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Dixon SB, Chow EJ, Hjorth L, Hudson MM, Kremer LCM, Morton LM, Nathan PC, Ness KK, Oeffinger KC, Armstrong GT. The Future of Childhood Cancer Survivorship: Challenges and Opportunities for Continued Progress. Pediatr Clin North Am 2020; 67:1237-1251. [PMID: 33131544 PMCID: PMC7773506 DOI: 10.1016/j.pcl.2020.07.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
As treatment evolves and the population who survive childhood cancer ages and increases in number, researchers must use novel approaches to prevent, identify and mitigate adverse effects of treatment. Future priorities include collaborative efforts to pool large cohort data to improve detection of late effects, identify late effects of novel therapies, and determine the contribution of genetic factors along with physiologic and accelerated aging among survivors. This knowledge should translate to individual risk prediction and prevention strategies. Finally, we must utilize health services research and implementation science to improve adoption of survivorship care recommendations outside of specialized pediatric oncology centers.
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Affiliation(s)
- Stephanie B Dixon
- Department of Oncology, St. Jude Children's Research Hospital, MS 735, 262 Danny Thomas Place, Memphis, TN 38105, USA.
| | - Eric J Chow
- Fred Hutchinson Cancer Research Center, University of Washington, 1100 Fairview Avenue North, M4-C308, Seattle, WA 98109, USA
| | - Lars Hjorth
- Department of Paediatrics, Skane University Hospital, Lund, Sweden; Clinical Sciences Lund, Lund University, Lund 221 85, Sweden
| | - Melissa M Hudson
- Division of Cancer Survivorship, Department of Oncology, St. Jude Children's Research Hospital, MS 735, 262 Danny Thomas Place, Memphis, TN 38105, USA
| | - Leontien C M Kremer
- Princess Maxima Center, Heidelberglaan 25, Utrecht 3584 CS, Netherlands; Emma Children's Hospital, Amsterdam UMC, Amsterdam, Netherlands
| | - Lindsay M Morton
- Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, Department of Health and Human Services, National Cancer Institute, National Institutes of Health, 9609 Medical Center Drive, MSC 9778, Bethesda, MD 20892-9778, USA
| | - Paul C Nathan
- Division of Hematology/Oncology, The Hospital for Sick Children, 555 University Avenue, Room 9402 Black Wing, Toronto, ON M5G 1X8, Canada
| | - Kirsten K Ness
- Department of Epidemiology and Cancer Control, St. Jude. Children's Research Hospital, MS 735, 262 Danny Thomas Place, Memphis, TN 38105, USA
| | - Kevin C Oeffinger
- Duke Center for Onco-Primary Care, Duke Cancer Institute, 2424 Erwin Drive, Suite 601, Durham, NC 27705, USA
| | - Gregory T Armstrong
- Department of Epidemiology and Cancer Control, St. Jude. Children's Research Hospital, MS 735, 262 Danny Thomas Place, Memphis, TN 38105, USA
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Dixon SB, Howell CR, Lu L, Plana JC, Joshi VM, Luepker RV, Durand JB, Ky B, Lenihan DJ, Jefferies JL, Green DM, Ehrhardt MJ, Mulrooney DA, Folse TE, Partin RE, Santucci AK, Howell RM, Srivastava DK, Hudson MM, Robison LL, Ness KK, Armstrong GT. Cardiac biomarkers and association with subsequent cardiomyopathy and mortality among adult survivors of childhood cancer: A report from the St. Jude Lifetime Cohort. Cancer 2020; 127:458-466. [PMID: 33108003 DOI: 10.1002/cncr.33292] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 09/11/2020] [Accepted: 09/29/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Survivors of childhood cancer exposed to cardiotoxic therapies are at significant cardiovascular risk. The utility of cardiac biomarkers for identifying the risk of future cardiomyopathy and mortality is unknown. METHODS N-terminal pro-B-type natriuretic peptide (NT-proBNP) and cardiac troponin T (cTnT) were assessed in 1213 adults 10 or more years from a childhood cancer diagnosis; 786 were exposed to anthracycline chemotherapy and/or chest-directed radiation therapy (RT). NT-proBNP values above age- and sex-specific 97.5th percentiles were considered abnormal. Generalized linear models estimated cross-sectional associations between abnormal NT-proBNP and anthracycline or chest RT doses as risk ratios with 95% confidence intervals (CIs). A Poisson distribution estimated rates and a Cox proportional hazards model estimated hazard ratios (HRs) for future cardiac events and death. RESULTS At a median age of 35.5 years (interquartile range, 29.8-42.5 years), NT-proBNP and cTnT were abnormal in 22.5% and 0.4%, respectively. Exposure to chest RT and exposure to anthracycline chemotherapy were each associated with a dose-dependent increased risk for abnormal NT-proBNP (P for trend <.0001). Among exposed survivors with no history of Common Terminology Criteria for Adverse Events-graded cardiomyopathy and with normal systolic function, survivors with abnormal NT-proBNP had higher rates per 1000 person-years of cardiac mortality (2.93 vs 0.96; P < .0001) and future cardiomyopathy (32.10 vs 15.98; P < .0001) and an increased risk of future cardiomyopathy (HR, 2.28; 95% CI, 1.28-4.08) according to a multivariable assessment. CONCLUSIONS Abnormal NT-proBNP values were prevalent and, among survivors who were exposed to cardiotoxic therapy but did not have a history of cardiomyopathy or current systolic dysfunction, identified those at increased risk for future cardiomyopathy. Further longitudinal studies are needed to confirm this novel finding.
