification, prevention, surveillance, early diagnosis, and treatment of cancer patients at risk of CVD from exposure to cardiotoxic cancer therapies and their underlying risk factors.(24) In the present study, we did not present participants with an operational definition of what services were included in “cardio-oncology services” in part because we sought to understand from participants what the term and field meant to them and how services could be envisioned by multidisciplinary stakeholders.
State of Implementation
After two initial champions—a cardiologist and medical oncologist—began collaborating on cardiology consults for oncology patients undergoing cardio-toxic therapies, the organization’s Cardiology division hired a specialized cardio-oncologist. At the time of interviews (April 2021), the cardio-oncologist had been practicing for five months and a full-time support staff had been hired; most cardio-oncology services were delivered to breast cancer patients due to two initial champions’ area of expertise and the physical location of CV imaging (e.g., echocardiogram) equipment.
CFIR Model
Below, we outline facilitators and barriers to implementing cardio-oncology services as described by participants. Sections reporting results from qualitative interviews reflect these CFIR domains: Innovation Characteristics, Inner Setting, and Process. Provider survey results reflect the CFIR domain of Individual Characteristics. See Fig. 2 for an illustration of overall findings.
Qualitative Interview Findings
Innovation Characteristics Domain
See Table 2 for Innovation Characteristics constructs, themes, and quotes.
Table 2
Innovation Characteristics’ Themes and Supporting Quotes
CFIR construct | Reflective quotes |
---|
Evidence Strength and Quality (Facilitator) | There is a goal, as people are surviving their malignancies, to make sure we're not killing them with heart disease subsequently. (Clinician administrator) It's very established that that many chemo agents have adverse metabolic effects, including cardiac. (Clinician administrator) |
Relative Advantage (Facilitator) | If it's anything that would help in the NCI comprehensive status… that would be a huge advantage. Everything we can do to get the next status. (Clinician administrator) In terms of just sort of [the hospital] marketing itself, broadly to the public…“The place to get your best care.” (Administrator) |
Cost (Barrier) | Space and Staff That's going to be our biggest issue is space. In regards to physical aspects of, you know, where do we grow the program, where's the best location? … We're still early and figuring that out. But I think really kind of our big thing will be … you know, who quote unquote owns it. (Administrator) Other costs: marketing, capital equipment, research infrastructure I would think that there will be minimal cost at this point, because the [imaging] machine is here. (Administrator) |
Complexity (Barrier) | Cross disciplinary nature of the service in a siloed organization It's really hard to do… I'll give you an example we do that right now with ophthalmology. So ophthalmology has a space in our emergency department. And there are specific tests that have to be done in that space. And it oftentimes requires them to bring someone from across the street. And so, it's, it takes more time when you have to get that person, make sure that they're freed up from taking care of a patient that's already in the clinic, walk across the street, do whatever it is you're doing.(Clinician Administrator) The need to gradually scale up the service So, let's say there's a multidisciplinary cardio-onc clinic, all day Monday. That's fine. What will the respective staff do on the rest of the week? And, that's where I think the financials get difficult. Because it then becomes, “Well no, this is a cardiology pharmacist, and they go back to cardiology. This is an oncology nurse who goes back to oncology.” … if it's a full-time thing then I think it's much easier to overcome some of the infrastructure challenges. (Clinician administrator) I think what's best for the patients is that the staff that lives on that unit be the staff that care for the patient … because they're comfortable with the unit. They know the flow of the unit. They know where things are. They know how to direct patients. (Administrator) |
Evidence Strength (facilitator). Most participants were aware that some cancer therapies had adverse cardiac effects and believed that the evidence base supported cardio-oncology service provision. As one physician administrator noted, “it’s very established that many chemo agents have adverse metabolic effects, including cardiac.”
Relative Advantage (facilitator). Participants viewed cardio-oncology services as advantageous for comprehensive patient care, enhancing patient satisfaction and experience. In addition, both provider and administrator participants referenced the benefit of integrated cardio-oncology services as helpful in maintaining or advancing the organization’s current National Cancer Institute (NCI) status. As a physician administrator noted: “anything that would help in the NCI comprehensive status…that would be a huge advantage.”
