Integrated Cardio-oncology Service

Cancer and cardiovascular disease (CVD) are the two leading causes of mortality globally, including in Australia; jointly, these entities account for over half of all deaths nationwide.¹ CVD remains the most common non-cancer-related cause of death among cancer survivors. Like many other countries, Australia has seen a steady increase in its cancer demographic, with an estimate of more than 169,000 new cancer diagnosis in 2024, a number expected to increase by over 20% by 2031.^2,3 Importantly, cancer patients are living longer due to many factors, such as improved screening, education and the implementation of primary prevention, as well as the exponential growth of therapeutic advances in cancer treatment overall resulting in improved survival.⁴

With cancer survivorship increasing, there is a growing population at risk of cancer therapy-related cardiac disease. There is now broader recognition of the cardiovascular (CV) toxicities associated with both traditional and novel treatments, making CV care a crucial component of comprehensive oncological management.^5–7 Cardio-oncology has emerged in response to this growing burden, offering a multidisciplinary approach to optimise CV outcomes across the cancer continuum. Australian and international peak bodies have called for structured, collaborative cardio-oncology models integrating primary care, oncology and cardiology, an imperative echoed globally for services that are clinically robust, yet adaptable to local contexts and resource-constrained settings.^7,8

Here, we define an integrated cardio-oncology service as a structured, team-based model that risk-stratifies patients before therapy; delivers protocolised monitoring and early intervention during treatment to maintain best-practice cancer treatment; and ensures tailored survivorship follow-up. We explore the translation of basic CV research into clinical care, the evolution of local service structure and how a collaborative, bench-to-bedside model can address the unique challenges of cardio-oncology in a geographically and socioeconomically diverse healthcare environment, incorporating local insights from the Hunter New England (HNE) Local Health District in Newcastle, Australia.

Evolution of Service Structure and Consensus International Guidelines

Cardio-oncology has its roots in the early 1970s, when anthracycline chemotherapy (doxorubicin) was first reported to cause heart failure in cancer patients, with subsequent recognition of radiation injury and trastuzumab cardiotoxicity highlighting the need for specialised cardiac input to oncology care.⁹ Early practice was often ad hoc, focusing on monitoring left ventricular function with the usage of troponin biomarkers and multigated acquisition scans or echocardiography to guide chemotherapy dose adjustments, until survivorship growth and late CV morbidity drove formal programmes; the founding of International Cardio-Oncology Society (IC-OS) in 2009 marked the subspeciality’s emergence.^10,11

The 2010s saw rapid clinic and literature expansion, society guidance (European Society of Cardiology [ESC] 2016 position paper; 2019 service roadmap) and the launch of JACC: Cardio-Oncology.^8,12,13 By the early 2020s, integrated cardio-oncology service models appeared.¹⁴

More recently, cardio-oncology is increasingly being recognised as a cardiology subspeciality with close alignment to heart failure and multimodality cardiac imaging, reflecting shared pathophysiological mechanisms and management strategies.^15,16 The subspeciality addresses a distinct cancer population with heightened CV morbidity and mortality, arising from the interplay of cancer-related factors (e.g. thrombosis, bleeding, accelerated atherosclerosis, hypertension), treatment-related toxicities (e.g. QTc prolongation, arrhythmias, immune-mediated CV injury) and traditional CV risk factors.¹⁷ Despite this, CV risk across the cancer continuum remains under-recognised and incompletely characterised.

Effective cardio-oncology practice requires broad oncological literacy and detailed expertise in CV toxicities associated with both established and rapidly expanding novel anticancer therapies.⁸ Internationally, cardio-oncology has largely evolved within cardiology; however, as the shared burden of cancer and CV disease becomes increasingly evident, cross-disciplinary training pathways may emerge.¹³ At present, cardiology and oncology continuing professional development frameworks in Australia remain distinct, and formal cardio-oncology training is not mandated within either speciality programme, an educational gap recently highlighted in emerging literature.^7,18

Today, consensus supports a structured, multidisciplinary service with harmonised definitions and risk-based pathways. The 2022 ESC cardio-oncology guidelines standardised baseline risk stratification, surveillance and early cardioprotective interventions so patients can safely complete cancer therapy, with the focus on dedicated cardio-oncology services or cardiologists with cardio-oncology expertise working in collaboration with oncology teams.¹⁹

Figure 1 summarises common central components required for an integrated cardio-oncology service. Dedicated cardio-oncology clinics in tertiary centres coordinate inpatient and outpatient care, research and education, risk-stratify patients before therapy, monitor them during treatment, manage cardiotoxicity and provide survivorship follow-up. Co-location with cancer clinics improves access and real-time multidisciplinary team (MDT) decision-making. A cornerstone of best-practice cardio-oncology care, the MDT, at its core, should consist of a lead cardiologist (with or without a Fellow or Advanced Trainee), a medical and radiation oncologist, haematologist and specialist nurse, with pharmacist, general practitioner/primary care and laboratory scientists embedded in the service. Subspecialist (interventional, electrophysiology), psychology and rehabilitation services are included as needed. Most programs start lean and scale up, emphasising dedicated time and training.