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Affiliation(s)
- Stephanie B Dixon
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Carrie R Howell
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lu Lu
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Juan C Plana
- Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Vijaya M Joshi
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Russell V Luepker
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota
| | - Jean B Durand
- Division of Cardiology, Department of Medicine, The University of Texas at MD Anderson Cancer Center, Houston, Texas
| | - Bonnie Ky
- Division of Cardiology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Daniel J Lenihan
- Cardio-Oncology Center of Excellence, Washington University, St. Louis, Missouri
| | - John L Jefferies
- Cardiac Institute, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Daniel M Green
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee.,Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Matthew J Ehrhardt
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee.,Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Daniel A Mulrooney
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee.,Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee.,Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Timothy E Folse
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Robyn E Partin
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Aimee K Santucci
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Rebecca M Howell
- Division of Radiation Oncology, Department of Radiation Physics, The University of Texas at MD Anderson Cancer Center, Houston, Texas
| | - Deo Kumar Srivastava
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Melissa M Hudson
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee.,Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Leslie L Robison
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Kirsten K Ness
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Gregory T Armstrong
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee.,Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
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53
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Goldberg JF, Ness KK, Chi X, Santucci AK, Plana JC, Joshi VM, Luepker RV, Durand JB, Partin RE, Howell RM, Wilson CL, Towbin JA, Jefferies JL, Srivastava DK, Hudson MM, Robison LL, Armstrong GT. Cardiovascular Family History Increases Risk for Late-Onset Adverse Cardiovascular Outcomes in Childhood Cancer Survivors: A St. Jude Lifetime Cohort Report. Cancer Epidemiol Biomarkers Prev 2020; 30:123-132. [PMID: 33033146 DOI: 10.1158/1055-9965.epi-20-0809] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 08/18/2020] [Accepted: 09/30/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Survivors of childhood cancer have an increased risk of therapy-related cardiovascular disease. It is not known whether family history of cardiovascular disease further increases risk of adverse cardiovascular outcomes among survivors. METHODS Family history of cardiovascular disease was collected from 1,260 survivors [median age at diagnosis, 8 years (range, 0-23); age at last follow-up, 35 years (range, 18-66)] of childhood cancer in the St. Jude Lifetime Cohort Study. Multivariable risk models evaluated associations with cardiovascular disease (Common Terminology Criteria for Adverse Events grade 2-4 events) and cardiovascular risk factors. RESULTS Among survivors exposed to chest-directed radiation and/or anthracycline chemotherapy (n = 824), 7% reported a first-degree family history of heart failure, 19% myocardial infarction, 11% stroke, 26% atherosclerotic disease (myocardial infarction and/or stroke), 62% hypertension, and 31% diabetes mellitus. Eighteen percent of exposed survivors developed heart failure, 9% myocardial infarction, 3% stroke, 11% atherosclerotic disease, 30% hypertension, and 9% diabetes mellitus. Having a first-degree family history of atherosclerotic disease was independently associated with development of treatment-related heart failure [RR, 1.38; 95% confidence interval (CI), 1.01-1.88; P = 0.04] among exposed survivors. Risk for hypertension was increased among exposed survivors with a first-degree family history of hypertension (RR, 1.55; 95% CI, 1.26-1.92; P < 0.0001) or of any cardiovascular disease [myocardial infarction, stroke, or heart failure (RR, 1.30; 95% CI, 1.06-1.59; P = 0.01)]. CONCLUSIONS Family history of cardiovascular disease and cardiovascular risk factors independently increased risk of heart failure and hypertension among survivors of childhood cancer exposed to cardiotoxic therapies. IMPACT These data show the importance of cardiovascular family history as a risk factor for cardiovascular disease in survivors of childhood cancer.