Cost (barrier). Participants widely acknowledged the costs associated with implementing cardio-oncology services, including capital (e.g., imaging equipment), research infrastructure (e.g., research support staff), and marketing to physicians and patients. The most common and critical costs discussed were space and personnel, or, as one administrator noted, “who quote unquote owns it.” However, with plans for an integrated, comprehensive cancer center within the coming years, some participants viewed space a short-term obstacle rather than a long-term barrier.
Complexity (barrier). Personnel was not only a cost associated with cardio-oncology service development, but also a chief complexity stemming from the cross-disciplinary nature of the service line in a financially, geographically, and operationally siloed organization. While
participants tended to agree that oncology was a sensible site for services (e.g., patient visits and imaging), they also generally agreed that cardiology clinicians and support staff should perform specialized services due to their knowledge and training (e.g., operating an echo machine). Nonetheless, one administrator noted that “visitor” staff risked being unfamiliar with the unit and its workflows, which may impact patient experience: “I think what’s best for patients is that staff that lives on that unit be the staff that care for the patient … they're comfortable with the unit. They know the flow of the unit. They know where things are. They know how to direct patients.” However, co-locating cardiology/cardio-oncology technicians and clinicians in the cancer space again was complex when the demand for full time effort was not yet present. Finally, parsing out billing of non-technical services (e.g., registration) that supported the multidisciplinary effort was also complex, given cardiology and oncology’s separate financial streams. As one physician administrator noted, “So, let's say there's a multidisciplinary cardio-onc clinic, all day Monday…What will the respective staff do on the rest of the week? And, that's where I think the financials get difficult.”
Inner Setting Domain
See Table 3 for Inner Setting constructs, themes, and quotes.
Table 3
Inner Setting Themes and Supporting Quotes
CFIR construct | Reflective quotes |
---|
Structural Characteristics (Barrier) | Separate leadership and financials for service lines It's working well now but there was a lot of people involved with a lot of high-powered positions just to put one echo tech and one machine over [in the breast cancer center].(Administrator) Trying to organize some of these co-located services, it's our system makes that very challenging. I think it's the way we're set up in terms of our financial structure … too siloed…“Who's paying for this support staff? … Can this support staff check-in for that service?” (Clinician administrator) ..At the end of the day we both have to produce for [leadership], right?(Administrator) Need for Standardization Unfortunately, I do not believe that it really is that standard, standing protocol to automatically consult cardiology oncology. (Clinician) On the imaging side of things, we tried to have a standardization, but we don't. (Clinician) Process for initiating new service/new physician is slow You know when we hire new faculty…we basically say you don’t expect you to do anything for the first couple of years…Which is such an old-fashioned model…If you actually grease the slicks ahead of time with people come in ready to run, you actually have a business model that works as well in a better manner. So, I do think it’s really an innovative approach, but it’s not something that we do in academics and university practices as much as people do in private practice. (Clinician) |
Culture (Facilitator and Barrier) | Different cultures of collaboration across disciplines [Cardio-oncology] is not just a referral-based practice that we’re used to. It is much more collaborative than just, “Hey, here’s a referral for this problem. Help me address this problem, and move on,” because these are ongoing continuums of care… that need to be managed collaboratively. (Clinician) |
Networks and Communication (Barrier and Facilitator) | Relationships Most of the time I'm just getting those ECHOs and following them up myself … in the past, that was always just me emailing or calling [Cardiologist] to get those patients seen… But sometimes that was difficult to coordinate.) (Clinician) My plan, is really push [Cardio-Oncologist] hard in regards to that relationship building. To make sure that he's got that trust. (Administrator) Electronic Health Record Integration Given that we're moving to Epic…I actually am hopeful that actually could facilitate….because it won’t be two separate systems. (Clinician administrator) |
Implementation Climate (Facilitator and Barrier) | Tension for change We need to get out of a primary gender-specific service area [breast cancer center] getting into a more gender-neutral area. (Administrator) As a new specialty, it's probably been around for about 10 years in some of the leading centers, and we're way behind. (Clinician) Relative Priority These are the types of things that I think are barriers from an organizational standpoint. It's a recognition that not only do we value it, but we're willing to commit to the resources necessary to build it and support it, even if we recognize that it won't …directly result in a financial reward from it, but recognizing that with better care delivery, these patients will have better outcomes. (Clinician) One of the challenges that we struggle with is that we're…not that good at sort of stepping back and saying really strategically: “Here's where we want to go, and here is not where we want to go.” It’s still department chair, center directors, individual faculty coming up with an idea and the proposal and taking it. (Clinician administrator) |
