Cardio-oncology is one of the fastest growing subspecialties in cardiovascular medicine. As cancer treatments become more effective and patients live longer, the need for cardiologists who truly understand both sides of the equation has never been greater. But what does it take to develop that understanding? And does the structure of fellowship training actually matter for patient care?
I believe it does. And I want to explain why.
The rise of cardio-oncology training
Over the past decade, cardio-oncology has evolved from an area of interest into a recognised subspecialty with defined training pathways, dedicated clinical services, and a rapidly expanding evidence base. The European Society of Cardiology now publishes dedicated cardio-oncology guidelines, a core curriculum, and a formal certification pathway. Institutions around the world now offer fellowship programs of varying length and structure. Some are a few months embedded within a broader imaging or heart failure fellowship. Others are standalone programs lasting six months, or a focused clinical rotation. Formal training, however, remains the exception rather than the rule. In an international survey presented at ESC Cardio-Oncology 2026, 87% of respondents reported no structured cardio-oncology training programme at their institution, only 10% had any exposure during medical school, and only 17% during residency.
All of these experiences have value, and I want to be clear about that. But I think it is also fair to say that there is a meaningful difference between having an interest in cardio-oncology , even a well-informed one grounded in reading the guidelines and attending conferences, and spending a full year immersed in a dedicated fellowship program where every day is spent managing these patients, interpreting their imaging, and navigating their treatment decisions in real time. Guidelines give you a framework. In my experience, a full fellowship year builds the pattern recognition, the clinical judgment, and the comfort with uncertainty that come from sustained, hands-on experience with a high volume of complex cases. Clinicians appear to agree: when the same ESC survey asked how they preferred to build knowledge in the field, cardio-oncology fellowships headed the list of learning formats.
What a full year looks like in practice
My cardio-oncology fellowship at the University Health Network (UHN) in Toronto was a full twelve months of dedicated, immersive training. It was not an imaging fellowship with some clinical cardio-oncology tagged on at the end. It was not a general cardiology year with occasional exposure to oncology patients. It was purpose-built, from day one to day last, around one goal: learning to care for the hearts of people going through cancer treatment.
Most of my clinical time was based at the Peter Munk Cardiac Centre at Toronto General Hospital, an internationally recognised cardiovascular program. A significant portion of the year was also spent embedded within organ-specific oncology teams at Princess Margaret Cancer Centre, working alongside medical oncologists, radiation oncologists, and haematologists treating patients with breast cancer, lung cancer, thymoma, lymphoma, and those undergoing allogeneic bone marrow transplantation. The clinical exposure spanned roughly a thousand inpatient and outpatient consultations across a range of malignancies and treatment types.
What made this training particularly valuable was the integration of advanced cardiac imaging within the clinical framework. In cardio-oncology, imaging is not a standalone skill you acquire separately and then apply later. It is part of how you think about every patient. Strain echocardiography, 3D echo, cardiac MRI with late gadolinium enhancement and T1/T2 mapping, PET perfusion scanning, coronary CT angiography: all of these were part of the daily toolkit, woven into every clinical encounter rather than siloed into a distinct rotation. And when imaging was not enough, the fellowship included experience with myocardial biopsy for cases where tissue diagnosis was essential, such as confirming immune checkpoint inhibitor myocarditis in clinically ambiguous presentations.
Critically, I was trained to read and interpret these images myself, not simply to order them and wait for a report. That makes a real difference at the point of care. When I can sit down with a radiation oncologist and walk through the cardiac MRI findings together, or discuss the subtleties of a strain pattern with a haematologist deciding whether to continue a cycle of chemotherapy, the conversation is richer and more productive. It means I can engage in genuine multidisciplinary discussion with radiology and oncology colleagues about the nuances of what we are seeing, rather than relying solely on a written report.
Why integrated training changes clinical decisions
To understand why this matters, consider a few scenarios I have encountered.
A patient on an immune checkpoint inhibitor presents with a mildly elevated troponin and some fatigue. At first glance, this can look like demand ischaemia or a non-specific troponin bump, particularly if the ECG is unremarkable and the echocardiogram shows preserved systolic function. But in the cardio-oncology setting, this presentation raises the possibility of immune checkpoint inhibitor myocarditis, a rare but potentially fatal complication where normal-looking initial investigations can be falsely reassuring. Knowing when to push further with cardiac MRI, when to hold the immunotherapy, and when to escalate to high-dose steroids draws on a specific kind of clinical experience that comes from having seen these cases unfold over a full year of training.
Or consider a cancer survivor referred years after completing treatment, now presenting with new heart failure symptoms. A standard workup might focus on the usual suspects: ischaemic heart disease, hypertension, valvular disease. But if that patient received chest radiation twenty years ago, or anthracycline chemotherapy in their youth, the cause may be treatment-related cardiomyopathy or accelerated coronary disease with a different natural history and management approach. Without knowing to ask the right questions about a patient’s cancer treatment history, the underlying cause can be missed entirely.
A third example: a patient with a haematological malignancy develops atrial fibrillation while on a BTK inhibitor like ibrutinib. On the surface, it looks like straightforward new-onset AF. But managing AF in this context is different. The drug itself is often the cause, and the usual anticoagulation and rate control strategies need to be carefully weighed against bleeding risk, drug interactions, and the oncologic treatment plan. Getting this wrong can mean either unnecessary discontinuation of a life-saving cancer therapy or inadequate management of a cardiac complication.