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Affiliation(s)
- Jason F Goldberg
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee.
| | - Kirsten K Ness
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Xiaofei Chi
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Aimee K Santucci
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | | | - Vijaya M Joshi
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Russell V Luepker
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota
| | - Jean-Bernard Durand
- Division of Cardiology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Robyn E Partin
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Rebecca M Howell
- Division of Radiation Physics, Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Carmen L Wilson
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Jeffrey A Towbin
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
| | - John L Jefferies
- Division of Adult Cardiovascular Diseases, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Deo Kumar Srivastava
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Melissa M Hudson
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Leslie L Robison
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Gregory T Armstrong
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
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Foulkes S, Costello BT, Howden EJ, Janssens K, Dillon H, Toro C, Claus P, Fraser SF, Daly RM, Elliott DA, Conyers R, La Gerche A. Exercise cardiovascular magnetic resonance reveals reduced cardiac reserve in pediatric cancer survivors with impaired cardiopulmonary fitness. J Cardiovasc Magn Reson 2020; 22:64. [PMID: 32892749 PMCID: PMC7487601 DOI: 10.1186/s12968-020-00658-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 07/28/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Pediatric cancer survivors are at increased risk of cardiac dysfunction and heart failure. Reduced peak oxygen consumption (peak VO2) is associated with impaired cardiac reserve (defined as the increase in cardiac function from rest to peak exercise) and heart failure risk, but it is unclear whether this relationship exists in pediatric cancer survivors. This study sought to investigate the presence of reduced peak VO2 in pediatric cancer survivors with increased risk of heart failure, and to assess its relationship with resting cardiac function and cardiac haemodynamics and systolic function during exercise. METHODS Twenty pediatric cancer survivors (8-24 years; 10 male) treated with anthracycline chemotherapy ± radiation underwent cardiopulmonary exercise testing to quantify peak VO2, with a value < 85% of predicted defined as impaired peak VO2. Resting cardiac function was assessed using 2- and 3-dimensional echocardiography, with cardiac reserve quantified from resting and peak exercise heart rate, stroke volume index (SVI) and cardiac index (CI) using exercise cardiovascular magnetic resonance (CMR). RESULTS Twelve of 20 survivors (60%) had reduced peak VO2 (70 ± 16% vs. 97 ± 14% of age and gender predicted). There were no differences in echocardiographic or CMR measurements of resting cardiac function between survivors with normal or impaired peak VO2. However, those with reduced peak VO2 had diminished cardiac reserve, with a lesser increase in CI and SVI during exercise (Interaction P < 0.01 for both), whilst the heart rate response was similar (P = 0.71). CONCLUSIONS Whilst exercise intolerance is common among pediatric cancer survivors, it is poorly explained by resting measures of cardiac function. In contrast, impaired exercise capacity is associated with impaired haemodynamics and systolic functional reserve measured during exercise. Consequently, measures of cardiopulmonary fitness and cardiac reserve may aid in early identification of survivors with heightened risk of long-term heart failure.
