1
|
Jess L, Jarfelt M, Bäck M. Reliability and validity of self-report questions for assessing levels of physical activity and sedentary time in adult childhood cancer survivors. BMC Sports Sci Med Rehabil 2024; 16:66. [PMID: 38448950 PMCID: PMC10916125 DOI: 10.1186/s13102-024-00851-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 02/19/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Regular physical activity and limited sedentary time are recommended for adult childhood cancer survivors. The Swedish National Board of Health and Welfare designed a questionnaire to assess levels of physical activity (BHW-Q), including two questions: one on vigorous physical activity (BHW-Q VPA) and one on moderate physical activity (BHW-Q MPA). Furthermore, a single-item question was developed to measure sedentary time (SED-GIH-Q). These questions are recommended for clinical practice and have been found valid for the general population but have so far not been tested in adult childhood cancer survivors. The aim of the study was to assess test-retest reliability, agreement and criterion-related validity of the BHW-Q and the SED-GIH-Q in adult childhood cancer survivors. METHOD A non-experimental methodological study. In total 60 participants (50% women), median age 28 (min-max 18-54) years were included at the Long-Term Follow-Up Clinic at Sahlgrenska University Hospital. Participants were instructed to wear an accelerometer for seven days, and to answer the BHW-Q and the SED-GIH-Q before and after the seven days. Test-retest reliability and criterion-related validity comparing the BHW-Q and SED GIH-Q with accelerometer data were calculated with weighted Kappa (k) (agreement) and by using Spearman´s rho (r) (correlation). RESULTS Test-retest reliability regarding the SED-GIH-Q showed a high agreement (k = 0.88) and very strong correlation (r = 0.93), while the BHW-Q showed a moderate agreement and moderately strong correlation, BHW-Q VPA (k = 0.50, r = 0.64), BHW-Q MPA (k = 0.47, r = 0.58). Both the agreement and the correlation of the criterion-related validity were interpreted as fair for the BHW-Q VPA (k = 0.29, r = 0.45), while the agreement for BHW-Q MPA was interpreted as low (k = 0.07), but the correlation as fair (r = 0.37). The agreement of the SED-GIH-Q (k = 0.13) was interpreted as low and the correlation as poor (r = 0.26). CONCLUSION These simple questions assessing physical activity and sedentary time can be used as screening tools in clinical practice to identify adult childhood cancer survivors in need of support to increase physical activity level. Further development is needed on the design of a sufficiently valid question measuring sedentary time. TRIAL REGISTRATION This research project was registered in the Swedish National Database of Research and Development; identifier 275251, November 25, 2020. https://www.researchweb.org/is/vgr/project/275251 .
Collapse
Affiliation(s)
- Laura Jess
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Blå stråket 2, 413 45, Gothenburg, Sweden.
- Närhälsan Bollebygd Rehabilitation Clinic, Bollebygd, Sweden.
| | - Marianne Jarfelt
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Blå stråket 2, 413 45, Gothenburg, Sweden
- The Long-Term Follow-Up Clinic for Adult Childhood Cancer Survivors and Cancer Rehabilitation, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Maria Bäck
- Department of Occupational Therapy and Physiotherapy, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Health, Medicine and Caring Sciences, Division of Prevention, Rehabilitation and Community Medicine, Unit of Physiotherapy, Linköping University, Linköping, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| |
Collapse
|
2
|
Mikail N, Chequer R, Imperiale A, Meisel A, Bengs S, Portmann A, Gimelli A, Buechel RR, Gebhard C, Rossi A. Tales from the future-nuclear cardio-oncology, from prediction to diagnosis and monitoring. Eur Heart J Cardiovasc Imaging 2023; 24:1129-1145. [PMID: 37467476 PMCID: PMC10501471 DOI: 10.1093/ehjci/jead168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 07/07/2023] [Indexed: 07/21/2023] Open
Abstract
Cancer and cardiovascular diseases (CVD) often share common risk factors, and patients with CVD who develop cancer are at high risk of experiencing major adverse cardiovascular events. Additionally, cancer treatment can induce short- and long-term adverse cardiovascular events. Given the improvement in oncological patients' prognosis, the burden in this vulnerable population is slowly shifting towards increased cardiovascular mortality. Consequently, the field of cardio-oncology is steadily expanding, prompting the need for new markers to stratify and monitor the cardiovascular risk in oncological patients before, during, and after the completion of treatment. Advanced non-invasive cardiac imaging has raised great interest in the early detection of CVD and cardiotoxicity in oncological patients. Nuclear medicine has long been a pivotal exam to robustly assess and monitor the cardiac function of patients undergoing potentially cardiotoxic chemotherapies. In addition, recent radiotracers have shown great interest in the early detection of cancer-treatment-related cardiotoxicity. In this review, we summarize the current and emerging nuclear cardiology tools that can help identify cardiotoxicity and assess the cardiovascular risk in patients undergoing cancer treatments and discuss the specific role of nuclear cardiology alongside other non-invasive imaging techniques.