Readiness for Implementation (Facilitator and Barrier) | Leadership engagement [The challenge] has been the physician leadership as its evolving and understanding what their desired state is going to be. (Administrator) I think conceptually people are very, very interested in novel approaches to care delivery. But there is a certain commitment that needs to happen in helping providers provide structure and a construct around it. (Clinician) Available Resources There’s nothing that we can do for a provider before they get here. I’ve put together business proposals on the front-end, say, “Hey, listen, we’re hiring these five people on. This is what they are going to be doing. Can we get them set up with the support staff?” And, we will get a fraction of that. (Clinician) One of the biggest frustrations for us has always been identifying data points, manually pulling data points, …in terms of panel size, how many patients do we see, and what is our empanelment. So that way I can project for our next five attendings coming on…So that way we can staff appropriately. (Clinician) |
Structural characteristics (barrier). Separate leadership and financials for service lines. Cardiology and oncology are organizationally distinct services in their structure, financing, leadership, and personnel. As one administrator noted, some of the technical challenges of the siloed structure, “I think it's the way we're set up in terms of our financial structure … [it’s] too siloed…“Who's paying for this support staff? … Can this support staff check-in for that service?” As a result, comingled services such as cardio-oncology, require negotiation of differences in the two systems (e.g., billing, revenue and staffing) and buy-in from both sets of leadership who are independently accountable for financial viability and productivity.
Need for standardization. Physician participants discussed how cardio-oncology referrals must become more standardized and less dependent on the specific knowledge or relationships among providers. As one physician noted, “On the imaging side of things, we tried to have a standardization, but we don't.” A formal process was needed to identify, refer and communicate information about patients who could benefit from the service.
Slow process onboarding new providers and services. Participants described a stepwise process for onboarding new physicians that precluded operational support prior to their arrival. As a result, clinicians’ early tenure at the healthcare facility was often consumed with navigating operational barriers (e.g., securing support staff, phone numbers, etc.) at the expense of delivering direct patient care. As one physician commented, and others agreed:
You know when we hire new faculty…we basically say we don’t expect you to do anything for the first couple of years…Which is such an old-fashioned model…If you actually grease the slicks ahead of time with people come in ready to run, you actually have a business model that works as well in a better manner.
Such practices also extended to establishing new services. Consequently, no prior structure was established to facilitate cardio-oncology service delivery (e.g., referral pathways, mechanisms, tracking systems) prior to the cardio-oncologist’s arrival, leading to operational inefficiencies.
Culture (facilitator and barrier). Some participants noted that the culture of collaborative care varied across specialities, with clinicians managing chronic diseases (with their often-concomitant comorbidities) being more practiced in cross-disciplinary collaboration than those managing acute conditions. As one provider noted, cardio-oncology “is much more collaborative than just, ‘Hey, here’s a referral for this problem. Help me address this problem, and move on,’ because these are ongoing continuums of care… that need to be managed collaboratively.”
Networks and Communication (facilitator and barrier). At present, individual relationships were the basis for referrals. One provider noted, “most of the time I'm just getting those ECHOs (echocardiograms) and following them up myself.” Similarly, a cardiology administrator acknowledged that forging relationships and trust among providers was critical to facilitate referrals. Participants suggested that provider education and electronic health record (EHR) prompts could help standardize referrals, especially given the enterprise’s recent transition to a system-wide EHR.
Implementation Climate (facilitator and barrier). Tension for change. Cardio-oncology services were already being implemented at the time of the interviews, with the recent hiring of a cardio-oncologist. However, their scope was limited, including imagining within the breast cancer center and patient consults with the cardio-oncologist. Both physician and administrator participants were eager to move out of the breast cancer center to a more gender-neutral space. Further, physicians expressed tension for standardization of the organization’s cardio-oncology services given the relative maturity of the specialty elsewhere: “it's probably been around for about 10 years in some of the leading centers, and we're way behind.”
