Abstract
Background:
cardiovascular disease and cancer are two leading causes of mortality worldwide. Advances in cancer therapy have improved survival but increased the risk of treatment-related cardiotoxicity. In response, the National Center for Cancer Care and Research (NCCCR) and Heart Hospital (HH) established a dedicated strategic plan for the development of cardio-oncology service in 2015 to address the prevention, early detection, and management of cardiotoxicity through a multidisciplinary approach in Qatar.
Objectives:
The objective of this study was to describe the development and implementation of the cardio-oncology service at NCCCR and HH.
Methods:
A retrospective descriptive study with a mixed-methods approach was conducted. Quantitative data were extracted from the electronic health records for all patients seen in the Cardio-Oncology Clinic during two key phases of service delivery: HH (January 2019 to August 2020) and NCCCR (September 2020 to July 2023). Descriptive qualitative data were obtained from informal staff feedback and clinical observations.
Results:
Between 2019 and 2023, 4197 patients attended the cardio-oncology clinics (1524 at HH and 2673 at NCCCR), with 77%–82% being noncitizens. Breast cancer was the most common diagnosis (48%), reflecting its high prevalence and cardiotoxic treatment profile. A total of 5289 echocardiographic studies were performed. In 2023, 494 cardiovascular events were recorded, but therapy was held in three cases (0.06%) due to significant cardiotoxicity. Service expansion included the introduction of a clinical nurse specialist-led clinic and a dedicated echocardiography unit.
Conclusion:
cardio-oncology program demonstrates that early, structured cardiac surveillance within a multidisciplinary framework can effectively minimize therapy interruptions and optimize cancer patient outcomes.
Keywords: Cancer survivorship, cardio-oncology, cardiotoxicity, multidisciplinary care, precision medicine, Qatar
INTRODUCTION
Cardiovascular disease (CVD) and cancer are the two leading causes of death worldwide.[1] In the United States alone, heart disease and cancer are the first and second leading causes of death, respectively.[2] Advances in cancer treatment have increased life expectancy. However, the side effects and toxicities of cancer treatment have become a cause of concern for both cancer patients and cancer survivors.[3,4]
CVDs are one of the most observed side effects of cancer treatment, and there is an increasing recognition that they might lead to premature morbidity and death among cancer patients and cancer survivors. Hence, early detection of initial cardiac injury or dysfunction due to cancer treatment-related cardiotoxicity is crucial since it may assist in early therapeutic interventions to reduce the risk of CVDs.[5] Cardiotoxicity incidence in cancer patients depends on different variables, including the type of chemotherapy, medication dosage, cumulative dosage, schedule of administration, route of administration, and combination with other cardiotoxic medicines and/or association with radiotherapy.[6]
In the United States, the expected number of cancer survivors by 2029 is 21.7 million. In 2024, approximately 19 million cancer survivors were expected, and this increase is due to population increase, aging, and advancements in early diagnosis and anticancer therapy.[6,7] In cancer survivors, it has been noticed that the subsequent cause of morbidity and mortality is cardiotoxicity.[4] The advancement of cancer treatment led to an increase in the risk of CVD, which is the leading cause for cancer treatment interruption and mortality among cancer survivors.[8] Consequently, the complexity of treating cancer patients with cardiotoxicities led to the development of cardio-oncology services.[8,9] Worldwide, cardio-oncology service is considered a new cardiac specialty and consists of a multidisciplinary team that focuses on the prevention and treatment of cardiotoxicity in cancer patients and survivors.[6,9] Herein, this article aims to describe the development and implementation of the joint cardio-oncology service at the National Center for Cancer Care and Research (NCCCR) and Heart Hospital (HH) in Qatar. Furthermore, it seeks to retrospectively evaluate the clinic’s operational performance, patient demographics, and clinical outcomes over the past 5 years. NCCCR serves as the premier cancer center for the state of Qatar, providing multidisciplinary care to cancer patients.