Collapse
Affiliation(s)
- Nidaa Mikail
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Wagistrasse 12, 8952 Schlieren, Switzerland
| | - Renata Chequer
- Department of Nuclear Medicine, Bichat University Hospital, AP-HP, University Diderot, 75018 Paris, France
| | - Alessio Imperiale
- Nuclear Medicine, Institut de Cancérologie de Strasbourg Europe (ICANS), University Hospitals of Strasbourg, 67093 Strasbourg, France
- Molecular Imaging-DRHIM, IPHC, UMR 7178, CNRS/Unistra, 67093 Strasbourg, France
| | - Alexander Meisel
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Kantonsspital Glarus, Burgstrasse 99, 8750 Glarus, Switzerland
| | - Susan Bengs
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Wagistrasse 12, 8952 Schlieren, Switzerland
| | - Angela Portmann
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Wagistrasse 12, 8952 Schlieren, Switzerland
| | - Alessia Gimelli
- Imaging Department, Fondazione CNR/Regione Toscana Gabriele Monasterio, Via G. Moruzzi 1, 56124 Pisa, Italy
| | - Ronny R Buechel
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Cathérine Gebhard
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Wagistrasse 12, 8952 Schlieren, Switzerland
- Department of Cardiology, University Hospital Inselspital Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
| | - Alexia Rossi
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Wagistrasse 12, 8952 Schlieren, Switzerland
| |
Collapse
|
3
|
Berg T, Böhmer J, Nwaru BI, Karason K, Jarfelt M. Heart failure in childhood cancer survivors-a systematic review protocol. Syst Rev 2022; 11:54. [PMID: 35351203 PMCID: PMC8966343 DOI: 10.1186/s13643-022-01929-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 03/18/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Over the past decades, the survival rate for childhood cancer has greatly improved. However, the risk of late cardiac complications after cancer treatment remains high. Previous studies have shown that the risk for heart failure among childhood cancer survivors is significantly higher than that observed in varying control populations. The aim of this systematic review is to identify, critically appraise, and synthesize existing population-based studies reporting on the frequency of heart failure, both the incidence and prevalence, that may develop after treatment for childhood cancer. METHOD The following databases will be searched from their inception date until May 17, 2021: MEDLINE, Embase, Scopus, CINAHL, CAB International, AMED, Global Health, PsycINFO, Web of Science, and Google Scholar. Population-based studies reporting on the incidence and/or prevalence of heart failure after the treatment of any type of childhood cancer will be included. The screening of articles, data extraction, and quality assessment will be performed independently by two reviewers. The quality and risk of bias in the included studies will be assessed by using the Effective Public Health Practice Project tool. A narrative synthesis of the extracted data will be carried out, and for studies that are sufficiently homogenous, a meta-analysis using random-effects models will be performed. DISCUSSION This systematic review will provide a clearer picture of the epidemiology of heart failure after the treatment of childhood cancer. The collected data will be of value for future childhood cancer treatment protocols and will offer guidance for posttreatment cardiac surveillance among survivors. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42021247622 . Registered on April 28, 2021. This protocol follows the structure of the recommendation of the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P).
Collapse
Affiliation(s)
- Tove Berg
- Department of Pediatric Medicine, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Behandlingsvagen 7, 416 50, Gothenburg, Sweden. .,Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Box 426, 405 30, Gothenburg, Sweden.
| | - Jens Böhmer
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Box 426, 405 30, Gothenburg, Sweden.,Pediatric Heart Center, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Behandlingsvagen 7, 416 50, Gothenburg, Sweden
| | - Bright I Nwaru
- Krefting Research Centre, Institute of Medicine, University of Gothenburg, Box 424, 405 30, Gothenburg, Sweden
| | - Kristjan Karason
- Department of Cardiology, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden.,Transplant Institute, Sahlgrenska University Hospital, Bruna straket 5, 6th floor, 413 45, Gothenburg, Sweden.,Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Box 424, 405 30, Gothenburg, Sweden
| | - Marianne Jarfelt
- Long-term follow-up Clinic for Adult Childhood Cancer Survivors, Department of Oncology, Sahlgrenska University Hospital, Bla straket 2, 413 45, Gothenburg, Sweden.,Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Box 426, 405 30, Gothenburg, Sweden
| |
Collapse
|
4
|
Herrmann J, McCullough KB, Habermann TM. How I treat cardiovascular complications in patients with lymphoid malignancies. Blood 2022; 139:1501-1516. [PMID: 34752600 PMCID: PMC8914183 DOI: 10.1182/blood.2019003893] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 10/27/2021] [Indexed: 11/20/2022] Open
Abstract
The prognosis of several lymphoid malignancies has improved through development of novel therapies, combination with traditional chemotherapies, and delineation of appropriate therapeutic sequencing. Toxicities that are arising because of prolonged or multiple sequential therapeutic interventions are becoming increasingly impactful. Among the broad spectrum of complications that patients with lymphoid malignancies may experience, cardiovascular toxicities are significant in terms of morbidity and mortality. The entire cardiovascular system can be affected, but cardiomyopathy, heart failure, and arrhythmias remain of greatest concerns with the use of anthracyclines, hematopoietic stem cell transplantation, and radiation therapy in patients with lymphoid malignancies. These aspects will be covered in this article within the framework of case-based discussions. Key to the management of cardiovascular complications in patients with lymphoid malignancies is awareness and preparedness across the cancer continuum. Baseline risk stratification helps to direct surveillance and early intervention efforts before, during, and after cancer therapy, which are paramount for the best possible outcomes. Along these lines, the overall goal is to enable the best possible therapies for lymphoid malignancies without the complications of clinically significant cardiovascular events.
Collapse
Affiliation(s)
| | | | - Thomas M Habermann
- 3Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| |
Collapse
|
5
|
Powell AW, Urbina EM, Madueme P, Rotz S, Chin C, Taylor MD, Mays WA, Davies SM, Lane A, Berger S, Jodele S, Dandoy CE, Ryan TD. Abnormal maximal and submaximal cardiopulmonary exercise capacity in pediatric stem cell transplant recipients despite normal standard echocardiographic parameters: a pilot study. Transplant Cell Ther 2022; 28:263.e1-263.e5. [PMID: 35219851 DOI: 10.1016/j.jtct.2022.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 02/10/2022] [Accepted: 02/20/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Left ventricular systolic dysfunction is a known complication of stem cell transplant (SCT). There has been minimal research to determine if subclinical cardiac dysfunction exists in SCT patients utilizing tools other than standard echocardiography, such as maximal and submaximal effort cardiopulmonary exercise testing (CPET) and vascular function studies. OBJECTIVE The objective of this study was to determine the rate of subclinical cardiac dysfunction in patients with normal ejection fraction after SCT, identified by abnormal values by CPET, tissue-Doppler imaging, and arterial stiffness measurements and to further describe submaximal exercise test measures in this population. STUDY DESIGN A prospective cohort study of SCT survivors who were at least three years post-SCT without prior anthracycline or radiation exposure and with preserved systolic function (LV ejection fraction > 50%) was performed to evaluate for abnormalities in exercise, vascular function, and diastolic function in an effort to detect subclinical dysfunction in SCT patients. RESULTS There were 11 patients (12.4±3.8-years-old) included in the study. No patients had diastolic dysfunction. All patients completed a maximal effort exercise test, and 73% (8/11) had abnormal peak oxygen consumption (VO2peak), which is a measure of aerobic fitness. However, during submaximal effort CPET, 45% (5/11) had an abnormal VO2 at anaerobic threshold (i.e. the point in exercise where aerobic transitions to anaerobic metabolism and fatigue starts), and 64% (7/11) had an abnormal oxygen uptake efficiency slope (a measure that relates VO2peak to total ventilation). 86% (6/7) of the patients with an abnormal oxygen uptake efficiency slope ultimately had an abnormal VO2peak. There were no vascular function abnormalities. CONCLUSION Pediatric survivors of SCT often have abnormal maximal and submaximal exercise capacity without vascular or cardiac dysfunction.
