Table 1.

Barriers to Establishing a Cardio-Oncology Training Program

	Challenges	Potential Solutions
Institutional Support for an overall cardio-oncology program	• Professional/academic obligations of faculty with limited time to invest in new interests • Geographical barriers (clinical practices physically separated by long distances) • Concern from oncologists of potentially having to limit or delay therapy based on a cardiovascular evaluation	• Integrate practices within or very close to cancer centers and build volume, justifying the need for a dedicated cardio-oncology program • Grand Rounds attendance and presentations, frequent feedback with Hematology/Oncology colleagues regarding shared patients • Availability for urgent referrals and imaging requests • Targeted outreach to oncologists • Development of billing codes relevant to cardio-oncology
Financial Support	• Cardio-oncology fellowships are currently non-ACGME approved and thus hospital support may be limited without accreditation • Research/institutional support delegated elsewhere within division deemed “higher priorities”	• Enroll in clinical trials both in Hematology/Oncology and Cardiology to generate revenue to support faculty and ancillary staff for a cardio-oncology training program • Increase private sector support • Research grant funding for fellowship funding (i.e., NIH, Cancer center related Seed funds, T32 teaching grants, industry support grants, foundation support)
Designing an optimal educational curriculum	• No official, ACGME/ACC/AHA sponsored educational curriculum to date or COCATS equivalent • Many institutions have varying cancer populations, which may make spectrum of cardio-oncology related issues very heterogeneous and inconsistent • Limited evidence-based guidelines for management of alternative cardiac effects of other cancer treatments. • Rapid expansion of oncology drugs with limited long-term cardiovascular follow-up	• Didactics and education sessions need to be integrated into General Cardiology fellowship training until accreditation of a fellowship is established • Ongoing national efforts to design a cardio-oncology training curriculum that fit the heterogeneous nature of multiple health care systems, both in community and academic centers • Determine outpatient and inpatient experience and patient volume, as well as different cancer/cancer treatment types that a competent cardio-oncologist should be exposed to
Varying Access to Imaging Technologies	• Cardio-oncology centers have variable access to imaging modalities (i.e. echo, CT, MRI, vascular imaging) • Imaging faculty may hesitant to embrace cardio-oncology applications of imaging due to time constraints and lack of payer reimbursement	• Frequent collaboration and education of imaging colleagues in Cardiology, Radiology, and Vascular Medicine on screening and diagnosing cardio- or vasculotoxicity in cancer patients • Consider external rotations for trainees, if home institutions do not have access to advanced technologies
Research Programs	• Limited funding • Limited interest to develop careers as physician scientists • Limited institutional support • Overall paucity of national/international cardio-oncology collaborations and guidelines	• Ongoing training and increased awareness amongst Internal medicine, Cardiology and Hematology/Oncology housestaff, to inspire and recruit future generations to conduct clinical/basic science/translational and clinical research • National and international efforts to promote registry data collection • Ongoing application to national grants (e.g., NIH, AHA, American Cancer Society, Leukemia and Lymphoma Society and other organizations) and investigator-initiated industry support from cardiology and hematology/oncology physician scientists