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Affiliation(s)
- Stephen Foulkes
- Department of Sports Cardiology, Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, VIC, 3004, Australia
- Institute for Physical Activity and Nutrition, Deakin University, Geelong, VIC, Australia
| | - Benedict T Costello
- Department of Sports Cardiology, Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, VIC, 3004, Australia
- Cardiology Department, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
| | - Erin J Howden
- Department of Sports Cardiology, Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, VIC, 3004, Australia
| | - Kristel Janssens
- Department of Sports Cardiology, Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, VIC, 3004, Australia
| | - Hayley Dillon
- Department of Sports Cardiology, Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, VIC, 3004, Australia
- Institute for Physical Activity and Nutrition, Deakin University, Geelong, VIC, Australia
| | - Claudia Toro
- Children's Cancer Centre, The Royal Children's Hospital, Melbourne, VIC, Australia
| | - Piet Claus
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Steve F Fraser
- Institute for Physical Activity and Nutrition, Deakin University, Geelong, VIC, Australia
| | - Robin M Daly
- Institute for Physical Activity and Nutrition, Deakin University, Geelong, VIC, Australia
| | - David A Elliott
- Children's Cancer Centre, The Royal Children's Hospital, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, The Royal Children's Hospital, Melbourne, VIC, Australia
- Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
| | - Rachel Conyers
- Children's Cancer Centre, The Royal Children's Hospital, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, The Royal Children's Hospital, Melbourne, VIC, Australia
- Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, VIC, Australia
| | - Andre La Gerche
- Department of Sports Cardiology, Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, VIC, 3004, Australia.
- Cardiology Department, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia.
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55
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Leerink JM, de Baat EC, Feijen EA, Bellersen L, van Dalen EC, Grotenhuis HB, Kapusta L, Kok WE, Loonen J, van der Pal HJ, Pluijm SM, Teske AJ, Mavinkurve-Groothuis AM, Merkx R, Kremer LC. Cardiac Disease in Childhood Cancer Survivors: Risk Prediction, Prevention, and Surveillance: JACC CardioOncology State-of-the-Art Review. JACC CardioOncol 2020; 2:363-378. [PMID: 34396245 PMCID: PMC8352294 DOI: 10.1016/j.jaccao.2020.08.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/07/2020] [Accepted: 08/08/2020] [Indexed: 02/06/2023] Open
Abstract
Cardiac diseases in the growing population of childhood cancer survivors are of major concern. Cardiotoxicity as a consequence of anthracyclines and chest radiotherapy continues to be relevant in the modern treatment era. Mitoxantrone has emerged as an important treatment-related risk factor and evidence on traditional cardiovascular risk factors in childhood cancer survivors is accumulating. International surveillance guidelines have been developed with the aim to detect and manage cardiac diseases early and prevent symptomatic disease. There is growing interest in risk prediction models to individualize prevention and surveillance. This State-of-the-Art Review summarizes literature from a systematic PubMed search focused on cardiac diseases after treatment for childhood cancer. Here, we discuss the prevalence, risk factors, prevention, risk prediction, and surveillance of cardiac diseases in survivors of childhood cancer.