Regular MDT meetings standardise care, help with decision-making and manage complex cases across the service/network. Smaller hospitals can benefit from links to core centres (e.g. virtual MDTs) to align plans and quality.

Clear referral pathways target patients about to start high-risk cancer therapies (e.g. anthracyclines, human epidermal growth factor receptor 2 [HER2] inhibitors or thoracic radiation), those with multiple CV risk factors, those with prior cardiotoxicity or pre-existing CVD and anyone developing new CV issues during treatment.^15,20 Typically, cancer teams will screen for these criteria and then refer to the cardio-oncology clinic, as per guideline recommendations.^15,19

Biomarkers and imaging, including Troponin and N-terminal pro B-type natriuretic peptide monitoring, are used to detect injury before symptoms develop, whereas echocardiography with global longitudinal strain (GLS) identifies subclinical dysfunction earlier than left ventricular ejection fraction.^15–19,21 Protocols now include baseline biomarkers and scheduled echocardiography with GLS during high-risk regimens, supported by American College of Cardiology (ACC)/American Heart Association and ESC 2019/2022 guidance.^15,19,21 Abnormal biomarkers or a >15% decrease in GLS should prompt an expedited review and consideration of cardioprotective therapy.

Survivorship care needs to be carefully planned, with follow-up typically at 6–12 months after therapy and then risk-based (often annually) for several years.^8,15,19 Integrated programmes partner with primary care to address late effects (cardiomyopathy, coronary artery disease), optimise risk factors and transition to general cardiology when appropriate, recognising that clinically relevant late toxicity can emerge decades later.^19,21

The Newcastle Experience as an Integrated Cardio-oncology Service: Case Example

Designing an integrated service must take into account the local cancer and CV epidemiology of the particular health catchment. The HNE health district (Newcastle and surrounds) in New South Wales (NSW) is unique for several different reasons; geographically, the HNE area serves approximately 1,000,000 people (including a diverse multi-ethnic and Australian Indigenous population) spread out over metropolitan, regional and remote areas covering an expanse of 130,000 km² (for context, an area larger than that of England). It also includes two regional universities (The University of Newcastle and the University of New England) and a large research institute, the Hunter Medical Research Institute (Figure 2 ).²²

Cancer incidence and mortality in the HNE district slightly exceed the state average (~1.05-fold higher incidence and 1.11-fold higher cancer mortality than in NSW overall), believed to be partly due to an older, regional population with higher rates of risk factors and limited access to specialist care.²³ Approximately 6,000 new cancer cases per year are projected in this region by the mid-2020s contributing to a growing cohort of survivors at risk of cardiotoxicity and late cardiac effects.²⁴

Newcastle responded by establishing the Newcastle Centre of Excellence in Cardio-Oncology, one of Australia’s first dedicated cardio-oncology services to address this intersection of cancer and heart health.²⁵ This centre operates as a comprehensive learning health system, integrating discovery science, biobanking and human models with pragmatic clinical research, registries and protocolised pathways to help ensure rapid bench-to-bedside models of care and policy and practice translation.^20,26,27 The centre works in partnership with national and international collaborators and helps expand professional and community education, and develop national and international policy and practice documents.

International Models of Integrated Cardio-oncology Services

Across diverse healthcare systems, successful cardio-oncology services look different on the surface but converge on the same foundational pillars (Table 1 ).^{7,8,18–21,27–30} Although governance and resourcing vary, key principles are universal, including comprehensive risk assessment and management, multidisciplinary backbone and fast-track access, with each model reporting improvements in care and outcomes.

Common Frameworks in Integrated Cardio-oncology Services

Despite differences in scale, integrated cardio-oncology programmes share several common frameworks and best practices that are highlighted in Figure 2. Different models exist to suit local health system structures. In Europe and Australia, some tertiary centres and university centres run hub-and-spoke networks, coordinating smaller district hospital clinics and accepting complex referrals.¹⁸ Overall, what began with isolated observations of chemotherapy cardiotoxicity has evolved into a recognised discipline with structured, team-based services focused on protecting CV health, ensuring cancer patients receive the optimal cancer treatment with minimal interruption to cancer therapy due to CV complications.

Multidisciplinary Team and Allied Health Involvement

Integrated cardio-oncology succeeds or fails on timely triage, consistent surveillance and safe continuation of cancer therapy. In our proposed model, nurses and clinical pharmacists are not adjuncts; they are the operating system that makes the pathway work day to day.^19,31

Nurse-enabled Triage and Surveillance

Nurse specialists can run much of the initial assessment and surveillance loop. They can complete the baseline CV screen (history, blood pressure, ECG) and arrange regimen-specific tests (imaging and biomarkers where indicated); streamline triage and bookings; deliver risk-factor optimisation (blood pressure, lipids, smoking, weight, exercise); run triage protocols to secure timely cardiology review without delaying oncology timelines; and provide targeted patient education.