Relative Priority. Most participants viewed the development of cardio-oncology services as a priority, but to varying degrees. One leader noted, “we are in the business of putting out fires and [cardio-oncology] is not a fire”. While the comment was positive—cardio-oncology services did not present a threat or crisis—it reflected a retroactive approach to onboarding the service rather than the proactive strategic investment that was desired by clinical participants. As one administrator noted:
We are not that good at sort of stepping back and saying really strategically, “Here's where we want to go, and here is not where we want to go.” It’s still department chair, center directors, individual faculty coming up with an idea, and the proposal and taking it.
Readiness for Implementation (facilitator and barrier). Leadership engagement. Early leadership support was expressed through Cardiology’s hiring of a dedicated cardio-oncologist, however, providers spoke to the importance of leadership buy-in to strategically build the program. As one provider noted, “I think conceptually people are very, very interested in novel approaches to care delivery. But there is a certain commitment that needs to happen in helping providers provide structure and a construct around it.” Simultaneously, administration noted that a challenge to service integration included transitions in physician leaders “and understanding what their desired state is going to be,” given the importance of the clinical champion in shaping the program.
Available resources. Participants decried that resource allocation to support new services was slow. New providers were not offered operational support prior to arrival; as a result, there is a degree of “tripping through it” as new services are established. In addition, other resources—i.e., data to forecast needs and justify resource allocations—were difficult to obtain.
Process
See Table 4 for Process constructs, themes, and quotes.
Table 4
Process Themes and Supporting Quotes
CFIR construct | Reflective quotes |
---|
Planning | Financial Planning [If] the appropriate costs and the appropriate revenues can be allocated on the back-end and not have to be so parcelled out at the front-end—the patient-facing experience—then it should be able to work. You know, the patient should be able to come in, be roomed by a CST without it mattering whether the CST belongs to oncology versus cardiology. (Clinician administrator) Projecting Staffing Needs …A clinician seeing patients in the outpatient space…an Advanced Imaging Cardiographer that will have some time needed in the advanced imaging space; One of the things that we will have to just fundamentally understand and navigate is how much time is allocated to each one of those activities. (Clinician) Balancing Capacity and Demand One of the problems that we often have…we think that things are a good idea and we try to implement them and then then they either grow really, really quickly really fast, and we don't have the necessary resources, or we don't market them well enough. (Administrator) We actually have a tendency to oversell very quickly and then we're not able to deliver because we're at capacity. (Administrator) |
Engaging | Champion If it's up to me to always build the program, when there's a slip, a patient isn't satisfied because they were having trouble finding a location… that falls on us as individual providers way too often. It's our job to find the problem, solve the problem, and prevent it from happening again when the problem wasn't ours to begin with. So I think that if there is an interest from an organizational standpoint to build these services, there has to be a blueprint. (Clinician) Key Stakeholders: Clinicians and Staff Working across disciplines, to some extent, there's a big learning curve…you can't just assume people could wear multiple hats, you have to actually train them. (Clinician administrator) The blueprint on how to create a supportive service and integrating it in a multi-clinic, multi-specialty platform…is active participation in tumor boards, active participation in departmental meetings, and collectively just making sure that the program is visual…And coming up with in-clinic, physician workspace signage that speaks to referral patterns and referral process and where the service is located. (Administrator) Implementation Participants: Patients Every patient that we've encountered is so focused on the cancer diagnosis that…it's kind of been our job to really guide them to make sure that we're taking care of their whole body and particularly their heart…there's a lot of patient education that has to occur. (Administrator) |
Planning. Financial planning. Participants highlighted that when planning for co-mingled services, the organization’s siloed financial structure should remain invisible to the patient who “should be able to come in, be roomed by a CST [certified surgical technologist] without it mattering whether the CST belongs to oncology versus cardiology.” While financial stratification vexed other multidisciplinary programs, the organization’s multidisciplinary cancer clinic and hospital-based clinics with centralized costs were cited as potential examples.
Projecting staff needs. Related to financial planning, understanding and sufficiently allocating clinical and support staff effort was paramount to ensuring sufficient resources were allocated to the service.
Balancing capacity and demand. Similarly, balancing the allocation and capacity of cardio-oncology staff with the clinical demand for those services was difficult given their mutual dependency. Participants did not want to oversell the program beyond their capacity to deliver; however, to justify capacity-building investments (i.e., clinician and support roles), demand must be demonstrated.