Collapse
Affiliation(s)
- Adam W Powell
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
| | - Elaine M Urbina
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Peace Madueme
- The Division of Pediatric Cardiology, Nemours Children's Hospital, Orlando, FL
| | - Seth Rotz
- The Division of Hematology, Oncology, and Blood and Marrow Transplantation, Cleveland Clinic, Cleveland, OH
| | - Clifford Chin
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Michael D Taylor
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Wayne A Mays
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Stella M Davies
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; The Division of Bone Marrow Transplantation, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Adam Lane
- The Division of Bone Marrow Transplantation, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Suzanne Berger
- The Division of Bone Marrow Transplantation, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Sonata Jodele
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; The Division of Bone Marrow Transplantation, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Christopher E Dandoy
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; The Division of Bone Marrow Transplantation, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Thomas D Ryan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| |
Collapse
|
6
|
Andrikopoulou E. Diastolic assessment by CZT-SPECT: Could it be the next best thing for the detection of subclinical chemotherapy-induced cardiotoxicity? J Nucl Cardiol 2020; 27:1202-1206. [PMID: 31309461 DOI: 10.1007/s12350-019-01792-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 06/13/2019] [Indexed: 11/29/2022]
|
7
|
Cadeddu Dessalvi C, Deidda M, Giorgi M, Colonna P. Vascular Damage - Coronary Artery Disease. J Cardiovasc Echogr 2020; 30:S11-S16. [PMID: 32566461 PMCID: PMC7293870 DOI: 10.4103/jcecho.jcecho_3_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 02/23/2019] [Accepted: 10/03/2019] [Indexed: 12/13/2022] Open
Abstract
Cardiovascular complications during chemotherapy and radiotherapy are becoming an increasing problem because many patients with cancer are treated with agents that exert significant vascular toxicity. Coronary heart disease in patients with cancer presents particular challenges, which directly impact the management of both the coronary disease and malignancy. Several chemotherapeutic agents have been shown to trigger ischemic heart disease, and as it has happened for myocardial cardiotoxicity, more attention should be dedicated to improving early recognition and prevention of cardiac vascular toxicity. Cardiac imaging could facilitate early detection of vascular toxicity, but a thorough risk stratification should always be performed to identify patients at higher risk of vascular impairment.
Collapse
Affiliation(s)
| | - Martino Deidda
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Mauro Giorgi
- Department of Cardiology, University Hospital Città della Scienza e Salute, Molinette Hospital, Turin, Italy
| | - Paolo Colonna
- Department of Cardiology, Hospital Policlinico of Bari, Bari, Italy
| |
Collapse
|
8
|
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.
Collapse
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
| |
Collapse
|
9
|
Wolf CM, Reiner B, Kühn A, Hager A, Müller J, Meierhofer C, Oberhoffer R, Ewert P, Schmid I, Weil J. Subclinical Cardiac Dysfunction in Childhood Cancer Survivors on 10-Years Follow-Up Correlates With Cumulative Anthracycline Dose and Is Best Detected by Cardiopulmonary Exercise Testing, Circulating Serum Biomarker, Speckle Tracking Echocardiography, and Tissue Doppler Imaging. Front Pediatr 2020; 8:123. [PMID: 32296665 PMCID: PMC7136405 DOI: 10.3389/fped.2020.00123] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 03/06/2020] [Indexed: 12/13/2022] Open
Abstract
Background: Survivors of childhood cancer are at risk for anthracycline- and/or radiotherapy-induced cardiotoxicity. Aims: The aim of this study was to assess clinical, laboratory, and imaging parameters of subclinical cardiovascular disease in childhood cancer survivors. Methods: Patients underwent cardiopulmonary exercise test (CPET), laboratory testing, transthoracic echocardiography (TTE) with tissue doppler imaging (TDI) and speckle tracking. A subset of patients also underwent cardiovascular magnetic resonance imaging (CMR). Findings were correlated to cumulative anthracycline and exposure to mediastinal irradiation during cancer treatment. In a subgroup analysis, TTE and CMR findings were compared to data from 40 gender- and age-matched patients with childhood onset hypertrophic cardiomyopathy (HCM). Results: Cardiac evaluation was performed in 79 patients (43 males) at 11.2 ± 4.5 years after cancer treatment. Oncologic diagnosis at a median age of 12.0 years was Hodgkin lymphoma in 20, sarcoma in 17, acute leukemia in 24, relapse leukemia in 10, and others in 8 patients. Cumulative anthracycline dose exceeded 300 mg/m2 in 28 patients. Twenty six patients also received mediastinal irradiation. Decreased peak respiratory oxygen uptake in % predicted on CPET, increased levels of N-terminal pro-brain natriuretic peptide (NTproBNP), increased global longitudinal strain on TTE speckle tracking, and diastolic dysfunction on TDI were the most prominent findings on detailed cardiology follow-up. In contrast to HCM patients, childhood cancer survivors did not show left ventricular hypertrophy (LVPWd z-score median 0.9 vs. 2.8, p < 0.001), hyperdynamic systolic function on TTE (Ejection fraction 62 ± 7 vs. 72 ± 12%, p = 0.001), or fibrotic myocardial changes on CMR (Late gadolinium positive 0/13 vs. 13/36, p = 0.001; extracellular volume fraction 22 ± 2 vs. 28 ± 3, p < 0.001) at time of follow-up. There was no correlation between chest radiation exposure and abnormal cardiac findings. Cumulative anthracycline dose was the only significant independent predictor on multivariate analysis for any cardiovascular abnormality on follow-up (p = 0.036). Conclusion: Increasing cumulative anthracycline dose during cancer treatment correlates with subclinical cardiac dysfunction in childhood cancer survivors best detected by elevated cardiac serum biomarkers, decreased exercise capacity on CPET, and abnormalities on echocardiographic speckle tracking and TDI.
