Increasing Cardiomyopathy Screening in At-Risk Adult Survivors of Pediatric Malignancies: A Randomized Controlled Trial

Abstract

Purpose To determine whether the addition of advanced-practice nurse (APN) telephone counseling to a printed survivorship care plan (SCP) significantly increases the proportion of at-risk survivors who complete cardiomyopathy screening. Patients and Methods Survivors age ≥ 25 years participating in the Childhood Cancer Survivor Study who received cardiotoxic therapy and reported no history of cardiomyopathy screening in the previous 5 years were eligible for enrollment. The 472 participants (mean age, 40.1 years; range, 25.0 to 59.0; 53.3% women) were randomly assigned to either standard care, consisting of an SCP summarizing cancer treatment and cardiac health screening recommendations (n = 234), or standard care plus two APN telephone counseling sessions (n = 238). The primary outcome—completion of cardiomyopathy screening within 1 year—was validated by medical records and compared between the two arms using adjusted relative risks (RRs) with 95% CIs. Results Participants in the standard and APN counseling groups were not statistically different by demographic or clinical characteristics. At the time of 1-year follow-up, 107 (52.2%) of 205 survivors in the APN group completed screening compared with 46 (22.3%) of 206 survivors in the non-APN group (P < .001). With adjustment for sex, age (< 30 v ≥ 30 years), and Children's Oncology Group–recommended screening frequency group (annual, 2 years, or 5 years), survivors in the APN group were > 2× more likely than those in the control group to complete the recommended cardiomyopathy screening (RR, 2.31; 95% CI, 1.74 to 3.07). Conclusion The addition of telephone counseling to an SCP with cardiac health screening recommendations increases cardiomyopathy screening in at-risk survivors.

Factors supporting cardiomyopathy screening among at-risk adult survivors of pediatric malignancies

“…Many primary care providers are not aware of the fact that childhood cancer survivors have a higher risk of cardiomyopathy related to their cancer treatment and the cardiomyopathy surveillance recommended for them or of resources that summarize these recommendations [39–41]. Several survivors’ physicians declined to order an echocardiogram in the absence of symptoms [14]. This refusal may well have contributed to survivors’ perception of their health care environment as less supportive of autonomy and more control-based.…”

“…The methods of the randomized trial are described elsewhere [14] Briefly, long-term survivors of childhood cancer recruited for the study were current participants in the CCSS and met the following criteria: they a) had received anthracycline chemotherapy and/or chest irradiation; b) had a diagnosis of leukemia, CNS tumor, Hodgkin lymphoma, non-Hodgkin lymphoma, kidney tumor, neuroblastoma, soft tissue sarcoma, or bone tumor; c) had diagnosis and initial treatment at one of 27 collaborating CCSS institutions; d) had a diagnosis between January 1, 1970 and December 31, 1986; e) were ≤21 years of age at diagnosis; f) were currently age ≥25 years; g) had undergone no cardiovascular (CV) screening during the previous 5 years; h) were not being followed at an institution actively recruiting adult survivors to a long-term follow-up program; and i) had a history of satisfactory, non-surrogate response to CCSS surveys. Of the 1257 survivors meeting the eligibility criteria, we achieved our targeted accrual of 509 participants.…”

“…Those survivors completing the study included 206 participants in the usual care group and 205 in the intervention group. Compared with survivors who were enrolled and randomly assigned, eligible survivors who did not participate were more likely to be men and < 5 years of age at cancer diagnosis, have lower educational attainment and household income, received cranial irradiation, report health status as fair to poor, and have a lower prevalence of grade 2 or 4 chronic health conditions [14]. …”

“…We recently reported the results of a 1-year randomized trial of an intervention aimed at increasing at-risk adult survivors’ cardiomyopathy screening adherence [14]. The standard care (control) intervention comprised a mailed SCP with individualized details about the survivor’s treatment, late effects risks, and recommended follow-up and lifestyle modifications, while the experimental intervention comprised the SCP plus two telephone-counseling sessions conducted by an advanced-practice nurse (APN).…”

Screening and management of adverse endocrine outcomes in adult survivors of childhood and adolescent cancer

“…121,122 As noted, many country-specific guidelines for the long-term follow-up of childhood cancer have been developed; 13,15–17,104 a continuing international harmonisation effort will unify and clarify these recommendations. 18,105,123 Therefore, continued enhancements to survivorship care via the survivorship care plan, the Survivorship Passport work of the European Network for Cancer Research in Children and Adolescents, 120 and the harmonised guidelines 18,105,123 should result in improvements in care for survivors of childhood cancer.…”