METHODS
Study design
This article represented a retrospective descriptive design to review the development and implementation of cardio-oncology service at two specialized institutions in Qatar: NCCCR and HH. A mixed-methods approach was used by combining quantitative data analysis and qualitative insights to evaluate the service utilization and workflow evolution overtime. NCCCR serves as the country’s tertiary cancer center, providing multidisciplinary care to cancer patients across Qatar.
Study setting and time frame
The study was conducted at two sites: HH, from which the data were collected from January 2019 to August 2020, and NCCCR, from which the data were collected from September 2020 to July 2023. The time frames reflect the key phases of the cardio-oncology service development and implementation at each facility. The NCCCR is an advanced and well-developed cancer center in the region. It is the only center that provides cancer service in the country, including a wide variety of cancer therapies, and serves all cancer patients of different ethnicities and nationalities who reside and work in the country, as well as those who come from other countries seeking a second opinion.
Patient population
Patients followed in the cardio-oncology service at NCCCR who were identified as high risk based on cancer treatment type (e.g., anthracyclines and human epidermal growth factor receptor 2 [HER2]-targeted therapies), pre-existing cardiovascular risk factors, and/or the presence of clinical symptoms requiring more frequent cardiac evaluation.
Data sources and collection
The quantitative data were retrieved from the electronic health records for all patients seen in the Cardio-Oncology Clinic during the defined periods. All data were anonymized prior to analysis. The variables that were collected included the total number of new and follow-up visits, walk-in consultations, referral resources, types and frequency of echocardiographic studies performed, primary cancer diagnoses, and cardiovascular events. The qualitative information related to the service’s development and implementation challenges was gathered from internal service development reports, minutes of multidisciplinary team meetings, and observational notes from clinical practice and administrative meetings. This qualitative component aimed to explore the team’s roles, workflow integration, and operational barriers during the establishment of the cardio-oncology service.
Echocardiography service
Baseline echocardiography measurement included left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) prior to initiation of cardiotoxic cancer therapy. The follow-up assessments were scheduled for 3 months after initiation of treatment, 6 months during therapy, and posttreatment. Cancer therapy-related cardiac dysfunction is defined as a decline in LVEF by 10% or to a value below 50%.[10,11] This assessment protocol followed the recognized international guidelines including the British Society and American Society of Echocardiography recommendation for the evaluation of left ventricular systolic and diastolic function.[12] In accordance with the 2022 European Society of Cardio-oncology (ESC) guidelines, the NCCCR service implemented standardized risk stratification and surveillance criteria that include baseline and periodic echocardiographic evaluations based on patient risk category and treatment protocol. Local adaptations included flexible imaging intervals determined by patient risk level and imaging resource availability, while ensuring that the core ESC principles of early detection and multidisciplinary decision-making were maintained and workflow within the local healthcare system was optimized.[12,13] The echocardiography findings were reviewed by cardio-oncology physicians to guide individualized management plans and optimize cardiac health with cancer treatment continuation. In patients experiencing mild left ventricular dysfunction, a follow-up echocardiography was repeated after 1 month, and if cardiac function improved, treatment would be continued with a repeated evaluation by an echocardiography every two chemotherapy cycles.
Data analysis
Quantitative data were analyzed using descriptive statistics, including frequencies and percentages, to summarize the clinical activity and patient characteristics. No inferential statistical analysis was applied due to the descriptive nature of the article. Qualitative data were thematically analyzed to identify key milestones, role definitions, and barriers encountered in service delivery. Findings from both data types were integrated to provide a comprehensive overview of service implementation and functionality.
RESULTS
Quantitative data
Patient demographics and clinic activity
Between January 2019 and August 2020 (i.e. 20 months), a total of 1524 patients were seen in the Cardio-Oncology Clinic at HH. Of these, 1131 (74.2%) patients were follow-up cases and 393 (25.7%) patients were registered as new clinic cases. All referrals were from the oncology, hematology, and surgical teams at NCCCR. Among the total cases, 931 (82.3%) patients were noncitizens, while 200 (17.7%) patients were citizens. Out of the 393 new cases, 302 (76.8%) patients were noncitizens, and 91 (23.2%) patients were citizens.