Collapse
Affiliation(s)
- Cordula Maria Wolf
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
| | - Barbara Reiner
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany.,Faculty of Sport and Health Sciences, Institute of Preventive Pediatrics, Technical University Munich, Munich, Germany
| | - Andreas Kühn
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
| | - Alfred Hager
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
| | - Jan Müller
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany.,Faculty of Sport and Health Sciences, Institute of Preventive Pediatrics, Technical University Munich, Munich, Germany
| | - Christian Meierhofer
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
| | - Renate Oberhoffer
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany.,Faculty of Sport and Health Sciences, Institute of Preventive Pediatrics, Technical University Munich, Munich, Germany
| | - Peter Ewert
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
| | - Irene Schmid
- Department of Pediatric Hematology and Oncology, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Jochen Weil
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
| |
Collapse
|
10
|
Caru M, Samoilenko M, Drouin S, Lemay V, Kern L, Romo L, Bertout L, Lefebvre G, Andelfinger G, Krajinovic M, Laverdiere C, Sinnett D, Curnier D. Childhood Acute Lymphoblastic Leukemia Survivors Have a Substantially Lower Cardiorespiratory Fitness Level Than Healthy Canadians Despite a Clinically Equivalent Level of Physical Activity. J Adolesc Young Adult Oncol 2019; 8:674-683. [DOI: 10.1089/jayao.2019.0024] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Maxime Caru
- Laboratory of Pathophysiology of EXercise (LPEX), School of Kinesiology and Physical Activity Sciences, Faculty of Medicine, University of Montreal, Montreal, Canada
- Sainte-Justine University Health Center, Research Center, Montreal, Canada
- Laboratoire EA 4430–Clinique Psychanalyse Developpement (CliPsyD), University of Paris Nanterre, Nanterre, France
| | - Mariia Samoilenko
- Sainte-Justine University Health Center, Research Center, Montreal, Canada
- Department of Mathematics, Université du Québec à Montréal, Montreal, Canada
| | - Simon Drouin
- Sainte-Justine University Health Center, Research Center, Montreal, Canada
| | - Valérie Lemay
- Laboratory of Pathophysiology of EXercise (LPEX), School of Kinesiology and Physical Activity Sciences, Faculty of Medicine, University of Montreal, Montreal, Canada
- Sainte-Justine University Health Center, Research Center, Montreal, Canada
| | - Laurence Kern
- Laboratoire EA 4430–Clinique Psychanalyse Developpement (CliPsyD), University of Paris Nanterre, Nanterre, France
| | - Lucia Romo
- Laboratoire EA 4430–Clinique Psychanalyse Developpement (CliPsyD), University of Paris Nanterre, Nanterre, France
| | - Laurence Bertout
- Sainte-Justine University Health Center, Research Center, Montreal, Canada
| | - Geneviève Lefebvre
- Sainte-Justine University Health Center, Research Center, Montreal, Canada
| | - Gregor Andelfinger
- Sainte-Justine University Health Center, Research Center, Montreal, Canada
- Department of Pediatrics, University of Montreal, Montreal, Canada
| | - Maja Krajinovic
- Sainte-Justine University Health Center, Research Center, Montreal, Canada
- Department of Pediatrics, University of Montreal, Montreal, Canada
| | - Caroline Laverdiere
- Sainte-Justine University Health Center, Research Center, Montreal, Canada
- Department of Pediatrics, University of Montreal, Montreal, Canada
| | - Daniel Sinnett
- Sainte-Justine University Health Center, Research Center, Montreal, Canada
- Department of Pediatrics, University of Montreal, Montreal, Canada
| | - Daniel Curnier
- Laboratory of Pathophysiology of EXercise (LPEX), School of Kinesiology and Physical Activity Sciences, Faculty of Medicine, University of Montreal, Montreal, Canada
- Sainte-Justine University Health Center, Research Center, Montreal, Canada
| |
Collapse
|
11
|
Long TM, Lee F, Lam K, Wallman KE, Walwyn TS, Choong CS, Naylor LH. Cardiovascular Testing Detects Underlying Dysfunction in Childhood Leukemia Survivors. Med Sci Sports Exerc 2019; 52:525-534. [PMID: 31652239 DOI: 10.1249/mss.0000000000002168] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
PURPOSE Childhood leukemia survivors commonly develop late-onset cardiovascular disease after treatment with anthracyclines. Resting echocardiogram is the standard procedure for monitoring cardiac health but this method may not be sensitive enough to detect subclinical injury. Exercise echocardiography may provide a viable alternative. METHODS Nineteen (9 males; age, 19 ± 3 yr) anthracycline-treated survivors of childhood leukemia and 17 (8 males) healthy individuals of similar age (22 ± 2 yr) were recruited. All survivors had normal resting echocardiography upon recruitment. Exercise echocardiography was performed using contemporary imaging techniques. Flow-mediated dilation (FMD), body composition, and cardiorespiratory fitness (V˙O2peak) were assessed to determine predisposition to additional disease. RESULTS Mitral valve peak flow velocity in late diastole (interaction, P = 0.007) increased from rest in survivors (P = 0.023) and controls (P = 0.020) immediately postexercise but did not recover again in the survivors (exercise-recovery, P = 0.784) after recuperation. Consequently, E/A ratio (interaction, P < 0.001) was lower in the survivors at recovery (P < 0.001). Survivors had reduced FMD (7.88 ± 1.70 vs 9.65 ± 2.83; P = 0.030), maximal and recovery HR (P = 0.001; P < 0.001), minute ventilation (P < 0.001), and V˙O2peak (absolute, 2.64 ± 0.62 vs 3.14 ± 0.74 L·min, P = 0.034; relative, 36.78 ± 11.49 vs 45.14 ± 6.80 mL·kg·min; P = 0.013) compared with controls. They also had higher total body fat (percentage, P = 0.034; mass, P = 0.024) and fat mass in the central (P = 0.050), peripheral (P = 0.039) and visceral (P < 0.001) regions. Survivors matched controls with regard to height (173.0 ± 7.8 cm vs 173.8 ± 9.1 cm; P = 0.796), body mass (76.16 ± 19.05 kg vs 70.07 ± 13.96 kg; P = 0.287) and body mass index (25.2 ± 5.1 vs 22.9 ± 2.7; P = 0.109). CONCLUSIONS Exercise echocardiography unmasked subclinical diastolic dysfunction that may indicate late anthracycline toxicity in apparently healthy survivors of childhood leukemia. Presence of secondary risk factors indicates increased predisposition to comorbidities and highlights the importance of assessing cardiovascular health during follow-up.
