Knowledge level of cardio-oncology in oncologist and cardiologist: a survey in China.

To the Editor: Cancer has been the leading cause of death worldwide and in China since 2010.[1] As advances are made in the treatment of cancer, the survival rate of cancer improves; at the same time, many cancer patients and cancer survivors suffer from cardiovascular disease (CVD) as a result of intense anticancer treatment.[2-4] To prevent and treat cardiovascular problems mediated by cancer treatments, a new medical discipline called cardio-oncology was established. Although the field of cardio-oncology has existed for 20 years,[5] its development in China is still in the early stages. In our survey, we focused on examining the knowledge of cardio-oncology and systematically assessed the awareness of, attitudes toward, barriers to, and implementation of cardio-oncology among Chinese oncologists and cardiologists. A structured questionnaire was developed by the cardio-oncology team at the National Cancer Center and National Center for Cardiovascular Disease, and the study was conducted from September 30, 2018 to December 3, 2019. The structured questionnaire included three items relating to the awareness of cardio-oncology, one item relating to attitudes toward the building of a cardio-oncology unit, four items relating to barriers to the development of a cardio-oncology unit, 34 items for measuring the level of knowledge of cardio-oncology, and two items relating to the application of cardio-oncology knowledge in practice [the questionnaire is shown in Supplementary Material 1, https://links.lww.com/CM9/B380]. The content validity was examined by six experts working at cardio-oncology units. The content validity index was 0.923, indicating adequate content validity [Supplementary Table 1, https://links.lww.com/CM9/B380].[6] The questionnaire was randomly distributed to a cardiologist or an oncologist drawn from the pool of physicians attending the 29th Great Wall International Congress of Cardiology, Asia Pacific Heart Congress 2018, International Congress of Cardiovascular Prevention and Rehabilitation 2018, and China Cancer Management Symposium 2019. The target respondents for this survey were defined as oncologists and cardiologists working in tertiary hospitals, cancer centers, and cardiovascular centers in Chinese mainland. According to the data from the China Health Statistical Yearbook 2019,[7] a simplified Yamane formula was adopted to calculate the sample size.[8] With a margin of error of 5% and a 95% confidence interval, the required sample size was 398 in each specialty to improve generalizability to the total population of cardiologists and oncologists. Categorical variables were analyzed using a chi-square test. Comparisons of the mean score of knowledge level were performed by analysis of variance (ANOVA). To explore the significant factors of the knowledge level of cardio-oncology, a general linear model (GLM) was used. P < 0.05 was considered statistically significant. A total of 973 valid responses from a total of 1049 were collected and included in the analysis. The baseline profile of the participants is shown in Supplementary Table 1, https://links.lww.com/CM9/B380. Of the 973 physicians who responded, 444 (45.6%) were oncologists, and 529 (54.4%) were cardiologists. A total of 41.3% (N = 402) of surveyed physicians worked in the eastern region of Chinese mainland, and 25.5% (N = 248) and 33.2% (N = 323) of surveyed physicians practiced in the middle and western regions of Chinese mainland, respectively. The geographical information of the surveyed physicians was correlated with the geographical profile of tertiary hospitals from China Health Statistical Yearbook 2019 (proportion of tertiary hospitals by region: eastern, 46.2%; middle, 25.3%; western, 28.5%).[7] First, we focused on doctors’ awareness of cardio-oncology. Of 973 respondents, only 3 (0.3%) were not aware of cardio-oncology at all, and 970 (99.7%) respondents were aware of cardio-oncology. A total of 343 (35.3%) respondents were fully aware of cardio-oncology in terms of patients, discipline, and special units. Full awareness of cardio-oncology was associated with the following characteristics of respondents: specialty (P value < 0.001), hospital level (P value < 0.001), and physician level (P value = 0.010). The highest awareness of cardio-oncology was among oncologists working in a tertiary grade A hospital as chief doctors [Table 1]. Table 1 - Awareness and the barriers of cardio-oncology. Awareness of cardio-oncology Barriers of building a special unit of cardio-oncology Characteristics All respondents (n = 973) Full awareness of cardio-oncology (n = 343 [35.3]) P Barriers exist (n = 960 [98.7]) P Lack of awareness and knowledge of cardio-oncology (n = 749 [77.0]) P Lack of demand for cardio-oncology service (n = 220 [22.6]) P Inadequate supports from cardiologist & oncologist (n = 691 [71.0]) P Specialty Oncology 444 196 (44.1) <0.0001 437 (98.4) 0.750 345 (77.7) 0.678 103 (23.2) 0.746 328 (73.9) 0.0001 Cardiology 529 147 (27.8) 523 (98.9) 404 (76.4) 117 (22 (1) 363 (68.6) Level of hospital Tertiary grade A 885 327 (36.9) <0.001 874 (98.8) 0.752 691 (78.1) 0.014 198 (22.4) 0.669 641 (72.4) 0.003 Tertiary grade B 88 16 (18.2) 86 (97.7) 58 (65.9) 22 (25.0) 50 (56.8) Region Middle 246 99 (40.2) 0.169 239 (97.2) 0.058 188 (76.4) 0.064 56 (22.8) 0.733 160 (65.0) 0.008 Western 323 107 (33.1) 320 (90.1) 263 (81.4) 77 (23.8) 248 (76.8) Eastern 402 137 (34.1) 399 (99.3) 298 (74.1) 86 (21.4) 282 (70.1) Level of physician Chief doctor 221 92 (41.6) 0.010 215 (97.3) 0.225 166 (75.1) 0.649 51 (23.1) 0.861 158 (71.5) 0.027 Assistant chief doctor 280 98 (35.0) 278 (99.3) 216 (77.1) 58 (20.7) 191 (68.2) Doctor in charge 268 101 (37.7) 264 (98.5) 209 (78.0) 60 (22.4) 199 (74.3) Junior doctor 118 29 (24.6) 118 (100) 90 (76.3) 29 (24.6) 92 (78.0) Medical student 86 23 (26.7) 85 (98.8) 68 (79.1) 22 (25.8) 51 (59.3) Values were shown as N or n (%). Second, we analyzed the attitude toward and barriers to building a cardio-oncology unit. Among the 973 respondents, the majority (N = 929, 95.5%) were in favor of building a special