These are not rare or contrived examples. They are the kinds of decisions that come up regularly in cardio-oncology practice, and they reward time spent in the space: recognising the patterns and avoiding the pitfalls. The ESC survey found the same: respondents ranked diagnosing cancer therapy-related cardiovascular toxicity, together with risk stratification, prevention, and monitoring, as their highest-priority knowledge gaps. Those are precisely the decisions in the scenarios above.
The synergy of clinical fellowship and research
My year in Toronto was deliberately structured as a combined clinical fellowship and post-doctoral research year, and that combination turned out to be deeply synergistic. Seeing patients with immune checkpoint inhibitor myocarditis in clinic raised questions I could explore in the research setting. Analysing cardiovascular risk prediction tools gave me a sharper lens for assessing patients the following week. All of the research that came out of this year was clinically driven, motivated by questions that arose at the bedside. Whether the approach involved prospective data collection or retrospective analysis, the starting point was always a real clinical problem, and the goal was always to bring the findings back to the patient.
During the fellowship, I was invited to speak at the Canadian Cardiovascular Congress on cardiovascular surveillance before, during, and after cancer therapy, and at the Canadian Cardio-Oncology Network Scientific Meeting on immune checkpoint inhibitor toxicities and multimodality therapy complications. More recently, I have been invited to co-chair sessions and serve as a panel discussant at the Australian Cardio-Oncology Research Symposium (ACORES), which speaks to the ongoing relevance of this work as I establish my practice in Australia.
Training at the right institution
Where you train matters. The Peter Munk Cardiac Centre is an internationally recognised centre for cardiovascular care, and Princess Margaret Cancer Centre consistently ranks among the top ten oncology hospitals in the world in Newsweek’s World’s Best Specialized Hospitals rankings. The cardio-oncology program sits at the intersection of these two centres of excellence, and that positioning means fellows see the full spectrum of cancer therapy-related cardiovascular complications.
When I started the fellowship, UHN’s Toronto General Hospital was ranked third in the world by Newsweek. As of this week, it has risen to number two, just behind the Mayo Clinic. I maintain a concurrent post-doctoral appointment with UHN, so technically I can claim a sliver of credit for the climb, though I suspect the other 44,000 members of TeamUHN might have had something to do with it. In all seriousness, being part of an institution operating at that level shapes your expectations for what good care looks like. You absorb a standard that stays with you.
Working alongside your general cardiologist
One question that comes up, particularly in the private setting, is how a cardiologist with subspecialty cardio-oncology training fits alongside a patient’s existing cardiologist. It is a fair question, and I want to address it directly.
I am not here to replace anyone’s general cardiologist. Many of my patients already have a cardiologist they know and trust, and that relationship is important. What I offer is a complementary skill set for a specific clinical problem. When a patient is going through cancer treatment and a cardiac question arises that sits at that intersection, my role is to provide the subspecialty input and then work with the existing care team in the patient’s best interests.
In practice, this often looks like a time-limited consultation: risk-stratify the patient, advise on monitoring during treatment, manage any complications that arise, and then hand ongoing cardiac care back to their regular cardiologist once cancer treatment is complete. It is no different from how a general cardiologist might refer to an electrophysiologist for an arrhythmia or a structural heart specialist for a complex valve problem. The patient benefits from having the right expertise at the right time, and the referring cardiologist retains the longitudinal relationship.
The patients who benefit most are the ones whose cardiac and oncologic care teams are communicating clearly and working together. That is what I aim to facilitate, not to compete with.
Why this matters for patients in Brisbane
Cardio-oncology fellowship training is still uncommon, in Australia and internationally. As I write this, the number of cardiologists in Brisbane who have completed any dedicated period of cardio-oncology fellowship training can be counted on one hand. That number will grow over time, and it should. But right now, the gap between the demand for subspecialty cardio-oncology care and the available expertise is real, particularly as the use of immunotherapy and other novel cancer treatments continues to expand. The ESC survey quantifies that gap at a global level: the vast majority of respondents had no structured cardio-oncology training available at their institution, and access was lower again for clinicians outside Europe.
The core of what I do can be stated simply: I look after your heart during cancer treatment, with the aim of keeping you safely on the therapy you need. But the simplicity of that goal belies the complexity of achieving it. Every decision sits at the intersection of at least two high-stakes fields, each with its own evolving evidence base, its own risk-benefit calculations, and its own urgency. Getting it right means weighing cardiac risk against cancer prognosis, navigating drug interactions across two pharmacopoeias, interpreting imaging findings that may look familiar but mean something entirely different in the oncology context, and doing all of this in close coordination with multiple treating teams. Sometimes the answer is reassuring your oncologist that it is safe to continue. Sometimes it means adjusting cardiac medications to get a patient through the next cycle. Sometimes it means recognising a rare but serious complication early, when intervention is most likely to help. The judgment to know which situation you are facing, and to act on it decisively, is what fellowship training builds.
For patients and referring physicians in Brisbane, I hope this gives some context for the training and perspective I bring to every consultation. Cardio-oncology is about more than ticking a box on a referral form. It is about having someone in the room who has spent a full year doing nothing but thinking about how to look after hearts during cancer treatment, at one of the world’s top-ranked hospitals.
If you are a patient, a GP, or an oncologist with questions about cardiovascular care in the setting of cancer therapy, I am always happy to discuss how I can help. Please click here for contact information.
Reference: ESC press release, “Survey reveals major gaps in cardio-oncology training”, presented at ESC Cardio-Oncology 2026 (COOL group, ESC Council of Cardio-Oncology), 20 June 2026.