Collapse
Affiliation(s)
- Treya M Long
- School of Human Sciences: Exercise and Sport Science, The University of Western Australia, Perth, Western Australia, AUSTRALIA
| | - Felicity Lee
- Advanced Heart Failure Unit and Cardiac Transplant Service of Western Australia, Fiona Stanley Hospital, Murdoch, Western Australia, AUSTRALIA
| | - Kaitlyn Lam
- Advanced Heart Failure Unit and Cardiac Transplant Service of Western Australia, Fiona Stanley Hospital, Murdoch, Western Australia, AUSTRALIA
| | - Karen E Wallman
- School of Human Sciences: Exercise and Sport Science, The University of Western Australia, Perth, Western Australia, AUSTRALIA
| | | | | | - Louise H Naylor
- School of Human Sciences: Exercise and Sport Science, The University of Western Australia, Perth, Western Australia, AUSTRALIA
| |
Collapse
|
12
|
Is health status impaired in childhood cancer survivors? A systematic review and meta-analysis. Crit Rev Oncol Hematol 2019; 142:94-118. [PMID: 31394434 DOI: 10.1016/j.critrevonc.2019.07.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 07/05/2019] [Accepted: 07/09/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND An increase in survival rates of childhood cancer is associated with long-term health issues in survivors. METHODS We conducted a systematic review and meta-analysis comparing health status-related endpoints in childhood cancer survivors (CCS) versus controls. RESULTS Eighty-six studies (n = 98,480 participants, 62% CCS) were included in the review. Of these, 73 studies (n = 96,550, 63% CCS) could be meta-analyzed. CCS showed a lower left ventricular ejection and fractional shortening (SMD=-0.59 and -0.55, respectively, both p < 0.01 [n=1,824 and 1,880]), a lower HDL-cholesterol concentration (SMD=-0.48, p<0.001, n=1,378) and a higher waist-to-hip ratio (SMD=0.61, p < 0.01, n=229) than their healthy peers. No significant differences were found for the remaining endpoints. CONCLUSIONS CCS is associated with a lower left ventricular function and HDL-cholesterol level, and a higher waist-to-hip ratio than healthy controls. These findings support the need to closely monitor the cardiometabolic health status of CCS and to implement preventive lifestyle interventions for this population.
Collapse
|
13
|
Seraphim A, Westwood M, Bhuva AN, Crake T, Moon JC, Menezes LJ, Lloyd G, Ghosh AK, Slater S, Oakervee H, Manisty CH. Advanced Imaging Modalities to Monitor for Cardiotoxicity. Curr Treat Options Oncol 2019; 20:73. [PMID: 31396720 PMCID: PMC6687672 DOI: 10.1007/s11864-019-0672-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Early detection and treatment of cardiotoxicity from cancer therapies is key to preventing a rise in adverse cardiovascular outcomes in cancer patients. Over-diagnosis of cardiotoxicity in this context is however equally hazardous, leading to patients receiving suboptimal cancer treatment, thereby impacting cancer outcomes. Accurate screening therefore depends on the widespread availability of sensitive and reproducible biomarkers of cardiotoxicity, which can clearly discriminate early disease. Blood biomarkers are limited in cardiovascular disease and clinicians generally still use generic screening with ejection fraction, based on historical local expertise and resources. Recently, however, there has been growing recognition that simple measurement of left ventricular ejection fraction using 2D echocardiography may not be optimal for screening: diagnostic accuracy, reproducibility and feasibility are limited. Modern cancer therapies affect many myocardial pathways: inflammatory, fibrotic, metabolic, vascular and myocyte function, meaning that multiple biomarkers may be needed to track myocardial cardiotoxicity. Advanced imaging modalities including cardiovascular magnetic resonance (CMR), computed tomography (CT) and positron emission tomography (PET) add improved sensitivity and insights into the underlying pathophysiology, as well as the ability to screen for other cardiotoxicities including coronary artery, valve and pericardial diseases resulting from cancer treatment. Delivering screening for cardiotoxicity using advanced imaging modalities will however require a significant change in current clinical pathways, with incorporation of machine learning algorithms into imaging analysis fundamental to improving efficiency and precision. In the future, we should aspire to personalized rather than generic screening, based on a patient’s individual risk factors and the pathophysiological mechanisms of the cancer treatment they are receiving. We should aspire that progress in cardiooncology is able to track progress in oncology, and to ensure that the current ‘one size fits all’ approach to screening be obsolete in the very near future.
