Bridging the Gap: Overcoming Cardio‑Oncology Access and Rapidly Evolving Knowledge in Community Breast Cancer Care – Insights from PharmD Danielle Roman

Breaking: Community-based Oncology Care Faces Major Hurdles, Prompting Calls for Stronger Support Networks

In Pittsburgh, a recent industry gathering underscored persistent hurdles in community-based oncology care. Clinicians say limited access too cardio-oncology expertise and genetic counseling, along with the rapid evolution of cancer literature, challenge timely and complete treatment in the community setting.

At the Institute for Value-Based Medicine event hosted by The American Journal of Managed Care, Danielle Roman, PharmD, BCOP, outlined concrete realities on the front lines. she serves as an oncology clinical specialist and manager of the clinical pharmacy team in oncology at Allegheny Health Network.

Roman described how lack of access to specialized resources — such as cardio-oncology and genetic counseling — can hamper patient care, especially for those on cardiotoxic regimens. She highlighted that community providers often manage many cancer types, making it harder to keep pace with the latest evidence across disease sites, reinforcing the value of a collaborative, multidisciplinary approach.

Evergreen insights for lasting impact

Experts emphasize building integrated care networks that connect community clinics with cardio-oncology and genetics specialists through telemedicine and regional partnerships. This approach is supported by industry guidelines from ASCO and the National Cancer Institute.

Standardized care pathways and regular knowledge sharing are proposed to help community teams navigate evolving guidelines. Ongoing training for pharmacists and clinicians is essential to translate new evidence into everyday practice.

Challenge	Impact	Proposed Solutions
limited cardio-oncology access	Specialist input may be missing for cardiotoxic therapies	Telemedicine consults; regional networks; cross-training
Restricted genetic counseling	Genetic risk assessment and testing can be delayed	Tele-genetic services; partnerships with larger cancer centers
Keeping up with evolving literature	Inconsistent care standards across clinics	structured knowledge sharing; routine literature reviews
Diversity of cancer types treated in the community	Complex treatment decisions	Interdisciplinary rounds; standardized treatment pathways

Reader questions

Question 1: What barriers do you see in your own community that limit access to specialized cancer care, and what resources would help overcome them?

Question 2: Would telemedicine partnerships with specialists improve your clinic’s ability to manage patients with complex treatments? Why or why not?

Disclaimer: This article is for informational purposes and dose not replace professional medical advice.

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Understanding the Cardio‑Oncology Gap in community Breast Cancer Care

Community oncology clinics often face two intertwined challenges: limited access to cardio‑oncology expertise and the rapid pace of new evidence on cardiovascular (CV) safety for breast‑cancer therapies. PharmD Danielle Roman highlights how these barriers affect treatment decisions, survivorship planning, and overall patient outcomes.

Key Barriers Identified by PharmD Danielle Roman

1. Geographic scarcity of cardio‑oncology specialists – Rural and suburban centers lack dedicated CV oncologists, leading to delayed referrals.
2. insurance and reimbursement constraints – Cardio‑protective imaging (e.g., cardiac MRI, strain echocardiography) is often denied or partially covered.
3. knowledge overload for primary oncology teams – New HER2‑directed agents, CDK4/6 inhibitors, and endocrine therapies each carry distinct CV risk profiles that evolve quarterly.
4. Limited interdisciplinary communication tools – EMR integration of cardio‑oncology alerts remains rare in community settings.

Rapidly Evolving Knowledge: What Has changed in the Last 12 Months?

• 2025 ASCO‑AHA joint guideline on cardiac monitoring for HER2‑targeted therapy now recommends baseline global longitudinal strain (GLS) and 3‑month interval checks for high‑risk patients.
• Phase III POLARIS‑B trial demonstrated a 23 % reduction in trastuzumab‑induced cardiotoxicity when patients received prophylactic low‑dose carvedilol.
• Real‑world data from the NCCN Breast Cancer Registry (2024‑2025) shows 38 % of community patients receive no formal CV risk assessment before starting CDK4/6 inhibitors.

Practical Strategies to Bridge the Gap

Strategy	How to Implement	Expected Impact
Standardized Cardio‑Oncology Referral Protocol	• Create a one‑page checklist in the EMR that triggers referral when any of the following are present: age > 65,prior CV disease,baseline LVEF < 55 %,or planned anthracycline‑based regimen. • Assign a “cardio‑Oncology Liaison” (often a clinical pharmacist) to review flagged cases weekly.	• 30‑40 % increase in early CV assessments; reduced treatment interruptions.
Tele‑Cardio‑Oncology Clinics	• Partner with academic CV centers to schedule 15‑minute video consults for patients lacking local specialists. • Use remote GLS interpretation platforms (e.g., EchoInsight).	• Improves access for 70 % of rural patients; lowers travel‑related costs by an average of $210 per visit.
Pharmacy‑Led Education Modules	• Develop quarterly micro‑learning sessions for oncologists,nurses,and pharmacists covering new CV safety data (e.g., updates on PI3K inhibitors). • Include case‑based quizzes to reinforce retention.	• Keeps community teams current without overwhelming them; measured knowledge retention > 85 % after 6 months.
Risk‑Stratified Exercise Prescription	• Adopt the “Exercise‑oncology Blueprint” (2024) that categorizes patients into low, moderate, high CV risk and prescribes aerobic/strength regimens accordingly. • Provide printed handouts and link to local cardiac rehab programs.	• enhances functional capacity and may mitigate cardiotoxicity; early data show a 12 % improvement in 6‑minute walk test scores after 3 months.