Engaging. Champion. The recently hired cardio-oncologist served as the program’s logical Champion. However, provider participants cautioned that the Champion must have institutional support or risk failure. One physician contended that building new programs, “falls on us as
individual providers way too often… if there is an interest from an organizational standpoint to build these services, there has to be a blueprint.”
Key Stakeholders. Both administrators and physicians vocalized the importance of engaging and educating institutional stakeholders in cardio-oncology service development. Potential “referrers” (e.g., hematologists, medical oncologists, radiologists) need training on referral indicators and processes to establish appropriate referral patterns. Likewise, support staff should be cross-trained on patients’ needs and context in the multidisciplinary setting. As one participant noted, “you can't just assume people could wear multiple hats, you have to actually train them.”
Participants suggested various approaches to inform clinicians about new referral protocols, including Grand Rounds, organizational publications, meetings, signage, and participation in departmental meetings and boards.
Innovation Participants. Participants also noted that patients needed education about the benefit of cardio-oncology services, or the long-term effects of cardio-toxic drugs on their heart health. One administrator noted their patients are “so focused on the oncology cancer diagnosis that …it's kind of been our job to really guide them to make sure that we're taking care of their whole body, and particularly their heart”
Individual Characteristics Domain.
The knowledge and beliefs of individuals regarding the potential design and delivery of cardio-oncology services were captured through the provider survey. See Tables 5–9.
Table 5
Perception of acceptable risk of cardio-toxicity for patients when consenting for cancer therapy.
| Curative setting | Incurable setting (metastatic) |
---|
| All specialtiesa (N = 32) n (%) | Cardiology (N = 13) n (%) | Oncology (N = 12) n (%) | All specialties* (N = 32) n (%) | Cardiology (N = 13) n (%) | Oncology (N = 12) n (%) |
< 1% | 5 (15.6) | 2 (15.4) | 2 (16.7) | 1 (3.1) | 0 (0.0) | 0 (0.0) |
1–5% | 22 (68.8) | 10 (76.9) | 9 (75.0) | 14 (43.8) | 3 (23.1) | 9 (75.0)† |
5–10% | 4 (12.5) | 1 (7.7) | 0 (0.0) | 8 (25.0) | 5 (38.5) | 1 (8.3) |
10–15% | 1 (3.1) | 0 (0.0) | 1 (8.3) | 6 (18.8) | 4 (30.8) | 1 (8.3) |
> 15% | 0 (0.0) | 0 (0.0) | 0 (0.0) | 3 (9.4) | 1 (7.7) | 1 (8.3) |
*All specialties: cardiology, oncology, primary care and/or other (internal medicine /family practice) †p < 0.05 |
Knowledge and Beliefs. Perception of cardio-toxicity risk. Cardiologists and oncologists’ cardio-toxicity risk tolerance in a curative setting was similar, with most perceiving ≤ 5% risk of cardio-toxicity as acceptable (68.8% accepting 1–5% risk; 15.6% accepting < 1% risk) (Table 5). However, in an incurable setting, cardiologists accepted significantly higher risk of cardio-toxicity than oncologists with the majority (77%) accepting higher than 1–5% risk levels (p < 0.05).
Participants held similar opinions about cardio-toxicity risk from trastuzumab with over half (53.8% cardiologists, 58.3% oncologists) believing patients’ greatest risk was during cancer treatment (Table 6). However, perceptions of chemotherapy with anthracyclines differed. The majority of cardiologists (53.8%) believed the greatest risk was 1-year post-therapy, followed by active treatment (30.8%) while a plurality of oncologists believed the risk was greatest 1–5 years post-therapy (41.7%); a quarter (25%) believed the highest risk was over 5 years post-therapy.
Table 6
Perception on when patients are at the greatest risk of experiencing cardio-toxicity from targeted therapies.