Collapse
Affiliation(s)
- Andreas Seraphim
- Department of Cardiovascular Imaging, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK.,Institute of Cardiovascular Sciences, University College London, Chenies Mews, London, UK
| | - Mark Westwood
- Department of Cardiovascular Imaging, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK.,Department of Cardio-oncology, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK
| | - Anish N Bhuva
- Department of Cardiovascular Imaging, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK.,Institute of Cardiovascular Sciences, University College London, Chenies Mews, London, UK
| | - Tom Crake
- Department of Cardio-oncology, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK
| | - James C Moon
- Department of Cardiovascular Imaging, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK.,Institute of Cardiovascular Sciences, University College London, Chenies Mews, London, UK
| | - Leon J Menezes
- Department of Cardiovascular Imaging, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK
| | - Guy Lloyd
- Department of Cardiovascular Imaging, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK
| | - Arjun K Ghosh
- Department of Cardiovascular Imaging, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK.,Department of Cardio-oncology, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK
| | - Sarah Slater
- Department of Haematology, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK
| | - Heather Oakervee
- Department of Oncology, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK
| | - Charlotte H Manisty
- Department of Cardiovascular Imaging, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK. .,Institute of Cardiovascular Sciences, University College London, Chenies Mews, London, UK. .,Department of Cardio-oncology, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK.
| |
Collapse
|
14
|
Rubnitz JE, Lacayo NJ, Inaba H, Heym K, Ribeiro RC, Taub J, McNeer J, Degar B, Schiff D, Yeoh AEJ, Coustan-Smith E, Wang L, Triplett B, Raimondi SC, Klco J, Choi J, Pounds S, Pui CH. Clofarabine Can Replace Anthracyclines and Etoposide in Remission Induction Therapy for Childhood Acute Myeloid Leukemia: The AML08 Multicenter, Randomized Phase III Trial. J Clin Oncol 2019; 37:2072-2081. [PMID: 31246522 DOI: 10.1200/jco.19.00327] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
PURPOSE To identify effective and less toxic therapy for children with acute myeloid leukemia, we introduced clofarabine into the first course of remission induction to reduce exposure to daunorubicin and etoposide. PATIENTS AND METHODS From 2008 through 2017, 285 patients were enrolled at eight centers; 262 were randomly assigned to receive clofarabine and cytarabine (Clo+AraC, n = 129) or high-dose cytarabine, daunorubicin, and etoposide (HD-ADE, n = 133) as induction I. Induction II consisted of low-dose ADE given alone or combined with sorafenib or vorinostat. Consolidation therapy comprised two or three additional courses of chemotherapy or hematopoietic cell transplantation. Genetic abnormalities and the level of minimal residual disease (MRD) at day 22 of initial remission induction determined final risk classification. The primary end point was MRD at day 22. RESULTS Complete remission was induced after two courses of therapy in 263 (92.3%) of the 285 patients; induction failures included four early deaths and 15 cases of resistant leukemia. Day 22 MRD was positive in 57 of 121 randomly assigned evaluable patients (47%) who received Clo+AraC and 42 of 121 patients (35%) who received HD-ADE (odds ratio, 1.86; 95% CI, 1.03 to 3.41; P = .04). Despite this result, the 3-year event-free survival rate (52.9% [44.6% to 62.8%] for Clo+AraC v 52.4% [44.0% to 62.4%] for HD-ADE, P = .94) and overall survival rate (74.8% [67.1% to 83.3%] for Clo+AraC v 64.6% [56.2% to 74.2%] for HD-ADE, P = .1) did not differ significantly across the two arms. CONCLUSION Our findings suggest that the use of clofarabine with cytarabine during remission induction might reduce the need for anthracycline and etoposide in pediatric patients with acute myeloid leukemia and may reduce rates of cardiomyopathy and treatment-related cancer.
Collapse
Affiliation(s)
- Jeffrey E Rubnitz
- 1St Jude Children's Research Hospital and the University of Tennessee Health Science Center, College of Medicine, Memphis, TN
| | - Norman J Lacayo
- 2Lucile Packard Children's Hospital and Stanford Cancer Center, Palo Alto, CA
| | - Hiroto Inaba
- 1St Jude Children's Research Hospital and the University of Tennessee Health Science Center, College of Medicine, Memphis, TN
| | | | - Raul C Ribeiro
- 1St Jude Children's Research Hospital and the University of Tennessee Health Science Center, College of Medicine, Memphis, TN
| | | | | | | | | | | | | | - Lei Wang
- 1St Jude Children's Research Hospital and the University of Tennessee Health Science Center, College of Medicine, Memphis, TN
| | - Brandon Triplett
- 1St Jude Children's Research Hospital and the University of Tennessee Health Science Center, College of Medicine, Memphis, TN
| | - Susana C Raimondi
- 1St Jude Children's Research Hospital and the University of Tennessee Health Science Center, College of Medicine, Memphis, TN
| | - Jeffery Klco
- 1St Jude Children's Research Hospital and the University of Tennessee Health Science Center, College of Medicine, Memphis, TN
| | - John Choi
- 1St Jude Children's Research Hospital and the University of Tennessee Health Science Center, College of Medicine, Memphis, TN
| | - Stanley Pounds
- 1St Jude Children's Research Hospital and the University of Tennessee Health Science Center, College of Medicine, Memphis, TN
| | - Ching-Hon Pui
- 1St Jude Children's Research Hospital and the University of Tennessee Health Science Center, College of Medicine, Memphis, TN
| |
Collapse
|
15
|
Tocchetti CG, Cadeddu C, Di Lisi D, Femminò S, Madonna R, Mele D, Monte I, Novo G, Penna C, Pepe A, Spallarossa P, Varricchi G, Zito C, Pagliaro P, Mercuro G. From Molecular Mechanisms to Clinical Management of Antineoplastic Drug-Induced Cardiovascular Toxicity: A Translational Overview. Antioxid Redox Signal 2019; 30:2110-2153. [PMID: 28398124 PMCID: PMC6529857 DOI: 10.1089/ars.2016.6930] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Significance: Antineoplastic therapies have significantly improved the prognosis of oncology patients. However, these treatments can bring to a higher incidence of side-effects, including the worrying cardiovascular toxicity (CTX). Recent Advances: Substantial evidence indicates multiple mechanisms of CTX, with redox mechanisms playing a key role. Recent data singled out mitochondria as key targets for antineoplastic drug-induced CTX; understanding the underlying mechanisms is, therefore, crucial for effective cardioprotection, without compromising the efficacy of anti-cancer treatments. Critical Issues: CTX can occur within a few days or many years after treatment. Type I CTX is associated with irreversible cardiac cell injury, and it is typically caused by anthracyclines and traditional chemotherapeutics. Type II CTX is generally caused by novel biologics and more targeted drugs, and it is associated with reversible myocardial dysfunction. Therefore, patients undergoing anti-cancer treatments should be closely monitored, and patients at risk of CTX should be identified before beginning treatment to reduce CTX-related morbidity. Future Directions: Genetic profiling of clinical risk factors and an integrated approach using molecular, imaging, and clinical data may allow the recognition of patients who are at a high risk of developing chemotherapy-related CTX, and it may suggest methodologies to limit damage in a wider range of patients. The involvement of redox mechanisms in cancer biology and anticancer treatments is a very active field of research. Further investigations will be necessary to uncover the hallmarks of cancer from a redox perspective and to develop more efficacious antineoplastic therapies that also spare the cardiovascular system.