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Key Words
- CAD, coronary artery disease
- CCS, childhood cancer survivors
- ECG, electrocardiogram
- FS, fractional shortening
- GLS, global longitudinal strain
- IGHG, International Late Effects of Childhood Cancer Guideline Harmonization Group
- LV, left ventricle
- LVEF, left ventricular ejection fraction
- RCT, randomized controlled trial
- cardiotoxicity
- cardiovascular risk factors
- chest RT, chest-directed radiotherapy
- childhood cancer survivors
- prevention
- risk prediction
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Affiliation(s)
- Jan M. Leerink
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Esmée C. de Baat
- Department of Pediatric Oncology, Princess Máxima Center, Utrecht, the Netherlands
| | | | - Louise Bellersen
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Elvira C. van Dalen
- Department of Pediatric Oncology, Princess Máxima Center, Utrecht, the Netherlands
| | - Heynric B. Grotenhuis
- Department of Pediatric Cardiology, Wilhelmina Children's Hospital, University of Utrecht, Utrecht, the Netherlands
| | - Livia Kapusta
- Department of Pediatric Cardiology, Radboud University Medical Center, Amalia Children’s Hospital, Nijmegen, the Netherlands
- Department of Pediatrics, Tel Aviv University, Sackler School of Medicine, Tel Aviv Sourasky Medical Center, Pediatric Cardiology Unit, Tel Aviv, Israel
| | - Wouter E.M. Kok
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Jacqueline Loonen
- Department of Pediatric Hematology and Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Saskia M.F. Pluijm
- Department of Pediatric Oncology, Princess Máxima Center, Utrecht, the Netherlands
| | - Arco J. Teske
- Department of Cardiology, Utrecht University Medical Center, Utrecht, the Netherlands
| | | | - Remy Merkx
- Department of Medical Imaging, Radboud University Medical Center, Medical UltraSound Imaging Center, Nijmegen, the Netherlands
| | - Leontien C.M. Kremer
- Department of Pediatric Oncology, Princess Máxima Center, Utrecht, the Netherlands
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Hayek S, Brinkman TM, Plana JC, Joshi VM, Leupker RV, Durand JB, Green DM, Partin RE, Santucci AK, Howell RM, Srivastava DK, Hudson MM, Robison LL, Armstrong GT, Ness KK. Association of Exercise Intolerance With Emotional Distress, Attainment of Social Roles, and Health-Related Quality of Life Among Adult Survivors of Childhood Cancer. JAMA Oncol 2020; 6:1194-1202. [PMID: 32584369 PMCID: PMC7317652 DOI: 10.1001/jamaoncol.2020.2054] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 04/17/2020] [Indexed: 12/19/2022]
Abstract
Importance Exercise intolerance is associated with increased risk for morbidity and mortality in childhood cancer survivors. However, an association between exercise intolerance and psychosocial outcomes has not been fully explored. Objective To examine the associations between exercise intolerance and emotional distress, attainment of social roles, and health-related quality of life in childhood cancer survivors. Design, Setting, and Participants A cross-sectional study including 1041 adult survivors of childhood cancer and 286 community controls in the St Jude Lifetime Cohort was conducted at St Jude Children's Research Hospital. The study was performed from April 1, 2012, to March 15, 2020. Exposures Exercise intolerance was defined as relative peak oxygen uptake less than 85% of age- and sex-estimated levels from maximal cardiopulmonary exercise testing. Main Outcomes and Measures Emotional distress was measured with the 18-item Brief Symptom Inventory-18, which includes overall Global Severity Index and depression, anxiety, and somatization subscales. Participants with T scores greater than or equal to 63 were classified as having elevated levels of distress. Social attainment was evaluated using patient-reported educational, employment, and marital status. Health-related quality of life was examined with the Medical Outcomes Survey Short Form-36. Participants with T scores less than or equal to 40 were classified as reporting poor health-related quality of life. Results Of the 1041 participants, 528 were women (50.7%). The prevalence of exercise intolerance among survivors (mean [SD] age, 35.5 [9.2] years) was higher than that among controls (age, 34.5 [10.0] years) (survivors: 634 [60.9%] vs controls: 75 [26.2%], P < .001). After adjusting for age at diagnosis and cardiopulmonary exercise testing, sex, race/ethnicity, smoking, physical activity, and exercise intolerance were associated with an increased risk for anxiety (prevalence rate ratio [PRR], 1.95; 95% CI, 1.20-3.16), somatization (PRR, 1.86; 95% CI, 1.23-2.80), and unemployment (PRR, 1.76; 95% CI, 1.23-2.52); an inverse association was noted with having a college degree (PRR, 0.67; 95% CI, 0.50-0.88). Exercise intolerance was associated with an increased the risk for scoring less than or equal to 40 on the physical component summary of the Medical Outcomes Survey Short Form-36 (PRR, 3.69; 95% CI, 2.34-5.84). These associations persisted when either cancer treatment exposures or chronic health conditions were added to the model. Conclusions and Relevance The findings of this study suggest that exercise intolerance is independently associated with emotional distress, attainment of social roles, and health-related quality of life of long-term survivors of childhood cancer. The results also suggest that improving physiologic capacity may benefit general health and wellness, as well as emotional health, ability to participate in social roles, and health-related quality of life.