Pharmacist-enabled Drug Safety and Optimisation

Clinical pharmacists can reconcile all medicines, including herbal and over-the-counter medicines, and flag high-risk interactions; monitor regimen-specific CV toxicities and advise of timing/substitutions; initiate or uptitrate cardioprotective therapy in consultation with the medical team; and standardise transition-of-care plans, reducing therapy pauses and unplanned emergency presentations.

Integrated Models of Care

Nurse-led models of care are mainstays of CV care, underpinned by senior clinical nurses with advanced clinical skills and a commitment to patient education, and are endorsed by the international guidelines and consensus statements.^32–34 Importantly, nurse-led models of care can be delivered across inpatient, outpatient, home-based and telehealth settings, improving access, adherence to guidelines and outcomes. As cancer treatments continue to improve the prognosis of cancer patients and enhance outcomes, long-term vigilance and support will remain of the utmost importance to this population.^35,36

The Newcastle cardio-oncology service successfully pioneered the nation’s first nurse-led cardio-oncology risk stratification clinic, achieving excellent clinical results, winning local and national awards and receiving positive local media attention, further underscoring the need for this type of service within the community. The nurse-led clinic in this service has three major focuses: baseline/early clinical assessment, lifestyle advice and education. The early experience of our specialised cardio-oncology nursing services is extremely positive.^20,37 Translating this to accepted international standards of care, while using current models, remains of the utmost importance in the delivery of care for cancer patients.

Exercise-based interventions and cardio-oncology rehabilitation and exercise are essential, yet underutilised, components of integrated multidisciplinary cardio-oncology care.³⁷ Supervised rehabilitation and exercise programmes, incorporating aerobic and resistance training, have demonstrated benefits in cardiorespiratory fitness, physical function, fatigue and quality of life in patients with cancer, while also addressing modifiable CV risk factors exacerbated by cancer therapies.^38,39 Emerging data support the safety and feasibility of structured exercise across the cancer continuum, including during active treatment and in survivorship, when delivered within appropriately risk-stratified and supervised frameworks.^39,40 Integration of accredited exercise physiologists and allied health specialists, such as physiotherapists, within cardio-oncology services while leveraging established cardiac rehabilitation and chronic disease management models offers a scalable approach to CV risk modification, functional preservation and long-term survivorship care.^30,39,41,42 In the Australian context, embedding exercise programmes within multidisciplinary cardio-oncology pathways may enhance the equity of access and continuity of CV care for cancer patients at elevated risk. This ideal strategy of integrated multidisciplinary care faces many similar barriers and challenges that plague a majority of locally led programmes, most pertinently the issue of adequate and sustainable funding to support these roles in clinical practice.

Educating the Community

Periodic clinician-led community forums/webinars can improve literacy, early help-seeking and risk-factor management in regional populations, complementing clinic-based care.⁴³ For example, at a community education forum recently held by the Newcastle Cardio-Oncology Centre of Excellence, feedback from participants highlighted that the initiative has increased confidence in managing their health and provided a clearer understanding of cardio-oncology risks.

Pharmacist Integration Into Cardio-oncology Services

Pharmacists are integral for maintaining the quality use of medicines across different clinical settings and disciplines, delivering monitoring for drug–drug and drug–disease interactions, adverse effect management, medication management solutions and tailored education and counselling for patients, each linked to better therapeutic and patient outcomes.^44–49

We have previously articulated the unique roles and responsibilities of pharmacists working within a cardio-oncology MDT.³⁰ In this context, the pharmacists bridge oncology and cardiology. They conduct baseline CV risk assessment, optimise modifiable risks (e.g. hypertension) and co-drive medication decisions during potentially cardiotoxic therapy.⁵⁰ They also provide patient-centred education on cardiotoxicity, self-monitoring and concordance to reduce medication-related harm.^50–54 Given that drug interactions affect nearly 80% of patients on anticancer therapy, the proactive identification and resolution of potential drug-drug interactions helps maintain cancer dose intensity while minimising toxicity.^55–58

At transitions of care, pharmacist-led medication reconciliation/review has been reported to reduce adverse drug events, readmissions and emergency department visits in multiple CV cohorts, and these principles plausibly extend to oncology patients with multimorbidity and polypharmacy.^59–61 Although pharmacist medication reconciliation and review services are not routinely incorporated into the transition of care for patients in our healthcare system (in Australia), this may highlight a possible future role for pharmacists within the cardio-oncology MDT.