Collapse
Affiliation(s)
| | - Christian Cadeddu
- 2 Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Daniela Di Lisi
- 3 Biomedical Department of Internal Medicine, University of Palermo, Palermo, Italy
| | - Saveria Femminò
- 4 Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Rosalinda Madonna
- 5 Center of Aging Sciences and Translational Medicine - CESI-MeT, "G. d'Annunzio" University, Chieti, Italy.,6 Department of Internal Medicine, The Texas Heart Institute and Center for Cardiovascular Biology and Atherosclerosis Research, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Donato Mele
- 7 Cardiology Unit, Emergency Department, University Hospital of Ferrara, Ferrara, Italy
| | - Ines Monte
- 8 Department of General Surgery and Medical-Surgery Specialities, University of Catania, Catania, Italy
| | - Giuseppina Novo
- 3 Biomedical Department of Internal Medicine, University of Palermo, Palermo, Italy
| | - Claudia Penna
- 4 Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Alessia Pepe
- 9 U.O.C. Magnetic Resonance Imaging, Fondazione Toscana G. Monasterio C.N.R., Pisa, Italy
| | - Paolo Spallarossa
- 10 Clinic of Cardiovascular Diseases, IRCCS San Martino IST, Genova, Italy
| | - Gilda Varricchi
- 1 Department of Translational Medical Sciences, Federico II University, Naples, Italy.,11 Center for Basic and Clinical Immunology Research (CISI) - Federico II University, Naples, Italy
| | - Concetta Zito
- 12 Division of Cardiology, Clinical and Experimental Department of Medicine and Pharmacology, Policlinico "G. Martino" University of Messina, Messina, Italy
| | - Pasquale Pagliaro
- 4 Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Giuseppe Mercuro
- 2 Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| |
Collapse
|
16
|
Awadalla M, Hassan MZO, Alvi RM, Neilan TG. Advanced imaging modalities to detect cardiotoxicity. Curr Probl Cancer 2018; 42:386-396. [PMID: 30297038 PMCID: PMC6628686 DOI: 10.1016/j.currproblcancer.2018.05.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 05/18/2018] [Indexed: 12/31/2022]
Abstract
Recent advances in cancer treatments have significantly improved survival rates, reemphasizing the focus on reducing the potential complications associated with some therapies. Cardiovascular disease associated with chemotherapies is a major cause of morbidity and mortality in cancer survivors. Early detection of cardiotoxicity improves cardiac outcomes among cancer patients. The review will focus on imaging modalities used to assess cardiotoxicity - the cardiovascular consequences of chemotherapies. The review will discuss the benefits and limitations associated with each technique, as well as the guidelines available to help identify at risk patients. We will discuss novel techniques that may help detect earlier signs of cardiotoxicity, directing management that may improve clinical outcomes.
Collapse
Affiliation(s)
- Magid Awadalla
- Cardiac MR PET CT Program, Massachusetts General Hospital, Boston, MA
| | - Malek Z O Hassan
- Cardiac MR PET CT Program, Massachusetts General Hospital, Boston, MA
| | - Raza M Alvi
- Cardiac MR PET CT Program, Massachusetts General Hospital, Boston, MA
| | - Tomas G Neilan
- Cardiac MR PET CT Program, Massachusetts General Hospital, Boston, MA; Cardio-oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA.
| |
Collapse
|
17
|
Cifra B, Chen CK, Fan CPS, Slorach C, Manlhiot C, McCrindle BW, Dragulescu A, Redington AN, Friedberg MK, Nathan PC, Mertens L. Dynamic Myocardial Response to Exercise in Childhood Cancer Survivors Treated with Anthracyclines. J Am Soc Echocardiogr 2018; 31:933-942. [PMID: 29615292 DOI: 10.1016/j.echo.2018.02.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Anthracycline cardiotoxicity can cause significant long-term morbidity in childhood cancer survivors (CCS), but many CCS do not manifest clinical symptoms until adulthood. The aims of this study were to characterize the dynamic myocardial response to exercise of CCS at long-term follow-up by combining semisupine bicycle exercise stress echocardiography with myocardial imaging techniques and to establish whether semisupine bicycle exercise stress echocardiography could identify CCS with abnormal exercise response. METHODS This was a single-center prospective cross-sectional study. One hundred CCS and 51 control subjects underwent semisupine bicycle exercise stress echocardiography. Color Doppler tissue imaging peak systolic (s') and diastolic (e') velocities, myocardial acceleration during isovolumic contraction, and longitudinal strain were measured at rest and at incremental heart rates in the left ventricular (LV) lateral wall, basal septum, and right ventricle. The relationship with increasing heart rate was evaluated for each parameter by plotting the values against heart rate at each stage of exercise. Kernel density estimate was used to establish the normality of the individual CCS exercise responses. RESULTS At rest, no significant differences were found for LV lateral wall, right ventricular (RV), and basal septal systolic and diastolic velocities between CCS and control subjects. Only septal e' was lower in CCS. LV longitudinal strain was similar between groups, while RV longitudinal strain was lower in CCS. At peak exercise, LV lateral wall, RV, and septal s' were not different between groups, while e' were significantly lower in CCS. LV lateral wall and septal isovolumic acceleration were also reduced in CCS. LV longitudinal strain was different between groups, while RV longitudinal strain was similar. The dynamic response of Doppler tissue imaging velocities, isovolumic acceleration, and strain was similar between CCS and control subjects. Kernel density estimate analysis confirmed that most CCS responses were within the normal range. CONCLUSIONS At 10-year follow-up, anthracycline-treated CCS with normal baseline ejection fractions have LV and RV systolic and diastolic myocardial exercise response comparable with that of control subjects. Minor differences were observed between CCS and control subjects at rest and at peak exercise, but the dynamic response is within the normal range.