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Affiliation(s)
| | - Tara M. Brinkman
- Department of Epidemiology and Cancer Control, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Juan C. Plana
- Section of Cardiology, Baylor College of Medicine, Houston, Texas
| | - Vijaya M. Joshi
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis
| | - Russell V. Leupker
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis
| | - Jean B. Durand
- Division of Cardiology, The University of Texas, MD Anderson Cancer Center, Houston
| | - Daniel M. Green
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Robyn E. Partin
- Department of Epidemiology and Cancer Control, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Aimee K. Santucci
- Department of Epidemiology and Cancer Control, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Rebecca M. Howell
- Division of Radiology Oncology, Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston
| | - Deo Kumar Srivastava
- Department of Biostatistics, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Melissa M. Hudson
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Leslie L. Robison
- Department of Epidemiology and Cancer Control, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Gregory T. Armstrong
- Department of Epidemiology and Cancer Control, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Kirsten K. Ness
- Department of Epidemiology and Cancer Control, St Jude Children’s Research Hospital, Memphis, Tennessee
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57
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Nielsen MKF, Christensen JF, Frandsen TL, Thorsteinsson T, Andersen LB, Christensen KB, Wehner PS, Hasle H, Adamsen LØ, Schmiegelow K, Larsen HB. Effects of a physical activity program from diagnosis on cardiorespiratory fitness in children with cancer: a national non-randomized controlled trial. BMC Med 2020; 18:175. [PMID: 32624004 PMCID: PMC7336676 DOI: 10.1186/s12916-020-01634-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 05/14/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Children with cancer experience impaired cardiorespiratory fitness and physical function during and after treatment restricting their possibilities to engage in social activities including sport, leisure activities, and school. The objectives were to determine the effects of classmate-supported, controlled, supervised, in-hospital, physical activity program to preserve cardiorespiratory fitness and physical function from time of diagnosis in children with cancer. METHODS National non-randomized controlled trial including schoolchildren aged 6-18 years at diagnosis treated with chemo-/radiotherapy. We included 120 of 128 eligible patients (94%) in the intervention group (62.5% boys, 11.2 ± 3.1 years) from East Denmark and 58 patients in the control group (57% boys, 11.0 ± 3.2 years) from West Denmark. Eight children from the control group withdrew from participation. The groups were comparable in anthropometrics and cancer diagnoses (p > 0.05). The intervention consisted of (i) supervised in-hospital physical activity from diagnosis and throughout intensive treatment, (ii) 90-min general educational session on cancer and therapy in the child's school class, and (iii) selection of two classmates as ambassadors who took turns to support the child's physical training during the daytime. The primary outcome was cardiorespiratory fitness (VO2peak, mL/min/kg) at 6 months after diagnosis (sex, age, diagnosis adjusted). Secondary outcomes were sit-to-stand, timed-up-and-go, handgrip strength, and balance test scores. RESULTS Ambassadors were identified for all, and 2542 individual and 621 group training sessions were held. VO2peak deteriorated over time in the control group (- 0.17 [95% CI - 0.32 to - 0.02] per week, p = 0.02), but not in the intervention group (p = 0.14). At 6 months from diagnosis, VO2peak was higher in the intervention group (29.6 ± 5.6 mL/kg/min) than in the control group (22.1 ± 5.6 mL/kg/min) (p = 0.01), and the intervention group had a better physical function at 3 and 6 months (p < 0.0001). CONCLUSIONS Peer-supported, supervised, in-hospital, physical activity is safe and feasible in children with cancer during treatment. Further, the results suggest that the intervention might mitigate impairments in cardiorespiratory fitness during treatment in children with cancer. TRIAL REGISTRATION The study was prospectively registered on the 11 January 2013. Clinicaltrial.gov NCT01772849 and NCT01772862 .