Despite current literature acknowledging the need for pharmacist involvement within integrated cardio-oncology services, specific roles and scopes are inconsistently defined and formal training pathways are lacking.^8,53,62,63 Priorities include explicit guideline inclusion of pharmacists as core members of the MDT, clearer role descriptions and structured training/rotations or fellowships to build capability and capacity.^27,52

Translating Basic Science into Clinical Service

Modern oncology is advancing faster than our clinical characterisation of CV toxicity, making deliberate bench-to-bedside pipelines essential. International consortia now link clinical services, registries and biobanks to mechanistic discovery and prospective validation in patient cohorts, exemplified by Leducq, EU-funded RESILIENCE programme, CARDIOTOX registry; all explicitly target anthracycline cardiotoxicity through mitochondrial/mitophagy pathways and prospective imaging validation, as well as a more recent G-COR registry that is more broad.^64–67 However, very few clinical programmes further incorporate fundamental mechanistic studies to complement translation, clinical and models of care research, and much guidance still rests on expert consensus, underscoring the value of integrating discovery within care pathways.^7,64

Mechanistic and translational science can be embedded within integrated cardio-oncology services as a learning health system, linking deep clinical phenotyping and biobanking to models relevant to human disease. Current knowledge emphasises that anthracycline injury reflects convergent mechanisms (e.g. topoisomerase 2β-mediated DNA damage, mitochondrial/iron dysregulation and susceptibility factors), reinforcing the need for risk-informed prevention and surveillance pathways that are mechanistically anchored rather than a one-size-fits-all approach.^64,68 International translational priorities now highlight clinically translatable experimental designs (dosing, comorbidities and reproducible phenotyping) to accelerate bench-to-bedside cardioprotection discovery.⁶⁴ Human experimental platforms are also maturing: living myocardial slice and induced pluripotent stem cell–cardiomyocyte systems enable patient-relevant screening, with proof-of-concept data showing dexrazoxane can protect susceptible human slices from doxorubicin injury.⁶⁹ Beyond oxidative stress paradigms, sterile inflammation pathways have been implicated in delayed cardiac toxicity after DNA-damaging therapies, with stimulators of interferon genes (STING) antagonism mitigating dysfunction in preclinical models.⁷⁰ Mechanistic dissection of non-anthracycline toxicity is also advancing; selected tyrosine kinase inhibitors induce cardiomyocyte injury via endoplasmic reticulum stress and downstream inflammatory signalling in preclinical models.⁷¹ Complementing these frameworks, our work adds translational signals, including multiomics profiling that suggests shared pathway programmes across doxorubicin and carfilzomib.⁷² In addition, a human cardiomyocyte viability screen highlights that direct cardiotoxicity extends across multiple contemporary agents.⁷³ Importantly, dual-use strategies that not only preserve but enhance anticancer efficacy while protecting the heart are emerging: in a recent study we showed that the clinically available poly(ADP-ribose) polymerase inhibitor olaparib attenuated doxorubicin cardiotoxicity in vitro and in vivo and preserved left ventricular function in an anthracycline mouse model, supporting prioritisation of mechanism-based cardioprotection trials within integrated services.⁷⁴

A benchmark example of bench-to-bedside translation is the UCSF Cardio-Oncology and Immunology programme, which moved from the first clinicopathological description of immune checkpoint inhibitor-associated fulminant myocarditis and subsequent pharmacovigilance signals to ongoing mechanistic studies in a dedicated laboratory, and into a protocolised clinical service that operationalises early surveillance and MDT management at scale.^75–77

Our programme of fundamental science research incorporates all these aspects via prospective biobanking as well as in vitro, in vivo and patient-derived ex vivo models. At benchside, our key discoveries support mechanism-based cardioprotection and repurposing candidates, alongside translation into pragmatic clinical pathways and trials; current candidates include bisantrene (NCT06815575). Our DETECT-CARE study provides longitudinal registry and follow-up of patients throughout their cancer journey and beyond with imaging and blood biobanking at multiple time points, including patient-derived induced pluripotent stem cell-derived cardiomyocytes, which inform personalised risk and follow-up.⁷ Community forums/webinars extend this model of care, boosting literacy, early help-seeking and adherence in regional populations.

Ultimately, cardio-oncology will close gaps in care only by tightly coupling routine clinical pathways with biobanking, mechanistic platforms and pragmatic registries so discovery can be tested and implemented rapidly.^7,18,64

Clinical Service Integration and Patient Pathways

A successful cardio-oncology programme requires seamless integration into the clinical workflow of cancer care. Stakeholder engagement should include medical oncology/haematology/radiation oncology teams, surgery, primary care, nursing/allied health, pharmacy, imaging and hospital leadership, with regular MDT participation to build a stable referral base and shared ownership of decisions.^8,29 The essentials are a shared culture, clear referral gateways, risk-based assessment, patient priority and protocolised pathways that ensure best possible cancer therapy while protecting CV health (Table 2 ).

