34 Oncology Times • August 25, 2015 • oncology-times.com Lifelong Cardiomyopathy Screening Advised for Childhood Cancer Survivors BY KURT SAMSON C hildhood survivors treated with high doses of anthra- cyclines, high doses of chest radiation, or a combination of both, should undergo lifelong sur- veillance for cardiomyopathy. That is the conclusion of a large-scale review of the medical literature by an international group that at- tempted to coordinate existing recommendations and recon- cile and understand what had been differing conclusions. The study (Lancet Oncol 2015;16:e123-e136), by the International Late Effects of Childhood Cancer Guideline Harmonization Group, also advised that chil- dren treated with moderate or low doses should be considered for surveillance depending on other cardiac risk factors. “We have seen tremen- dous advances in childhood cancer treatment, with more than 80 percent of children expected to be sur- vivors for at least five years, but child- hood cancer survivors, regardless of their current age, should be aware of their increased risk of cardiovascular problems,” said the chair of the con- sortium’s cardiomyopathy working group, Saro Armenian, DO, Director of the Childhood Cancer Survivorship Clinic at City of Hope. “This is a lifelong risk, and many of these problems don’t appear until 10 or 20 years after treatment, so surveil- lance and monitoring should continue throughout their life.” According to American Cancer Society estimates, there are more than 400,000 childhood survivors in the United States, and the number is ex- pected to reach half a million by 2020. Echocardiography The panel recommended echocardiog- raphy as the primary method of surveil- lance, although other forms of screening, such as magnetic resonance imaging, should also be considered. Screening is advised starting two years after the completion of therapy and should be re- peated every five years, al- though more frequent testing is reasonable for those at higher risk. As described in the study, the au- thors conducted a comprehensive review of all available literature to as- sess risk and make recommendations on how best to protect the hearts of childhood cancer survivors. Even with all the treatment advances, more than 40 percent of childhood can- cer survivors who are still alive 30 years after their diagnosis have a severe or life-threatening chronic health disorder, including heart disease. Cardiovascular com- plications—coronary artery disease, stroke, and congestive heart failure— have emerged as a lead- ing cause of illness or death in survivors. The inves- tigators also said that child- hood cancer survivors should be espe- cially careful to manage their risk of high blood pressure and diabetes, both of which raise the likelihood of heart disease. Armenian noted that some of this is uncharted territory, since survivors of childhood cancer reaching their 50s and 60s is a fairly new phenomenon. But if they are screened early, even if asymptomatic, there is a chance to mit- igate the problems. The study showed that survivors have 10 times the risk for atheroscle- rosis, 5.9 times the risk of congestive heart failure, 6.3 times the risk of peri- cardial disease, and 4.8 times of the risk for heart valve disease. The risks were especially high for those treated with anthracycline drugs, such as doxorubicin, or high-dose radiation therapy to the heart. “We are trying to develop uni- form guidelines. Health care groups around the world have recommended different screening parameters and definitions for these children, and there is some discordance, which can result in confusion,” he said. “We found compelling evidence that the use of anthracyclines and chest radiation can raise the risk of later cardiovascular issues in long-term survivors, and that this requires regu- lar monitoring.” While there has been increased uni- formity in monitoring and screening in the United States and Europe, many other countries lack guidelines. This is especially true for certain subsets of survivors who might have other cardio- vascular risk factors. “As we get more information, we will continue to update these guide- lines,” Armenian said. “It is important to emphasize that this has been an ex- haustive effort as well as a transpar- ent process of evaluation. We relied on only high-impact, high-quality research.” Nonetheless, he said that there is a relative lack of research on such survivors and long-term heart is- sues. When only little evidence was available, the researchers extrapo- lated data from other populations at risk of congestive heart failure. “Importantly, there are key gaps in our knowledge of the frequency of screening in different risk groups, the role of cardiac MRI, myocardial strain testing, three-dimensional echocardiography, and the use of cardiac blood biomarkers in primary surveillance. “More research is also needed in the prognostic value of changes in intermediate echocardiographic indi- ces of left ventricular systolic and dia- stolic function as well as the efficacy of early intervention strategies for congestive heart failure preven- tion.” Answers to these and other key questions can be ad- dressed only through a comprehensive and systematic approach requiring multidisci- plinary and interna- tional collaborations The existing guidelines have differed with regards to key definitions as well as recommendations. T he International Late Effects of Childhood Cancer Guideline Harmonization Group, started in 2010, is a worldwide effort by several national guideline groups and the Cochrane Childhood Cancer Group, in partnership with the PanCare Childhood and Adolescent Cancer Survivor Care and Follow-up Studies consortium of 16 European institutions to col- laborate on developing guidelines. Group Started in 2010