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Affiliation(s)
- Martin Kaj Fridh Nielsen
- Department of Pediatrics and Adolescent Medicine, The Juliane Marie Center, University Hospital of Copenhagen (Rigshospitalet), Blegdamsvej 9, DK-2100, Copenhagen, Denmark.,The University of Copenhagen, Faculty of Health Science, Institute for Clinical Medicine, Copenhagen, Denmark
| | - Jesper Frank Christensen
- Center for Inflammation and Metabolism/Center for Physical Activity (CIM/CFAS), University Hospital (Rigshospitalet), Copenhagen, Denmark
| | - Thomas Leth Frandsen
- Department of Pediatrics and Adolescent Medicine, The Juliane Marie Center, University Hospital of Copenhagen (Rigshospitalet), Blegdamsvej 9, DK-2100, Copenhagen, Denmark
| | - Troels Thorsteinsson
- Department of Pediatrics and Adolescent Medicine, The Juliane Marie Center, University Hospital of Copenhagen (Rigshospitalet), Blegdamsvej 9, DK-2100, Copenhagen, Denmark
| | - Lars Bo Andersen
- Department of Sports Medicine, Norwegian School for Sports Sciences, Oslo, Norway.,Faculty of Education, Arts and Sports, Department of Sport, Food and Natural Sciences,Western Norway University of Applied Sciences, Post box 133, 6851, Sognal, Norway
| | | | - Peder Skov Wehner
- Department of Pediatric Hematology and Oncology, H.C. Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
| | - Henrik Hasle
- Pediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Lis Ørgaard Adamsen
- Faculty of Health Science, Department of Public Health, Institute for Clinical Medicine, The University of Copenhagen, Copenhagen, Denmark.,The University Hospitals Centre for Health Research (UCSF), University Hospital (Rigshospitalet), Copenhagen, Denmark
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, The Juliane Marie Center, University Hospital of Copenhagen (Rigshospitalet), Blegdamsvej 9, DK-2100, Copenhagen, Denmark.,The University of Copenhagen, Faculty of Health Science, Institute for Clinical Medicine, Copenhagen, Denmark
| | - Hanne Bækgaard Larsen
- Department of Pediatrics and Adolescent Medicine, The Juliane Marie Center, University Hospital of Copenhagen (Rigshospitalet), Blegdamsvej 9, DK-2100, Copenhagen, Denmark.
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58
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Maximal cardiopulmonary exercise testing in childhood acute lymphoblastic leukemia survivors exposed to chemotherapy. Support Care Cancer 2020; 29:987-996. [PMID: 32556714 DOI: 10.1007/s00520-020-05582-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/13/2020] [Indexed: 12/28/2022]
Abstract
PURPOSE The purpose of this study was to demonstrate if childhood acute lymphoblastic leukemia (ALL) survivors exposed to chemotherapy (i.e., doxorubicin) are able to achieve a safe maximal cardiopulmonary exercise test (CPET). METHODS A total of 250 childhood ALL survivors were eligible to undergo a CPET on ergocycle. Analyses were performed in 216 survivors and stratified in regard to their prognostic risk groups: 99 survivors (55 males and 44 females) at standard risk and 117 survivors (56 males and 61 females) at high risk. RESULTS Results showed that 100% (n = 216) of survivors completed a maximal CPET confirmed by the achievement of two out of three of the following criteria: 197 survivors (91.2%) reached a peak RER value of ≥ 1.15, 197 survivors (91.2%) reached a RPE score > 7, and 210 survivors (97.2%) reached a maximal heart rate ≥ 85% of the predicted value. Linear regression analysis showed a significant association between the survivors' cumulative dose of doxorubicin and their VO2 peak measured. Two non-fatal adverse events were observed and reported at the end of the maximal CPET, while non-fatal adverse events were reported in 5 survivors during the recovery period. None of these events resulted in a long-term complication. CONCLUSION Childhood ALL survivors with prior exposure to chemotherapy can achieve a safe maximal CPET. They were able of achieving a maximal exercise test without being limited by symptoms, potential overprotection, or musculoskeletal issues. Thus, it should be the norm to realize a CPET prior a physical activity program to propose an optimal prescription. This study provides important information regarding the maximal physiological parameters that childhood ALL survivors are able to reach and have important clinical implications in the exercise and oncology field for this population of survivors.