Operationally, this integration begins with clear referral criteria and a pathway that spans baseline assessment and CV optimisation, on-treatment surveillance and management and survivorship care. Broadly, key groups of patients that merit referral are those at high risk of cardiotoxicity (high-risk regimens, multiple risk factors/comorbidity), those with pre-existing cardiac disease or prior cardiotoxicity and those with any new CV symptoms/abnormalities during therapy.^8,19,31

Patient care pathways are then mapped out to minimise delays and optimise coordination. Ideally, the cardio-oncology team reviews high-risk patients before treatment for risk optimisation (e.g. CV risk factor screening and management, heart failure therapy), then establishes a monitoring schedule during therapy. If a patient develops asymptomatic left ventricular dysfunction or biomarker levels rise, the service can quickly intervene (starting cardioprotective medications and adjusting cancer therapy if needed) in consultation with the treating cancer specialists. Close integration with cancer services and timely communication and review can be vital; the service should aim to see urgent referrals within days to a week, so that necessary cardiac care does not unduly delay cancer treatment.^8,20

Different delivery models can achieve these goals. Clinics embedded within cancer centres facilitate real-time communication between specialities and patient convenience; e-consults and telehealth extend reach across hub-and-spoke networks; and a dedicated nurse coordinator synchronises cardiac testing with oncology appointments and ensures results are available for MDT review.²⁷ Ready access to cardiology subspecialities (imaging, heart failure, electrophysiology and interventional services) allows rapid co-management when issues arise. Complex cases should be discussed in a regular cardio-oncology MDT and, as services grow, centres may add tumour-stream clinics, survivorship clinics and inpatient consult teams to support hospitalised patients.^8,30,78,79

Regardless of model structure, the aim is a cohesive patient journey from cancer diagnosis through treatment and into survivorship, with cardio-oncology care interwoven into cancer care to provide a seamless patient experience. This can only be achieved by effective communication and coordinated protocols between specialities.¹⁸

Cancer Specialist Perspectives on Collaboration

From the cancer specialists’ point of view, an integrated cardio-oncology service can be both a relief and present unique challenges.

On the positive side, cancer specialists recognise that cardio-oncology collaboration helps ensure their patients receive uninterrupted cancer treatment with fewer serious cardiac events. The primary collaborative goal is to cure or control cancer; untreated or undertreated cancer can be suboptimal for a patient and their outcome, and therefore, cancer specialists value any intervention that keeps patients on potentially curative therapies. A well-run cardio-oncology clinic will prioritise maintaining cancer dose intensity whenever safely possible.¹⁴ In practice, this means rapid cardiology input to treat and manage issues (initiating preventative therapies and diuretics for early heart failure or uptitrating medications for rate or rhythm control in AF) rather than reflexively withholding chemotherapy. This was exemplified by the experience reported by Pareek et al. over a 5-year period in the UK: thanks to close monitoring and early intervention, all patients with only subclinical cardiac changes and 88% of those with actual cardiotoxicity were able to continue their cancer therapy.²⁸ This outcome, built around the core ethos of minimising oncology treatment disruptions, is a huge win from a cancer specialist’s perspective and embodies the promise of cardio-oncology services.

Cancer specialists also appreciate that cardio-oncology input often supports and aids in complex decision-making. Modern cancer care involves patients with multiple co-morbidities and, when cardiac disease overlaps with cancer, decisions on therapy become complex. Having cardiologists engaged means these decisions are made collaboratively, balancing risks and benefits. A recent review highlights this collaboration, describing the collegial aid between the cancer care teams and the cardio-oncologist.⁸⁰ Cancer specialists report that having an accessible and approachable cardiology partner to discuss borderline cases (such as mild baseline left ventricular dysfunction) provides reassurance and an added safety net.

From a cancer specialist’s point of view, another benefit is patient satisfaction and trust. When patients see that their specialists have enlisted a cardiology specialist to co-manage the cardiac side of their care, it reinforces that all aspects of their health are being considered. Patients feel they are not being ‘abandoned’ to deal with cardiac side effects alone, and this multidisciplinary solidarity can improve their confidence in continuing cancer therapy and navigating setbacks.¹⁴

With the increasing focus on the provision of clinically meaningful survivorship care, cardio-oncology clinics are best placed to drive many interventions resulting in long-term, evidence-based, improved outcomes. In addition to providing patients’ long-term cardiac follow-up (for late adverse cardiac effects), ongoing patient education on modifiable CV risk factors (e.g., controlling weight, increased exercise) aligns with demonstrated cancer survivorship interventions shown to reduce cancer recurrence.^81,82