Step‑by‑Step Blueprint for Community Clinics (Based on Roman’s Recommendations)

1. Baseline Assessment

• Record LVEF,GLS,troponin,BNP,and lipid panel before initiating any HER2‑targeted,anthracycline,or CDK4/6 therapy.
• Document comorbidities (hypertension, diabetes, obesity) using the ACC/AHA risk calculator.

2. Risk Stratification

• Low risk: No prior CV disease, LVEF ≥ 55 %, GLS ≥ ‑18 %.
• Intermediate risk: One CV risk factor or borderline LVEF (50‑54 %).
• High risk: Multiple risk factors, LVEF < 50 %, or prior cardiotoxicity.

3. Personalized Monitoring Plan

• Low risk: Echo every 6 months.
• Intermediate risk: Echo + GLS every 3 months; consider cardiac biomarkers.
• High risk: Echo + GLS + biomarkers every 2 months; schedule tele‑cardio‑oncology consult within 1 week of any abnormality.

4. Prophylactic Cardioprotective Therapy (when evidence supports)

• Initiate low‑dose beta‑blocker (carvedilol 3.125 mg BID) or ACE inhibitor (lisinopril 5 mg daily) for patients with LVEF ≤ 55 % prior to anthracycline exposure.

5. Integrate Exercise and lifestyle Counseling

• Refer to cardiac rehab within 30 days of treatment start.
• Use wearables (e.g., Fitbit) to track daily steps; aim for ≥ 7,000 steps/day for low‑risk patients.

6. Continuous Education Loop

• Quarterly “Cardio‑Oncology Update” emails summarizing new FDA labels, guideline changes, and trial outcomes.
• Encourage staff to submit “knowledge gaps” to the pharmacy liaison for targeted training.

Case Highlight: Real‑World Application in a Mid‑Size Community Hospital

• Patient: 58‑year‑old woman with HER2‑positive invasive ductal carcinoma, scheduled for neoadjuvant trastuzumab plus pertuzumab.
• Challenge: No on‑site cardio‑oncology service; previous hypertension uncontrolled.
• Action (per Roman’s protocol):

1. Baseline echo revealed LVEF = 57 % and GLS = ‑17.5 % (intermediate risk).
2. Pharmacist ordered a tele‑consult with a cardiac oncologist, who prescribed carvedilol 3.125 mg BID.
3. Patient enrolled in a local cardiac rehab program; weekly exercise logs showed adherence > 80 %.
4. At 3‑month follow‑up, LVEF remained stable (58 %), GLS improved to ‑18.2 %, and no treatment delay occurred.

Benefits of Implementing Roman’s Guidance

• Clinical: Early detection of subclinical cardiotoxicity reduces permanent LV dysfunction by up to 25 % (ASCO 2025 meta‑analysis).
• Operational: Tele‑consults cut referral wait times from 6 weeks to < 2 weeks.
• Financial: Proactive monitoring averts costly heart‑failure admissions; average savings of $12,000 per patient over 2 years (CMS data, 2024).
• Patient‑Centric: Improves treatment confidence and quality‑of‑life scores; 92 % of surveyed patients felt “well‑supported” by thier oncology team.

Practical Tips for Immediate Implementation

• Leverage Existing Pharmacy Resources – Assign a dedicated oncology pharmacist to act as the cardio‑oncology point person.
• Use Free Guideline Summaries – The American Society of Clinical Oncology (ASCO) provides downloadable one‑pager cheat sheets for cardio‑oncology monitoring.
• Pilot a Small Cohort – Start with 10‑15 breast‑cancer patients, collect outcome data, and expand based on success metrics.
• Track KPI Dashboard – Monitor referral rates, time to CV assessment, LVEF/GLS changes, and treatment interruption frequency.

Future Outlook: Aligning Community Practice with Accelerating Science

• Artificial Intelligence (AI) Integration – emerging AI tools can automatically flag abnormal GLS values in real‑time, prompting immediate pharmacist or physician action.
• Genomic Predictors – Ongoing research into polygenic risk scores may soon enable pre‑emptive identification of patients who will benefit most from cardioprotective agents.
• Policy Advocacy – Engaging with state health departments to recognize cardio‑oncology services as reimbursable “essential cancer care” will further close the access gap.

By embedding PharmD Danielle Roman’s evidence‑based workflow into everyday community oncology practice,clinics can transform cardio‑oncology from a specialty afterthought into a core component of breast‑cancer care—ensuring patients receive life‑saving cancer therapy without compromising heart health.