During the 35-month period at NCCCR (September 2020 to July 2023), a total of 2673 patients attended the Cardio-Oncology Clinic at NCCCR: 746 patients were new cases, and 1927 patients were follow-up cases. Of these 2673 patients, 2061 (77.1%) patients were noncitizens, and 612 (22.9%) patients were citizens, which is reflecting the improved continuity of care and integration in the cancer treatment pathway. The summary of follow-up cases, new cases, and walk-in cases is given in Figure 1. The annual number of new cases demonstrated an initial increase from 81 (3%) cases in 2020 to 241 (9%) cases in 2021, followed by a slight rise to 245 (9.1%) cases in 2022 and to 179 (6.6%) cases till July 2023.
Figure 1.
Total number of follow-up cases and new cases in National Center for Cancer Care and Research. FU: Follow-up, No: Number, pt.: Patients
Figure 2 depicts the pattern of the walk-in cases, which remained stable at 35 (1.3%) cases in the years of 2020 and 2021, before declining to 22 (0.8%) cases in 2022, and 19 (0.7%) cases by July 2023. In contrast, the follow-up cases increased substantially from 152 (5.7%) cases in 2020 to 741 (27.7%) cases in 2021 and then decreased to 680 (25.4%) cases in 2022 and 354 (13.2%) cases in 2023. Walk-in consultations remained low with a decreasing trend, indicating a structured and proper service utilization [Figure 2]. Between 2019 and 2023, cardio-oncology service demonstrated significant growth in the number of patients being referred to and seen within 2 weeks of referral, reflecting improvement in service efficiency. The majority of cases involved breast cancer patients receiving anthracycline or anti-HER2-targeted therapy. This predominance is due to the well-established breast cancer service in the region and the recognized cardiotoxicity associated with breast cancer therapies. Furthermore, the first cardiac risk assessment trial in the region was initiated within the breast specialty, contributing to higher referral and early case detection rates.
Figure 2.
Total number of new cases, follow-up, and walk-in cases at National Center for Cancer Care and Research
The distribution of the cases by specialty is illustrated in Figure 3. Breast cancer patients accounted for the largest proportion, representing 48% of all clinic cases.
Figure 3.
Number of cases per specialty. Ca: Cancer
Echocardiographic assessment and cardiac events
From September 2020 to July 2023, a total of 5289 patients performed a transthoracic echocardiographic study, all of them (100%) had their LVEF measured, while the GLS was reported when feasible. Of the total patients, 1054 (19.9%) were citizens, and 4235 (80.1%) patients were noncitizens. The walk-in patients accounted for 419 (7.9%) of the total cases. Figure 4 presents the distribution of new cases by cancer type and specialty for the year of 2023.
Figure 4.
Total number of cardio-oncology new cases with cancer types over the year of 2023. GI: Gastrointestinal
In 2023, 294 cardiovascular events were recorded [Figure 5]. The most frequent events were arrhythmias (n = 95) and heart failure (n = 93), followed by CVD manifestations (n = 65). Less frequent events included pericardial effusion (n = 12), QT prolongation (n = 11), valvular disease (n = 9), and new-onset hypertension (n = 6). In addition, anticoagulation initiation was recorded in three cases. Cardiac risk stratifications were completed for 404 patients, and treatment was withheld in only three cases due to significant cardiotoxicity risk. Table 1 summarizes the data from the aforementioned three cases. The table outlines the clinical indication leading to therapy interruption, the detection pathway (routine risk screening vs. symptom-triggered evaluation), the intervention initiated, and the clinical outcomes. Therapy withholding was temporary and guided cardiac function recovery. None of the cases progressed to a symptomatic heart failure or required permanent discontinuation of cancer treatment.
Figure 5.
The number of cardiovascular events for the year 2023. BP: Blood pressure, CVD: Cardiovascular disease, HF: Heart failure
Table 1.