However, there are also challenges and concerns from the cancer specialists’ point of view to be considered. One is the fear of treatment delays; cancer specialists may worry that involving cardiology could slow down the initiation of urgent cancer therapy (waiting for cardiac investigations and clearance). This underscores the need for cardio-oncology services to be highly responsive, including the implementation of rapid referral systems and pragmatic individualised approaches (sometimes proceeding with cancer treatment while simultaneously managing cardiac issues in parallel), aligning with broader aims for personalised cardio-oncology care. Building relationship trust is key; cancer specialists need assurance that cardiologists understand the urgency of cancer care. Many successful cardio-oncology programmes rely on advocacy from cancer specialist champions to bridge any culture gap. Newcastle’s service, for example, benefits significantly from invaluable collaboration between the directors and senior staff from all specialist fields, including oncology, radiation oncology and haematology, all of which play a crucial part in the core team, ensuring workflow.

Another challenge is that cancer specialists must incorporate additional cardiac tests or monitoring into their routine. Some specialists may be initially unfamiliar with interpreting an elevated troponin value or a drop in strain values; this, in turn, means that the cardio-oncology service must take responsibility for the cardiac screening and investigations ordered and provide clear guidance on what is actionable. Good communication and education help joint MDT discussions and educational grand rounds on cardio-oncology topics can bring both cancer specialists and non-cardio-oncologists on board.

A further concern is the lack of dedicated funding for integrated cardio-oncology services. This places the service at risk, with the possibility that clinically integrated and integral services could be defunded and removed at any time. The consequence of this will be either an explosion of workforce pressure on the cancer service or the removal of cardio-oncological intervention from the treatment paradigm.

Overall, it appears that the benefits of a collaborative cardio-oncology service integrated with local cancer care provide significant opportunity to improve patient cancer care, and that the benefits of an adaptive and communicable system outweigh any challenges. Thus, most cancer specialities now embrace cardio-oncology as an essential partnership that ultimately helps them achieve the goal of treating the cancer effectively while keeping patients healthier overall.

System-level Challenges and Enablers

Integrating cardio-oncology into routine cancer care faces well-recognised structural barriers in Australia, as worldwide, but the levers to overcome these barriers are increasingly clear (Table 3 ).

In everyday practice, baseline risk stratification, CV risk factor management and the use of cardioprotective therapies remain variably prescribed for people with cancer, reflecting siloed oncology and cardiology workflows, inconsistent referral pathways and the need for the upskilling of primary care physicians and improved tertiary-to-primary care transitions of care.⁸³ Recent real-world analyses from the UK primary care dataset highlight both the heterogeneity of the use of angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers and β-blockers after cancer diagnosis and its association with downstream cardiac outcomes.⁸⁴ Policy recognition has also lagged in many health systems, and where cardio-oncology lacks formal status as a service line, budgeting and strategic planning are easily deferred. The publication of the 2022 ESC cardio-oncology guidelines has started to standardise definitions, risk stratification, surveillance and escalation, giving services a common framework and ‘permission structure’ to implement pathway-based care. There are calls now to include cardio-oncology in national cancer control plans and to establish centres of excellence.⁸⁵

Persistent resource constraints limit clinic capacity, specialist posts and data infrastructure, especially in settings without dedicated reimbursement or quality metrics. Until recently, the shortage of evidence-based standards and scarce outcome data initially have made it harder to justify investment.^86,87 Yet, it is acknowledged that it is only with the dedicated support of health leadership and government that these services can truly integrate into standard care.^7,8 Coordination across departments remains a practical hurdle, with different scheduling systems, imaging bottlenecks and uncertainty over patient ownership slowing decisions. Guideline bodies explicitly endorse this multidisciplinary, trigger-driven model to preserve dose intensity while preventing CV harm.¹⁹

Concerns regarding equity of access for a range of reasons weigh heavily in the field, where patients are already disadvantaged by the financial toxicity of a cancer diagnosis.⁸⁸ Rural and remote populations have poorer access to CV care and worse CV outcomes; similar disparities are seen across racial and ethnic groups, with social vulnerability and structural barriers linked to worse cardio-oncology outcomes.⁸⁹ Rural cancer patients also have a high burden of CV risk factors, underscoring the compounding impact of remoteness and comorbidities.²⁶ Hub-and-spoke models, telehealth and culturally safe co-designed pathways are therefore central features of equitable service integration.

