Cardiac Outcomes After Cardiotoxic Cancer Therapy

Study Questions:

What are the cardiac outcomes among survivors of childhood cancer?

Methods:

This was a cross-sectional study performed at the St. Jude Children’s Research Hospital. A total of 1,853 adult survivors of childhood cancer, aged 18 years or older, who received cancer-related cardiotoxic therapy at least 10 years earlier, were included. Baseline history and physical examination, fasting metabolic and lipid panels, echocardiography, electrocardiography, and 6-minute walk test were collected. Frequencies of cardiac conditions reported before or diagnosed during the on-campus evaluations were ascertained, and prevalence by age at detection was reported. Multivariable logistic models were used to evaluate associations between potential risk factors and cardiac conditions detected during the on-campus evaluations.

Results:

One half of the survivors (52.3%) were men with a median age of 8 years (range, 0-24 years) at cancer diagnosis and 31 years (range, 18-60 years) at evaluation. Cardiomyopathy was present in 7.4% of survivors (newly identified at the time of evaluation in 4.7%), coronary artery disease in 3.8% (newly identified in 2.2%), valvular regurgitation or stenosis in 28.0% (newly identified in 24.8%), and conduction or rhythm abnormalities in 4.4% (newly identified in 1.4%). Nearly all survivors were asymptomatic. The prevalence of cardiac conditions increased with age at evaluation, ranging from 3% to 24% among survivors aged 30-39 years to 10% to 37% among those aged 40 years or older. In multivariable analysis, survivors exposed to anthracycline doses of 250 mg/m2 or more had greater odds of cardiomyopathy (odds ratio, 2.7; 95% confidence interval [CI], 1.1-6.9) than those who were not exposed. Survivors exposed to heart radiation also had increased odds of cardiomyopathy (odds ratio, 1.9; 95% CI, 1.1-3.7) compared with those who were not exposed. Radiation exposure greater than 1500 cGy with any anthracycline exposure conferred the greatest odds for valve findings.

Conclusions:

The authors concluded that cardiovascular screening identified considerable subclinical disease among adult survivors of childhood cancer.

Perspective:

This study identified subclinical cardiovascular disease among persons who previously received treatment for childhood cancer and generally too young for typical cardiovascular risk stratification. Although most cardiovascular disease was asymptomatic, significant associations with limited physical performance were identified and suggest a substantial future health care burden. These findings, if confirmed, may guide stratification of risk factors, screening practices, health counseling, and potential therapeutic measures aimed at ameliorating the disease process in this young adult population.

Clinical Topics: Cardio-Oncology, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Prevention, Valvular Heart Disease, Acute Heart Failure, Echocardiography/Ultrasound

Keywords: Anthracyclines, Cardiomyopathies, Cardiotoxins, Coronary Artery Disease, Diagnostic Imaging, Echocardiography, Electrocardiography, Heart Failure, Heart Valve Diseases, Neoplasms, Radiation Effects, Risk Factors, Secondary Prevention, Survivors, Cardiotoxicity


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