Summary of cases with chemotherapy withholding
| Case number | Demographic | Diagnosis/cancer treatment | Indication for therapy hold | Detection pathway | Cardio oncology intervention | Outcome |
|---|---|---|---|---|---|---|
| Case 1 | 72-Qatari | HER2-positive breast cancer History of congenital heart disease On trastuzumab/pertuzumab |
Progressive LV dysfunction (LVEF declined from 54% to 33%, GLS from 13.9% to 7.9%) | Serial Echo Elevated proBNP (2600 pg/mL) |
Temporary HER2 therapy withholding Initiation of HF medication regimen (bisoprolol, sacubitril/valsartan, dapagliflozin, spironolactone) Close follow-up with a repeat echocardiogram after 1 month Based on echocardiographic findings and patient clinical status, HER2-targeted treatment was resumed with subsequent echocardiographic monitoring scheduled every two cycles and cardiac biomarkers after each cycle |
LV function stabilization, symptom improvement, and being clinically compensated |
| Case 2 | 34-nonqatari | Metastatic HER2-positive breast cancer on maintenance trastuzumab | LV dysfunction (GLS drop from−19.1% to−14.7%) with uncontrolled hypertension (BP: 172/127 mmHg) | Serial Echo including EEF and GLS monitoring, BP monitoring, and normal cardiac biomarkers | Temporary withholding of trastuzumab, initiation and titration of bisoprolol and enalapril, home BP monitoring, and education of low salt diet | Normalization of BP and GLS, HER2 therapy safety resumed |
| Case 3 | 60-nonqatari | Metastatic HER2-positive breast cancer on lapatinib | Decline in LV function (LVEF from 51% to 44%, GLS 16.5 to 12.8% in a patient with preexisting cardiopathy) | Routine Echo surveillance (LVEF and GLS) | HER2 therapy held, continued optimized HF therapy (sacubitril/valsartan, metoprolol, ivabradine, dapagliflozin, spironolactone). Reassessment after 4 weeks with Echo. Based on echocardiographic findings and patient clinical status, cancer treatment was resumed with subsequent echocardiographic monitoring scheduled every two cycles and cardiac biomarkers after each cycle | Improvement in LV function therapy cautiously reintroduced Under close cardio-oncology observation |
LV: Left ventricular, LVEF: LV ejection fraction, GLS: Global longitudinal strain, BP: Blood pressure, HF: Heart failure, HER2: Human epidermal growth factor receptor 2, Echo: Echocardiogram, EEF: Echocardiographic evaluation and follow-up
Qualitative themes
Clinical decision-making and risk stratification
The early cardio-oncology involvement guided decisions on the continuation or temporary cancer treatment withholding dictated by cardiotoxicity risk stratification.[14] High-risk patients were managed with tailored personalized interventions, including cardioprotective medications or cancer therapy modification. In most cases, cancer treatment was continued when cardiotoxicity risk was assessed as a low or moderate risk and cases were managed with optimized cardiac therapies. Multidisciplinary team discussion was essential for complex cases, particularly high-risk cancer patients receiving cardiotoxic chemotherapy. In the three cases in which cancer therapy was held [Table 1], early detection and intervention clearly reduced therapy interruptions, demonstrating the impact of systematic cardiac monitoring on cancer treatment continuity.
Interdisciplinary communication and coordination
Integration of the service at NCCCR improved the timeliness of cardiac assessment and urgent inpatient referrals. The effective referral system implemented through Hamad Medical Corporation facilities enabled rapid communication among multiple specialties including oncology, cardiology, hematology, surgery, and radiotherapy which helped reduce delays in patient evaluations. The allocation of cardio-oncology services at NCCCR from 2020 further improved the timeliness of assessments, particularly for inpatients’ consultations. Despite these improvements, some delays were faced with urgent cases requiring cardiac clearance.
Patient-centered care
The aim of cardio-oncology service is to emphasize balancing cancer treatment efficacy with optimal cardiovascular safety and to support noncitizen patients residing in Qatar to navigate logistical and financial barriers. The cardio-oncologists emphasized the accurate balance between achieving oncologic efficacy and ensuring cardiovascular safety while actively incorporating patient preferences into treatment decisions.[15] Noncitizen patients, who represented most of the cohort, were supported for the frequently encountered additional barriers.
Service development challenges
Identified challenges included limited availability of imaging slots for urgent cases and inconsistent staff familiarity with cardio-oncology protocol and pathway. The opportunities for service enhancement encompassed the development of cardio-oncology structure roadmap, guideline and pathway, and education sessions for cancer teams and expansion of imaging capacity.