Workforce and training gaps further constrain implementation and integration, with limited accessible exposure to dedicated cardio-oncology education and training for both cardiology and oncology trainees and specialists in Australia. The absence of standardised training contributes to variability in care and presents a barrier to optimal CV risk education and long-term management. Surveys and reviews consistently report limited formal training, unclear roles and few funded career pathways; professional societies (ESC, IC-OS, ACC) are responding with curricula, fellowships and competency resources to build a pipeline of cardio-oncology-literate clinicians across both the cardiology and oncology disciplines.^18,90,91 More recently society-led initiatives, including the COSA–CSANZ Cardio-Oncology Working Group’s educational meetings and e-learning modules, have improved awareness, but most centres still rely on local initiatives and funding, and only one Australian centre (Newcastle) currently offers a dedicated cardio-oncology fellowship.^7,18

Against these challenges, several global enablers are accelerating adoption. First, consensus guidelines and position statements are harmonising referral criteria, surveillance cadence and escalation thresholds across centres, improving comparability and quality improvement. Second, multinational registries will provide the data backbone for benchmarking and for closing evidence gaps; for example, the Global Cardio-Oncology Registry is enrolling across continents to define incidence, risk factors and disparities. Third, mature integrated centres demonstrate the feasibility of embedded clinics, nurse-enabled pathways and MDT governance, offering practical blueprints for scale-up.²⁸

Together, the enablers, such as standardised guidelines, registry infrastructure, targeted training, proof-of-concept services, research investment and public awards and recognition, are turning early pilot programmes into standard, measurable and more equitable cardio-oncology care across health systems.

Future Directions and Global Implementation of an Integrated Approach

The next phase of cardio-oncology service evolution hinges on services functioning as learning agile health systems that continuously cycle discovery into care and back again. In practice, this means aligning evidence generation, standardisation, precision tools, equity and policy so that new signals translate rapidly into pathway updates and measurable patient benefit (Figure 3 ). The objective is not simply to add cardio-oncology to existing oncology workflows, but to fully integrate a bidirectional bench-to-bedside-to-population loop that preserves oncological best-practice treatment while preventing CV side effects and preserving long-term CV health.

Bench-to-bedside Model

The Australian and international experiences in developing an integrated cardio-oncology service offer valuable insights for scale-up. Co-location of research platforms with clinical pathways accelerates progress: biobanks and human-relevant models identify shared injury mechanisms and potential cardioprotective strategies; prospective registries and routine imaging/biomarker surveillance test those hypotheses in the clinic; and governance processes convert validated signals into order sets, surveillance cadence and escalation rules.^18,92 This approach enables rapid translation of discoveries into patient care, builds a workforce fluent in both research and service delivery, shortens the time from discovery to protocol change and creates a culture where cardioprotection is considered a core enabler of effective cancer therapy rather than an optional adjunct.

Addressing Gaps in the Evidence

Despite progress, significant evidence gaps remain globally, and addressing these is a priority for future directions. Many recommendations in cardio-oncology still rely on expert opinion or lower levels of evidence, reflecting the paucity of large clinical trials in this relatively young field.⁹³ Priority areas include the timing and thresholds for GLS and biomarker-triggered interventions, the choice and sequencing of cardioprotective therapies across regimens and the longer-term consequences of cancer therapy-related CV toxicity for survivorship. Multicentre trials and coordinated registries are beginning to fill these gaps, complemented by large real-world datasets that allow benchmarking and heterogeneity analyses across tumour streams and health systems.^{67,86,94–96} A deliberate emphasis on pragmatic designs, embedded in routine care with minimal extra burden, will ensure that results are generalisable and rapidly implementable.

Standardisation of Protocols and Benchmarks

Uniform definitions of cardiotoxicity, shared risk tools and harmonised surveillance intervals are essential for cross-centre comparison and quality improvement. The recent international guidelines provide a ready framework for baseline risk assessment, monitoring and escalation, and should be adopted as a common starting point, with local adaptation where needed.^19,97 As more centres implement standard datasets and dashboards, including baseline assessment and surveillance, biomarker and imaging, review timing and cardioprotection initiation and escalation, services can compare like with like, identify bottlenecks and iteratively refine pathways without losing alignment with global standards.

Global Implementation

Progression of cardio-oncology as a subspeciality must also account for healthcare system differences worldwide and strive for inclusivity. Lessons from Australia underscore the importance of reaching rural and underserved populations, a challenge many countries still face. In the same way that Australia expanded services to regional areas using innovative means (telehealth clinics, outreach services), other nations should plan for cardio-oncology delivery beyond academic centres.^20,26,27 Telemedicine can play a pivotal role in global cardio-oncology, allowing remote consultation for patients in areas without local specialists. In addition, training general practitioners and local healthcare workers in basic cardio-oncology principles can extend reach in low-resource settings. For example, educational short courses or toolkits could enable a primary care physician in a rural African or Asian community to screen cancer patients for hypertension or cardiomyopathy risk and liaise with distant specialists as needed.

Equity in Implementation

It is vital that cardio-oncology programmes are co-designed with local communities to overcome barriers like travel distance, cultural differences and cost.^8,87 Australia’s focus on Indigenous inclusion (ensuring clinical trials and services reach Aboriginal and Torres Strait Islander patients) offers a template for engaging marginalised groups elsewhere.^98,99 Globally, cardio-oncology initiatives should similarly ensure inclusion of minorities and economically disadvantaged groups so that the benefits of integrated care are widely shared and do not exacerbate health disparities. This includes ensuring diverse participation in trials and registries, providing culturally safe education resources and using telehealth and community-based screening to bring services to patients rather than the other way around.

