Echocardiographic screening may improve HFrEF prediction in childhood cancer survivors
Echocardiography at initial screening is one tool that may help identify childhood cancer survivors most at risk for future HF with reduced left ventricular ejection fraction, researchers reported.
“In this echocardiographic follow-up study of long-term childhood cancer survivors, we show in two independent cohorts that addition of an initial surveillance EF improves the 10-year prediction of LVEF < 40% in childhood cancer survivors and accurately identifies low-risk survivors who are unlikely to develop LVEF < 40% within 10 years,” Jan M. Leerink, MD, PhD candidate at the University of Amsterdam Heart Center, and colleagues wrote. “This may improve the current International Late Effects of Childhood Cancer Guideline Harmonization Group recommended risk stratification for cardiomyopathy, which is based solely on anthracycline and chest-directed radiotherapy dose to estimate risk.”
For this study, published in JACC: CardioOncology, researchers evaluated two childhood cancer survivor groups: a derivation cohort in Amsterdam (n = 299; mean age at first echo follow-up, 24 years; 56% women) and a validation cohort in Nijmegen, the Netherlands (n = 218; mean age at first echo follow-up, 23 years; 50% women), to assess the added predictive value of echocardiography together with cancer treatment exposures for HFrEF.
Additional screening and HFrEF prediction
At 10 years, the incidence of LVEF less than 40% was 3.7% in the derivation cohort and 3.6% in the validation cohort.
Researchers observed that the addition of EF measured at an initial surveillance echocardiogram to anthracyclines and chest-directed radiotherapy dose conferred an integrated area under the curve increase from 0.74 to 0.87 in the derivation cohort and from 0.72 to 0.86 in the validation cohort (likelihood ratio, P < .001).
Reclassification of childhood cancer survivors without LVEF of less than 40% improved after the addition of echocardiography together with cancer treatment exposures (non-case continuous net reclassification improvement, 0.5; 95% CI, 0.4-0.6).
Moreover, a 3% or lower risk for HFrEF as determined by echocardiography, which applied to 75% of the cohort, was associated with a negative predictive value of 99% (95% CI, 98-100) for HFrEF within 10 years.
However, LVEF of 40% to 49% at initial screening was associated with a HFrEF incidence of 11% and a nearly eightfold increased risk for HFrEF at 10 years among childhood cancer survivors (HR = 7.81; 95% CI, 2.07-29.5), according to the study.
Reducing ‘low-value care’
“Ongoing efforts to reduce low-value care across medical disciplines, such as the Choosing Wisely campaign, have focused on practices affecting large populations,” Matthew J. Ehrhardt, MD, MS, assistant member in the departments of oncology and epidemiology and cancer control at St. Jude Children’s Research Hospital, wrote in a related editorial. “While the number of childhood cancer survivors increasing, achieving a critical mass necessary to fall within this scope is unlikely. Consequently, the responsibility to do so rests on the survivorship research community.
“The importance is further heightened by poor adherence to survivorship guidelines and that successful strategies to improve adherence have not been widely saleable, highlighting a need for more effective resource allocation,” Ehrhardt wrote. “Despite these practicalities, a move toward reductions, omissions or even deviations from fixed-interval surveillance practices may be met with trepidation by providers concerned that less frequent assessments may increase loss to follow-up, delay recognition of potentially mitigatable cardiomyopathy or overlook high-risk individuals concealed within broad, population-level risk-stratifications.”