Echocardiographic Detection of Cardiac Dysfunction in Childhood Cancer Survivors: How Long Is Screening Required?

Abstract

BackgroundChildhood cancer survivors treated with anthracycline chemotherapy are at an increased risk of long-term cardiac toxicity, and guidelines recommend that exposed survivors undergo echocardiography every 1–5 years. However, it is unclear whether survivors should undergo echocardiographic screening indefinitely, or if a period of echocardiographic stability indicates that screening is no longer necessary. The objective of this study was to evaluate the outcomes of echocardiographic screening to aid in the refinement of existing guidelines.MethodsWe retrospectively analyzed the results of echocardiographic screening in a cohort of adult survivors of childhood cancer treated with anthracyclines and/or cardiac radiation therapy. Interval regression analysis was performed to identify predictors of single-episode or sustained abnormal echocardiograms.ResultsThe cohort constituted 333 survivors, with median follow-up time of 15.8 years post-treatment (range: 5.0–47.9), and median age at treatment of 8 years (range: 1.5–18). Forty-nine survivors had an abnormal echocardiogram (14.7%), and 29 (8.7%) had reproducible abnormal findings. An ongoing continual increase in the incidence of sustained echocardiographic abnormality was seen among patients treated with >250 mg/m2 doxorubicin at age <5 years, reaching 43% by 20 years of therapy. In contrast, no sustained abnormal echocardiographic findings arose after 10 years of therapy in survivors treated with <250 mg/m2 at age ≥5 years.ConclusionsSingle-episode echocardiographic abnormalities are often not reproduced in subsequent evaluations. The duration of echocardiographic screening for childhood cancer survivors should be reassessed for patients who received lower doses of anthracycline after age 5. Pediatr Blood Cancer © 2015 Wiley Periodicals, Inc.

Zebrafish as Toxicological model for screening and recapitulate human diseases

“…This fact has become an important issue, with particular relevance for children and adolescents, as they may be more susceptible to toxic effects, and often use these treatments off-label [8] .…”

Cardiac Mortality in Children and Adolescents with Hodgkin's Lymphoma: A Surveillance, Epidemiology and End Results Analysis

“…Last, data from a recent study reviewing echocardiograms of childhood cancer survivors found similar results demonstrating no correlation between receipt of RT and echocardiographic abnormalities. 22 The authors concluded that this was likely due to the lower median RT dose of their study population and that RT-associated valvular abnormalities may not have been captured as they may occur more than 20 years after treatment. However, the study did find that patients receiving anthracycline doses q250 mg/m 2 had significantly higher rates of persistent echocardiographic abnormalities.…”

Screening for Anthracycline-Related Cardiac Dysfunction in Childhood Cancer Survivors: Can Less be More?

“…The study by Ramjaun et al represents an important first step to answering some of the questions outlined above. The investigators used a retrospective cohort design to examine the incidence and persistence of cardiac dysfunction in 333 anthracycline‐exposed childhood cancer survivors who underwent risk‐based echocardiographic screening per the Children's Oncology Group (COG) long‐term follow‐up guidelines .…”

“…Ramjaun et al highlight the relatively poor overall PPV of echocardiography for cancer survivors in their study, a screening index that is largely dependent on the prevalence of disease in a given population. Considering that only 25% of survivors in this study were treated with high‐dose (≥250 mg/m 2 ) anthracyclines, it is not surprising that PPV was relatively low.…”

“…For these survivors, it is especially important to keep in mind the potential for additional distress caused by the cascade of follow‐up testing that is typically warranted as part of due diligence. Ramjaun et al should be commended for presenting researchers and policymakers with important data that can be used to temper the enthusiasm of those who advocate for more screening. Additional confirmatory studies are needed to determine if, in fact, less can be more for anthracycline‐exposed childhood cancer survivors who are at lowest risk for developing HF.…”