Navigating Survivorship
Navigating Survivorship
Source/Disclosures
Disclosures: Moslehi reports having served as an unpaid consultant for the FDA and research grants from Bristol-Myers Squibb and Pfizer. Bhatia, Chow, Philips, Robison and colleagues and Zaha report no relevant financial disclosures. Please see the studies for all other authors’ relevant financial disclosures.
April 13, 2020
5 min read
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Long-term cancer survival increases need for cardiac care

Source/Disclosures
Disclosures: Moslehi reports having served as an unpaid consultant for the FDA and research grants from Bristol-Myers Squibb and Pfizer. Bhatia, Chow, Philips, Robison and colleagues and Zaha report no relevant financial disclosures. Please see the studies for all other authors’ relevant financial disclosures.
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Cancer survivors pose a unique challenge to primary care providers and cardiologists, as they are not only living longer but also presenting with competing risk factors.

“Multiple gaps exist in the routine cardiovascular care of the cancer survivor, especially around primary prevention efforts and surveillance for incident cardiovascular disease [CVD],” Steven Philips, MD, PhD, cardiology fellow at UT Southwestern Medical Center, and Vlad G. Zaha, MD, PhD, assistant professor in the center’s division of cardiology, wrote in a column for Cardiology Today.

Cancer survivors, regardless of their age, are at risk for two health issues: recurrence of cancer and CVD, Javid J. Moslehi, MD, associate professor of medicine in the division of cardiovascular medicine at Vanderbilt University Medical Center, wrote in a perspective that accompanied the column. “The medical community is well aware of the former; however, only recently have we become aware of the latter,” he wrote.

CVD and cancer are the most common causes of death in the U.S., and they intersect in expected and surprising ways, Philips and Zaha wrote. Although smoking is a well-known shared risk factor, cases of fulminant myocarditis seen after treatment with immune checkpoint inhibitors have been unexpected.

Cardio-oncology has emerged as a cross-disciplinary subspecialty focused on charting out and managing this complex bridging area between cancer and CVD, they wrote. Cardiovascular care for a patient with cancer can be provided at all stages: upon diagnosis, during therapy and during survivorship.

“It is cancer survivors who often pose the greatest challenge to cardiologists, perhaps in part due to the lack of comfort with onco-pharmacology and inadequate understanding of the horizon of cardiovascular toxicity,” Philips and Zaha wrote. “Whether it is the lung cancer survivor with a non-[ST-elevation myocardial infarction], the breast cancer survivor with subclinical cardiomyopathy or the childhood lymphoma survivor with mildly elevated blood pressure, the survivor population demands and deserves our utmost attention.”

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Population studies of cancer survivors have revealed multiple clinical care gaps within cardiovascular care that revolve around primary prevention efforts, cardiotoxicity surveillance and CVD management, Philips and Zaha wrote.

The National Comprehensive Cancer Network released guidelines at the end of March that include “ABCDE principles of cardiovascular disease risk assessment,” Moslehi told Healio.

“This simple checklist that was initially developed in the Vanderbilt cardio-oncology clinic presents an opportunity for the patient and treating physician to identify cardiovascular risk factors and attenuate these as needed to optimize cardiovascular health in all patients,” he said.

The guidelines specify that cancer survivors should be counseled on and assessed for CVD risk; be treated with aspirin, if appropriate; have their blood pressure and cholesterol assessed and monitored; participate in a discussion of smoking cessation, diet and weight management, diabetes prevention and management, and exercise; be assessed for the dose of cardiotoxic cancer therapy received; and be evaluated with an echocardiogram or EKG, as appropriate.

“This will be relevant to all physicians, including primary care doctors, across the country —not just cardio-oncologists,” Moslehi said. “One hopes that the cardiology community will work closely with primary care physicians and oncologists to implement these for our patients.”

Childhood cancer study

In 2016, there was an estimated 15.5 million cancer survivors in the U.S., and as of 2015 at least 429,000 were first diagnosed at younger than age 20 years, according to the NCI. As a result of advances in cancer treatment, 84% of children diagnosed with cancer are alive at least 5 years after diagnosis.

The Childhood Cancer Survivor Study (CCSS), funded by the NCI and other organizations, was initiated in 1994 to better understand the late effects of cancer treatment, increase survival and minimize harmful health effects, according to the NCI.

A number of researchers have reported on various results of the CCSS.

Robison and colleagues reported in 2009 that the study evaluated more than 14,000 5-year survivors of childhood and adolescent cancer who were diagnosed between 1970 and 1986.

“The health behaviors of long-term survivors may, compared with the general population, have a greater impact on the quality and length of their lives,” the researchers wrote.

Knowledge of the late effects of therapy is critical for the pediatric team when choosing initial therapy for patients, as well as future follow-up and screening, according to Robison and colleagues. Other health care providers can benefit from the results of the CCSS because they can assess the impact of long-term cancer survivorship on their delivery of care.

Chow and colleagues, in a 2017 report based on the CCSS, aimed to predict individual risk of ischemic heart disease and stroke among 5-year survivors of childhood cancer.

They followed 13,060 CCSS participants through age 50 years and used 4,023 siblings as a comparison population.

By age 50 years, 265 CCSS participants (7.7%) compared with 26 siblings (1.2%) had ischemic heart disease, and 295 CCSS participants (6.3%) compared with 19 siblings (1.1%) had a stroke, Chow and colleagues reported.

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The CCSS has shown increased rates of modifiable cardiovascular risk factors, including hypertension, hyperlipidemia, obesity, diabetes, sedentary lifestyle and smoking, among cancer survivors compared with siblings, Philips and Zaha wrote.

“Interestingly, incident hypertension and anthracycline exposure increase multiplicatively the risk for development of congestive heart failure in survivors of childhood cancer,” they wrote. “This markedly increased risk raises the stakes for all primary prevention efforts, such as routine health screening and smoking-cessation resources.”

Medical record surveillance

The gaps in CVD care for cancer survivors “are ripe for innovative closure methods, perhaps leveraging the power of electronic health record systems to assimilate and distill data from multiple sources at a nationwide or even worldwide scale,” Philips and Zaha said.

Surveillance and management of CVD, in addition to prevention in the survivor population, are challenging, they added.

“Patients with breast cancer treated with anthracyclines or the HER-2-targeted therapies trastuzumab (Herceptin, Genentech) and pertuzumab (Perjeta, Genentech) are at increased short-term and long-term risk for cardiomyopathy necessitating routine left ventricular ejection fraction assessment during treatment,” they wrote. “Using a single-center tertiary care electronic medical record registry, we have found surprisingly inadequate surveillance for cancer therapy-related cardiomyopathy [Philips and colleagues].

“That same analysis, which we presented at the American College of Cardiology Scientific Session in 2018, revealed a large proportion of patients with documented cardiac dysfunction after cancer therapy who were not receiving guideline-directed medical therapies such as beta-blockers, ACE [angiotensin-converting enzyme] inhibitors and implantable cardioverter defibrillators,” Philips and Zaha wrote.

Although a cure continues to be the ever-elusive target, long-term survival has become a tangible outcome for survivors of many types of cancer, the duo wrote.

“With increased survival, the burden of CV risk becomes more evident,” they wrote. – by Nancy Hemphill, ELS, FAAO

Disclosures: Moslehi reports having served as an unpaid consultant for the FDA and research grants from Bristol-Myers Squibb and Pfizer. Bhatia, Chow, Philips, Robison and colleagues and Zaha report no relevant financial disclosures. Please see the studies for all other authors’ relevant financial disclosures.