Patterns in cardiotoxicity management
Cardiovascular and cardiotoxicity assessments were performed prior to chemotherapy, targeted therapy, immunotherapy, radiotherapy, and surgery. Cardiac evaluations were also conducted preoperatively. Ongoing assessments identified treatment-related cardiovascular complications such as congestive heart failure, pericardial disease, effusion, and arrhythmia.[16] Early detection protocols including routine echocardiography and cardiac biomarker monitoring played a critical role in preventing irreversible cardiac damage. Common clinical interventions included initiating cardioprotective medications such as beta-blockers, angiotensin-converting enzyme inhibitors, and modification of cancer therapy dosing schedules. Preventive strategies were most consistently applied among patients stratified as high risk at baseline.
DISCUSSION
This study provides a comprehensive evaluation of the cardio-oncology service at NCCCR, combining quantitative service metrics with qualitative insights from stakeholders. The findings demonstrate both measurable progress and ongoing challenges in delivering timely, coordinated, and patient-centered cardio-oncology care. While the quantitative data finding revealed an increase in the number of new cases and follow-up cases, on the other hand, the qualitative data finding showed the program efficiency in care coordination and communication within multidisciplinary team. Despite these achievements, the article identified ongoing challenges for resource allocation and team training for workflow optimization.
The number of follow-ups increased in parallel with new referrals, suggesting better continuity of care and integration in treatment pathways. Notably, treatment interruptions due to cardiac events were minimal, with only three cases recorded in 2023. Anticoagulation therapy was initiated in three cases, which represents a direct clinical response to underlying cardiovascular complications such as atrial fibrillation or other thromboembolic conditions. These events were detected during cardio-oncology follow-up, demonstrating a cardiovascular management burden among this patient cohort.
Cardio-oncology has emerged globally as a vital subspecialty bridging oncology and cardiology to mitigate cancer therapy-related cardiotoxicity. With improvement in cancer survival rates, therapy-induced cardiac dysfunction has become a significant clinical concern, necessitating a proactive strategy for risk assessment, early detection, and intervention. In response, Qatar established a dedicated cardio-oncology service to implement early cardiotoxicity screening, minimize treatment delays, and optimize outcome for patients receiving potential cardiotoxic therapies.
The phased implementation of the service across HH and NCCCR center included consult-based management, clinical nurse specialist-led clinic, echocardiography service, and both ambulatory and inpatient care. Multidisciplinary collaboration among cardiologists, oncologists, hematologists, radiotherapists, imaging specialists, nurses, and pharmacists has been central to the program success through shared decision-making, risk stratification, and integrated patient-centered care.[17] The team effectively monitored cardiotoxicity before, during, and after cancer therapy, thereby reducing the treatment-related cardiac complications and aligning care delivery with precision medicine principles.
The integration of quantitative and qualitative findings demonstrated that early cardiac surveillance and structured risk stratification contributed to minimal therapy interruptions. Multidisciplinary team practices, proactive management strategies, and interdisciplinary coordination further supported efficient care delivery and favorable patient outcomes. Strong leadership support remains essential to sustain resource allocation, facilitate staff training and promote continuous service development. We recommend that the cardio-oncology team establish a comprehensive patient registry to systematically evaluate clinical outcomes and assess the impact of specialized care. Further research is warranted to investigate the risk of treatment related cardiotoxity in breast cancer.
CONCLUSION
The cardio-oncology program is a rapidly evolving multidisciplinary specialty that plays a critical role in optimizing cardiovascular care for cancer patients. The establishment of a dedicated cardio-oncology service in the region represents a pivotal advancement, fostering effective collaboration among cardiologists, oncologists, hematologists, radiotherapists, surgeons, pharmacists, and nursing teams. This integrated approach can enhance patient outcomes through improved communication and coordinated care.
Conflicts of interest
There are no conflicts of interest.
Acknowledgments
We acknowledge the support of the medical and nursing administration from NCCCR.
Funding Statement
Nil.
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