Innovation and Precision Medicine

Precision tools are moving from research to care: biomarker-guided risk prediction, GLS-anchored surveillance strategies and artificial intelligence (AI)-assisted monitoring protocols promise earlier detection and faster time to action once validated across settings. AI is increasingly positioned as a practical enabler of integrated cardio-oncology services, particularly where it shortens time to action, supports risk-based streaming and extends specialist capability beyond tertiary centres.¹⁰⁰ Recent professional guidance highlights near-term applications across the pathway, including automated analysis of echocardiography (e.g. left ventricular ejection fraction/strain), ECG-based risk prediction and multimodal clinical decision support that integrates longitudinal data streams.^100,101

In implementation terms, AI-guided echocardiography approaches designed for rural and remote delivery (e.g. the AGILE-Echo study) aim to expand access to timely cardiac phenotyping.¹⁰² AI-enabled hand-held ultrasound has also demonstrated feasibility for task sharing, with oncology staff acquiring images and obtaining automated left ventricular ejection fraction estimates to prompt earlier escalation when dysfunction is detected.¹⁰³ In parallel, deep-learning models applied to baseline ECG have shown the potential to identify patients at higher risk of chemotherapy-induced cardiotoxicity before therapy commences, informing surveillance intensity.¹⁰⁴ Finally, opportunistic CV risk stratification from existing imaging, such as automated coronary calcium quantification from routine radiotherapy planning CT, can add value without additional testing burden.¹⁰⁵ For clinical adoption, these tools require robust external validation, transparent performance reporting across tumour streams and patient subgroups and clear governance for safe workflow integration.¹⁰⁰

As these future innovations emerge, international collaboration will be essential to validate and standardise new approaches. Global professional societies and councils (ESC Cardio-Oncology Council, American Society of Clinical Oncology/ACC initiatives and IC-OS) will serve as key platforms to disseminate new evidence, update guidelines and possibly certify new technologies for clinical use.

Policy, Workforce and Accreditation

Durable implementation depends on formal recognition of cardio-oncology as a formal service, workforce training and accreditation and linkage to quality metrics and reimbursement where relevant. Society-led curricula, fellowships and competency frameworks can build a pipeline of appropriately trained clinicians across cardiology, oncology, nursing, pharmacy and imaging. Accreditation and centre-of-excellence models help set minimum service standards and create a cycle in which recognition attracts resources, which, in turn, deliver measurable outcomes.

Challenge of Scale and Opportunities

Finally, the scale-up of cardio-oncology globally will require concerted policy efforts. Although health systems vary widely, the levers for progress are largely similar: shared definitions and datasets, pragmatic trials embedded in care, registry infrastructure, trained MDTs and visible success stories that demonstrate feasibility, patient benefit and cost-effectiveness. As these come together, integrated cardio-oncology can move from pilot programmes to standard practice. The goal is clear: earlier action on CV risk and side effects, fewer cancer treatment interruptions for cardiac reasons, preserved dose intensity and better survivorship for people with cancer.

How to Evaluate an Integrated Service

Formal quality metrics in cardio-oncology are still evolving; there is no trial-level evidence that any specific indicator improves outcomes. In line with emerging consensus, one should report a minimum descriptive set to characterise delivery and safety: baseline CV risk assessment documented before therapy; regimen- and risk-appropriate surveillance performed; incidence of cancer therapy-related cardiac dysfunction using standard definitions; and proportion of cancer therapy interruptions explicitly attributed to CV causes.^86,106

Conclusion

The establishment of an integrated cardio-oncology service is a multidisciplinary endeavour that bridges cardiology and oncology to provide holistic care for patients. It should now be a standard of care rather than an option. By translating cutting-edge research (biomarkers, imaging, cardioprotection trials) into practice in a bench-to-bedside approach, and by building robust clinical pathways and teams, cardio-oncology services can significantly reduce treatment-related cardiac morbidity without compromising cancer outcomes. System-level support is growing, as evidenced by new guidelines and increasing advocacy.

The immediate priorities are adoption of shared definitions and minimum datasets; embedding referral criteria and escalation rules into institutional protocols; resourcing to enable roles that make the pathway work; and investing in training and accreditation across cardiology, oncology, nursing, pharmacy and imaging. At a system level, registry participation, quality dashboards and equitable delivery models (including telehealth and co-designed care for underserved communities) turn isolated pilot programmes into accountable services that are comparable across centres.

In essence, an integrated cardio-oncology service exemplifies patient-centred care, ensuring that today’s cancer patients are not tomorrow’s cardiac patients by proactively safeguarding heart health throughout the cancer journey.