Trastuzumab Therapy | All specialties* (N = 32) n (%) | Cardiology (N = 13) n (%) | Oncology (N = 12) n (%) |
---|
During cancer treatment (trastuzumab) | 19 (59.4) | 7 (53.8) | 7 (58.3) |
1 year post cancer therapy (short term risk) | 4 (12.5) | 1 (7.7) | 3 (25.0) |
1 to 5 years post cancer therapy | 8 (25.0) | 5 (38.5) | 1 (8.3) |
Greater than 5 years post cancer therapy (long term risk) | 1 (3.1) | 0 (0.0) | 1 (8.3) |
Chemotherapy (e.g. anthracyclines) | All specialties n (%) | Cardiology n (%) | Oncology n (%) |
During cancer treatment (chemotherapy) | 12 (37.5) | 4 (30.8) | 4 (33.3) |
1 year post cancer therapy (short term risk) | 9 (28.1) | 7 (53.8) | 0 (0.0) |
1 to 5 years post cancer therapy | 6 (18.8) | 1 (7.7) | 5 (41.7) |
Greater than 5 years post cancer therapy (long term risk) | 5 (15.6) | 1 (7.7) | 3 (25.0) |
*All specialties: cardiology, oncology, primary care and/or other (internal medicine /family practice) †p < 0.05 |
Opinions towards cardio-oncology services. A majority of both specialties also believed (66.7% cardiologists; 83.3% oncologists) that access to a cardio-oncology service will significantly improve prognosis for cancer patients, though a full third of cardiologists were unsure (Table 7).
Table 7
To what extent would access to a cardo-oncology service improve the prognosis of cancer patients?
Access to a cardio-oncology service will… | All* (N = 31) n (%) | Cardiology (N = 12) n (%) | Oncology (N = 12) n (%) |
---|
Significantly improve prognosis for cancer patients | 23 (74.2) | 8 (66.7) | 10 (83.3) |
Not change prognosis for cancer patients | 1 (3.2) | 0 (0.0) | 1 (8.3) |
Worsen prognosis for cancer patients | 0 (0.0) | 0 (0.0) | 0 (0.0) |
Unsure whether cardio-oncology service will change prognosis | 7 (22.6) | 4 (33.3) | 1 (8.3) |
*All specialties: cardiology, oncology, primary care and/or other (internal medicine /family practice) †p < 0.05 |
A majority of both cardiologists and oncologists felt it was very important to consider cardio-toxic side effects during and after cancer treatment with oncologists generally finding initial treatment (66.7%) and cardiologists finding active treatment (66.7%) as most important (Table 8). The majority of oncologists (58.3%) indicated that standard of care should include a cardiology/cardio-oncology assessment, while cardiologists’ responses were mixed: a third (33.3%) preferred cardiology/cardio-oncology consult as standard of care, a third preferred cardiac monitoring regardless of symptomology, and a third preferred cardiology intervention only when cardio-toxicity symptoms arose.
Table 8
Knowledge and Perceptions of Cardio-Oncology Services and Protocols
Importance of oncologists considering possible cardiac problems and cardio-toxic side effects when planning to initiate treatment for a cancer patient | All (N = 31) n(%) | Cardiology (N = 12) n(%) | Oncology (N = 12) n(%) |
---|
Very unimportant | 5 (16.1) | 3 (25.0) | 2 (16.7) |
Unimportant | 0 (0.0) | 0 (0.0) | 0 (0.0) |
Neither important nor unimportant | 0 (0.0) | 0 (0.0) | 0 (0.0) |
Important | 5 (16.1) | 2 (16.7) | 2 (16.7) |
Very important | 21 (67.7) | 7 (58.3) | 8 (66.7) |
Importance of oncologists considering possible cardiac problems and cardio-toxic side effects during active cancer treatment | All n (%) | Cardiology n (%) | Oncology n (%) |
Very unimportant | 4 (12.9) | 2 (16.7) | 2 (16.7) |
Unimportant | 0 (0.0) | 0 (0.0) | 0 (0.0) |
Neither important nor unimportant | 0 (0.0) | 0 (0.0) | 0 (0.0) |
Important | 7 (22.6) | 2 (16.7) | 3 (25.0) |
Very important | 20 (64.5) | 8 (66.7) | 7 (58.3) |
Importance of oncologists considering possible cardiac problems due to cardio-toxicity in cancer survivors† | All n (%) | Cardiology n (%) | Oncology n (%) |
