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ASCO Makes Recommendations to Reduce Cardiac Risk in Survivors of Adult-Onset Cancers

Surabhi Dangi-Garimella, PhD
A panel of 21 expert clinicians from the field conducted a systematic review of meta-analyses randomized clinical trials, observational studies, and clinical experience, to develop recommendations that have been published in the Journal of Clinical Oncology.
Heart failure, a progressive disease, is a well-documented complication associated with chemotherapy and radiation therapy. In addition to asymptomatic or symptomatic disease, heart failure could interrupt cancer-directed treatment in patients, which could significantly affect their survival. Now, the American Society of Clinical Oncology (ASCO) has developed a set of guidelines in an effort to prevent and monitor cardiac dysfunction in individuals who have been treated for adult-onset cancer.

A panel of 21 expert clinicians from the field conducted a systematic review of meta-analyses randomized clinical trials, observational studies, and clinical experience, between 1996 and 2016. Hundred and four studies met eligibility criteria and were the basis of the final recommendations. The purpose of developing the guideline was to address the following questions:
  • Which patients with cancer are at an increased risk for developing cardiac dysfunction?
  • Which preventive strategies minimize risk before treatment initiation?
  • Which strategies reduce risk while on treatment with potentially cardiotoxic agents?
  • Which surveillance strategy works best during treatment in patients at high risk for cardiac dysfunction?
  • What are the ideal surveillance and monitoring strategies after treatment in patients at high risk for cardiac dysfunction?
Based on their review, the experts recommend the following:

1. Identifying patients at an increased risk for developing cardiac dysfunction.
a. The following treatments contribute to increased cardiac risk:
  • High-dose anthracycline
  • High-dose radiotherapy (RT) (≥ 30 Gy) where the heart is in the treatment field
  • Lower-dose anthracyclines in combination with lower-dose RT (< 30 Gy) where the heart is in the treatment field
b. Treatment with lower-dose anthracycline or trastuzumab alone, in an individual with:
  • Multiple cardiovascular risk factors
  • Age 60 or over at treatment
  • Compromised cardiac function before or during treatment
c.  Treatment with lower-dose anthracycline followed by trastuzumab.


However, no recommendation on the risk of cardiac dysfunction can be made for the following exposures:
a. Lower-dose anthracycline or trastuzumab alone and no additional risk factors
b. Lower-dose RT (< 30 Gy) where the heart is in the treatment field and no additional cardiotoxic therapeutic exposures or risk factors
c. Kinase inhibitors
 
2. Preventive strategies to reduce the risk of cardiac dysfunction prior to treatment initiation.
a. Use established alternatives to avoid exposure to potentially cardiotoxic treatments.
b. Clinicians should conduct a comprehensive assessment in patients with cancer—including history and physical examination, screening for cardiovascular disease risk factors (hypertension, diabetes, dyslipidemia, obesity, and smoking), and an echocardiogram—before initiating potentially cardiotoxic therapies.
 
3. Preventive strategies to minimize risk when administering potentially cardiotoxic therapies.
a. Clinicians should screen for and manage modifiable cardiovascular risk factors.
b. Clinicians can use various strategies to prevent cardiotoxicity in these patients, such as pretreatment with dexrazoxane or high-dose anthracycline.
c. In patients who need mediastinal radiotherapy, the treatment dose should be lowered if clinically appropriate and the treatment field should be more precise, avoiding the heart as much as possible. This can be achieved with:
  • Deep-inspiration breath holding by patients during treatment
  • Using intensity-modulated radiotherapy
4. Preferred surveillance and monitoring approaches in patients at risk for cardiac function.
a. Document patient history and conduct a complete physical exam.
b. If patients present with clinical signs or symptoms around cardiac dysfunction during routine assessment, the experts recommend:
  • An echocardiogram
  • Cardiac magnetic resonance imaging (MRI) or a multigated acquisition (MUGA) scan (MRI preferred)
  • Monitoring serum cardiac biomarkers or echocardiography-derived strain imaging
  • Referral to a cardiologist if needed
c.  Routine surveillance imaging in asymptomatic patients who are at an increased risk of developing cardiac dysfunction.
d.  In individuals with evidence of cardiac dysfunction, the oncologist must work in collaboration with a cardiologist to fully evaluate the risks and benefits of continuing the treatment that is responsible for cardiac dysfunction.
e.  Routine echocardiographic surveillance in patients with breast cancer who are on trastuzumab indefinitely; but the frequency of surveillance should be deciphered individually for each patient.
 
5. Identifying the preferred surveillance and monitoring approaches.
a. Document patient history and conduct a complete physical exam.
b. If an individual presents with clinical signs and symptoms of cardiac dysfunction, the following can be recommended for follow up:
  • An echocardiogram
  • Cardiac magnetic resonance imaging (MRI) or a multigated acquisition (MUGA) scan (MRI preferred)
  • Monitoring serum cardiac biomarkers or echocardiography-derived strain imaging
  • Referral to a cardiologist if needed
c. An echocardiogram may be performed 6 to 12 months after completion of cancer-directed therapy in asymptomatic patients who might be at an increased risk of cardiac dysfunction.
d. Cardiac MRI or MUGA may be offered in asymptomatic individuals if an echocardiogram is not available or not feasible (MRI preferred).
e. Patients with asymptomatic cardiac dysfunction during routine surveillance should be referred to a cardiologist or a cardio-oncologist.
f. No recommendations for frequency or duration of surveillance for patients at increased risk who are asymptomatic and do not have evidence of cardiac dysfunction on their 6- to 12-month post-treatment echocardiogram.
g. Regular evaluation of cardiovascular risk factors in patients previously treated with cardiotoxic cancer therapies. A heart-healthy lifestyle in the long term should be discussed with these patients.
 
Reference

Armenian SH, Lacchetti C, Barac A, et al. Prevention and monitoring of cardiac dysfunction in survivors of adult cancers: American Society of Clinical Oncology Clinical Practice Guideline [published online December 5, 2016]. J Clin Oncol. doi: 10.1200/JCO.2016.70.5400.

 
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