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59
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Clinical Practice and Research in Cardio-Oncology: Finding the "Rosetta Stone" for Establishing Program Excellence in Cardio-oncology. J Cardiovasc Transl Res 2020; 13:495-505. [PMID: 32444945 DOI: 10.1007/s12265-020-10010-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 04/17/2020] [Indexed: 02/06/2023]
Abstract
The burgeoning field of cardio-oncology (C-O) is now necessary for the delivery of excellent care for patients with cancer. Many factors have contributed to this increasing population of cancer survivors or those being treated with novel and targeted cancer therapies. There is a tremendous need to provide outstanding cardiovascular (CV) care for these patients; however, current medical literature actually provides a paucity of guidance. C-O therefore provides a novel opportunity for clinical, translational, and basic research to advance patient care. This review aims to be a primer for cardio-oncologists on how to develop a vibrant and comprehensive C-O program, use practical tools to assist in the construction of C-O services, and to proactively incorporate translational and clinical research into the training of future leaders as well as enhance clinical care.
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60
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Foulkes S, Claessen G, Howden EJ, Daly RM, Fraser SF, La Gerche A. The Utility of Cardiac Reserve for the Early Detection of Cancer Treatment-Related Cardiac Dysfunction: A Comprehensive Overview. Front Cardiovasc Med 2020; 7:32. [PMID: 32211421 PMCID: PMC7076049 DOI: 10.3389/fcvm.2020.00032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Accepted: 02/21/2020] [Indexed: 12/20/2022] Open
Abstract
With progressive advancements in cancer detection and treatment, cancer-specific survival has improved dramatically over the past decades. Consequently, long-term health outcomes are increasingly defined by comorbidities such as cardiovascular disease. Importantly, a number of well-established and emerging cancer treatments have been associated with varying degrees of cardiovascular injury that may not emerge until years following the completion of cancer treatment. Of particular concern is the development of cancer treatment related cardiac dysfunction (CTRCD) which is associated with an increased risk of heart failure and high risk of morbidity and mortality. Early detection of CTRCD appears critical for preventing long-term cardiovascular morbidity in cancer survivors. However, current clinical standards for the identification of CTRCD rely on assessments of cardiac function in the resting state. This provides incomplete information about the heart's reserve capacity and may reduce the sensitivity for detecting sub-clinical myocardial injury. Advances in non-invasive imaging techniques have enabled cardiac function to be quantified during exercise thereby providing a novel means of identifying early cardiac dysfunction that has proved useful in several cardiovascular pathologies. The purpose of this narrative review is (1) to discuss the different non-invasive imaging techniques that can be used for quantifying different aspects of cardiac reserve; (2) discuss the findings from studies of cancer patients that have measured cardiac reserve as a marker of CTRCD; and (3) highlight the future directions important knowledge gaps that need to be addressed for cardiac reserve to be effectively integrated into routine monitoring for cancer patients exposed to cardiotoxic therapies.
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Affiliation(s)
- Stephen Foulkes
- School of Exercise and Nutrition Sciences, Institute of Physical Activity and Nutrition, Deakin University, Geelong, VIC, Australia.,Department of Sports Cardiology, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Guido Claessen
- Department of Sports Cardiology, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia.,Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Erin J Howden
- Department of Sports Cardiology, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Robin M Daly
- School of Exercise and Nutrition Sciences, Institute of Physical Activity and Nutrition, Deakin University, Geelong, VIC, Australia
| | - Steve F Fraser
- School of Exercise and Nutrition Sciences, Institute of Physical Activity and Nutrition, Deakin University, Geelong, VIC, Australia
| | - Andre La Gerche
- Department of Sports Cardiology, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia.,Cardiology Department, St. Vincent's Hospital Melbourne, Melbourne, VIC, Australia
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