Very unimportant | 4 (12.9) | 2 (16.7) | 2 (16.7) |
Unimportant | 0 (0.0) | 0 (0.0) | 0 (0.0) |
Neither important nor unimportant | 2 (6.5) | 2 (16.7) | 0 (0.0) |
Important | 7 (22.6) | 1 (8.3) | 4 (33.3) |
Very important | 18 (58.1) | 7 (58.3) | 6 (50.0) |
Extent to which a cardiologist/cardio-oncologist should be involved in care of patient with no underlying cardiac issues being started on a cancer therapy with potential cardio-toxic side effects | All n (%) | Cardiology n (%) | Oncology n (%) |
No need for Cardiology involvement during treatment | 2 (6.5) | 0 (0.0) | 1 (8.3) |
Standard of care should include Cardiology/cardio-Oncology assessment | 13 (41.9) | 4 (33.3) | 7 (58.3) |
Cardiology should provide ongoing monitoring for cardio-toxicity even if patient has no clinical symptoms of cardiac issues | 10 (32.3) | 4 (33.3) | 2 (16.7) |
Cardiology should be involved only when patient develops active signs and symptoms of cardio-toxicity | 6 (19.4) | 4 (33.3) | 2 (16.7) |
*All specialties: cardiology, oncology, primary care and/or other (internal medicine /family practice) †patients with no active cancer who were treated 2–5 years ago. ‡p < 0.05 |
Table 9
Perceptions of comfort with cardiovascular complications of cancer therapy
Cardiologists are knowledgeable about cardiovascular complications of cancer therapy
|
Cardiology (N = 11)
n (%)
|
Oncology
(N = 12)
n (%)
|
Strongly disagree
|
0 (0)
|
0 (0)
|
Disagree
|
0 (0)
|
4 (33.3)
|
Neither agree nor disagree
|
3 (27.3)
|
4 (33.3)
|
Agree
|
7 (63.6)
|
4 (33.3)
|
Strongly agree
|
1 (9.1)
|
0 (0)
|
Cardiologists are comfortable treating cardiovascular complications of cancer therapy.
|
Cardiology
(N = 10)
n (%)
|
Oncology
(n = 12)
n (%)
|
Strongly disagree
|
0 (0.0)
|
0 (0.0)
|
Disagree
|
0 (0.0)
|
2 (16.7)
|
Neither agree nor disagree
|
1 (10.0)
|
8 (66.7)
|
Agree
|
8 (80.0)
|
1 (8.3)
|
Strongly agree
|
1 (10.0)
|
1 (8.3)
|
Oncologists are knowledgeable about cardiovascular complications of cancer therapy
|
Cardiology
n (%)
|
Oncology
n (%)
|
Strongly disagree
|
0 (0.0)
|
1 (16.7)
|
Disagree
|
1 (10.0)
|
4 (33.3)
|
Neither agree nor disagree
|
3 (30.0)
|
0 (0.0)
|
Agree
|
6 (60.0)
|
6 (50.0)
|
Strongly agree
|
0 (0.0)
|
0 (0.0)
|
Oncologists are comfortable with the management of cardiovascular complication of cancer therapy
|
Cardiology
n (%)
|
Oncology
n (%)
|
Strongly disagree
|
2 (20.0)
|
4 (33.3)
|
Disagree
|
5 (50.0)
|
2 (16.7)
|
Neither agree nor disagree
|
2 (20.0)
|
1 (8.3)
|
Agree
|
1 (10.0)
|
5 (41.7)
|
Strongly agree
|
0 (0.0)
|
0 (0.0)
|
*p < 0.05
|
Comfort with cardiovascular implications of cancer therapies. A majority of cardiologists reported being knowledgeable about cardiovascular (CV) complications of cancer therapy (63.6% agreed; 9.1% strongly agreed) and were comfortable with managing them (80% agreed; 10% strongly agreed). In contrast, only a third of oncologists thought cardiologists were knowledgeable about CV complications of cancer therapy (33.3% agreed; 0% strongly agreed)
and fewer reported that cardiologists were comfortable managing them (8.3% agreed; 8.3% strongly agreed 8.3%). When asked about their own knowledge and comfort with CV complications of cancer therapies, half of oncologists (50%) agreed they were knowledgeable about cardiovascular complications of cancer therapy, though fewer (41.7%) were comfortable with managing them; 0% strongly agreed with both statements. In contrast, over half of cardiologists (60.0%) agreed that oncologists were knowledgeable about cardiovascular
complications of cancer therapy, though the majority (70%) disagreed that oncologists were comfortable with managing them; 0% strongly agreed with both statements.