unit for cardio-oncology [Supplementary Table 2, https://links.lww.com/CM9/B380]. The oncologists who worked in a tertiary grade A hospital were more supportive of the development of cardio-oncology units than cardiologists. In addition, 960 (98.7%) respondents admitted that it would not be easy to establish a cardio-oncology unit since many barriers existed [Table 1]. The most recognized barrier was a lack of awareness and knowledge of this multidisciplinary area, particularly among the respondents who worked in a tertiary grade A hospital. In addition, approximately 23% of respondents believed that a lack of demand for cardio-oncology services was also a barrier to opening a cardio-oncology unit in the hospital. Third, we wanted to know how knowledgeable cardio-oncologists were. The average/median score was 22.8/23 (out of 34 cardio-oncology questions) for all the respondents. Scores are summarized in Supplementary Table 3, https://links.lww.com/CM9/B380 and varied by aspects of knowledge. Out of the respondents, 33.4% correctly answered all questions about the timing of CVD risk assessment. A total of 21.6% of respondents were correct about the recommended approaches for monitoring heart function. A total of 37.1% of respondents gained full marks in questions related to the types of cancer treatments that affect heart function. The percentages of respondents who earned full marks on questions about CVD complications and cardioprotective drugs were 7.4% and 3.3%, respectively, which were quite low [Supplementary Table 4, https://links.lww.com/CM9/B380]. GLM regression analysis demonstrated that the knowledge level of cardio-oncology was better in respondents who had a cardiology background (P value = 0.001), worked in tertiary grade A hospitals (P value = 0.01), worked in the eastern or western region of Chinese mainland (P < 0.001), worked at a high position of doctor (chief doctor, P = 0.009), were fully aware of cardio-oncology (P < 0.001), and had a favorable attitude toward cardio-oncology development (P < 0.001) [Supplementary Table 5, https://links.lww.com/CM9/B380]. Fourth, we wanted to understand the clinical application and implementability of cardio-oncology knowledge. Of the 973 respondents, 862 (88.6%) believed the CVD risk assessment for cancer patients should be performed before cancer therapy is initiated. Among the 862 respondents who opted to perform the CVD risk assessment before treatment, 781 (90.6%) stated that they did perform the CVD risk assessments. In addition, 914 (93.9%) respondents always checked the patient's clinical history of cancer and CVD. Chief doctors and oncologists implemented these practices more often [Supplementary Table 6, https://links.lww.com/CM9/B380]. From the results of the four survey topics we set, we get the following analysis and thinking. 1) Although 99.3% of respondents met with cancer patients with cardiac complications, the overall awareness of cardio-oncology was not very high, and 35.3% of the respondents (61.4%) were not aware of the building of special cardio-oncology units in China. This result is not surprising since the development of cardio-oncology in China is still in the early stage. 2) Oncologists were not only more aware of cardio-oncology than cardiologists but also had a more positive and supportive attitude toward cardio-oncology development. However, the better awareness and attitude of oncologists did not mean they had more knowledge of cardio-oncology. Cardiologists better answered questions related to approaches for monitoring heart function, CVD complications in cancer patients, and cardioprotective drugs. The oncologists only outperformed the cardiologists in the questions about the types of anticancer treatment that affect heart function. This result showed that they all answered the questions relating to their own field better. This also demonstrates the importance of cardio-oncology education and training. There are some limitations of this study. First, the sampling method is non-probability sampling, which provides less accuracy and reliability. Our questionnaire selected the participants from a series of academic conferences, which led to our participants being mainly from tertiary grade A hospitals. Second, our survey was web-based, which may have led to an inability to reach a certain population. Third, because our questionnaire is a cross-sectional study, we had no way to follow up on the patient's outcome, and so we could not determine whether cardiac preventive treatment methods or knowledge gaps among doctors affected the patient's prognosis. Finally, in the process of issuing the questionnaire, we received some feedback that some cardiology-related questions in the questionnaire may have an imperfect design, which needs to be improved in the future. Cardio-oncology has developed rapidly in China in the last 5 years, similar to a single spark starting a prairie fire.[3,4] We hope that our results can objectively reflect the development status of cardio-oncology and provide an important reference for future improvement. The present study showed that the demand for cardio-oncology services in China is great, but the current knowledge level of cardio-oncology among cardiologists and oncologists is insufficient. A well-prepared series of training courses may help to increase the awareness of cardio-oncology and improve the knowledge level of cardio-oncology among oncologists and cardiologists and ultimately benefit all cancer patients through standardized cardiovascular care in practice. Ethical approval and consent to participate This study was approved by the Institutional Review Boards of Cancer Hospital, Chinese Academy of Medical Sciences (No. NCT03537339), and the protocol has been registered on ClinicalTrials.gov with the number NCC201712029. Acknowledgments The authors would like to thank Sandra Wang, China iCardioOncology Network (CiON), for help in the design of this study and the distribution of the questionnaire. We thank the doctors and scholars from all over China who helped to distribute and collect the questionnaire and all the participants who completed it. Conflicts of interest None.