Collapse
Affiliation(s)
- Barbara Cifra
- Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Ching Kit Chen
- Cardiology Service, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, Singapore
| | - Chun-Po S Fan
- Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Cameron Slorach
- Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Cedric Manlhiot
- Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Brian W McCrindle
- Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Andreea Dragulescu
- Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Andrew N Redington
- Pediatric Cardiology, Department of Pediatrics, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Mark K Friedberg
- Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Paul C Nathan
- Division of Hematology/Oncology, The Hospital for Sick Children, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Luc Mertens
- Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
| |
Collapse
|
18
|
Clinical and Subclinical Cardiac Late Effects in Pediatric Hodgkin's Lymphoma Survivors. TUMORI JOURNAL 2017; 103:566-571. [DOI: 10.5301/tj.5000670] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2017] [Indexed: 11/20/2022]
Abstract
Purpose Cardiac late effects are responsible for a significant burden of mortality and morbidity among pediatric Hodgkin's lymphoma (HL) survivors (HLS). The aim of our study was to assess clinical and subclinical cardiac sequelae in a cohort of childhood HLS treated in the 1980s with doxorubicin, bleomycin, vinblastine, and dacarbazine (the ABVD regimen) and limited-field radiotherapy (RT). Methods We retrospectively examined a series of HLS treated from 1979 to 1989. We searched for subtle cardiac abnormalities in a subgroup of asymptomatic individuals, who underwent rest and exercise echocardiography at least 20 years after completing their therapies. Their cardiac assessment included physical examination, electrocardiogram (ECG), and resting and postexercise echocardiograms. Results On thorough cardiac assessment a mean of 21 years after their diagnosis, none of the 53 unselected asymptomatic HLS showed physical signs or significant ECG abnormalities during or after the stress echo test. Twenty-two (41%) of the 53 patients revealed valvular abnormalities, with mitral regurgitation in 28%, aortic regurgitation in 9%, and both in 4%. No significant myocardial dysfunction as a result of previous combined doxorubicin treatment and chest RT was identified. Only 2 individuals had mild pericardial alterations. Conclusions The present study shows that long-term cardiac effects are common in HLS treated with the ABVD regimen and RT. The most frequent complications observed in this sample were essentially coronary artery disease and valvular abnormalities. None of the survivors in this sample showed overt congestive heart failure, a finding in contrast with larger studies.
Collapse
|
19
|
|
20
|
Pepe A, Pizzino F, Gargiulo P, Perrone-Filardi P, Cadeddu C, Mele D, Monte I, Novo G, Zito C, Di Bella G. Cardiovascular imaging in the diagnosis and monitoring of cardiotoxicity: cardiovascular magnetic resonance and nuclear cardiology. J Cardiovasc Med (Hagerstown) 2017; 17 Suppl 1 Special issue on Cardiotoxicity from Antiblastic Drugs and Cardioprotection:e45-e54. [PMID: 27755242 DOI: 10.2459/jcm.0000000000000380] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Chemotherapy-induced cardiotoxicity (CTX) is a determining factor for the quality of life and mortality of patients administered potentially cardiotoxic drugs and in long-term cancer survivors. Therefore, prevention and early detection of CTX are highly desirable, as is the exploration of alternative therapeutic strategies and/or the proposal of potentially cardioprotective treatments. In recent years, cardiovascular imaging has acquired a pivotal role in this setting. Although echocardiography remains the diagnostic method most used to monitor cancer patients, the need for more reliable, reproducible and accurate detection of early chemotherapy-induced CTX has encouraged the introduction of second-line advanced imaging modalities, such as cardiac magnetic resonance (CMR) and nuclear techniques, into the clinical setting. This review of the Working Group on Drug Cardiotoxicity and Cardioprotection of the Italian Society of Cardiology aims to afford an overview of the most important findings from the literature about the role of CMR and nuclear techniques in the management of chemotherapy-treated patients, describe conventional and new parameters for detecting CTX from both diagnostic and prognostic perspectives and provide integrated insight into the role of CMR and nuclear techniques compared with other imaging tools and versus the positions of the most important international societies.
Collapse
Affiliation(s)
- Alessia Pepe
- aU.O.C. Magnetic Resonance Imaging, Fondazione Toscana G. Monasterio C.N.R., Pisa bDepartment of Clinical and Experimental Medicine. Section of Cardiology A.O.U. Policlinico 'G. Martino' University of Messina, Messina cSDN, Institute of Diagnostic and Nuclear Development dDepartment of Advanced Biomedical Sciences, 'Federico II' University, Naples eDepartment of Medical Sciences 'Mario Aresu', University of Cagliari, Cagliari fCardiology Unit, University Hospital of Ferrara, Ferrara gDepartment of General Surgery and Medical-Surgery Specialities, University of Catania, Catania hChair and Division of Cardiology, University of Palermo, Palermo, Italy
| | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Kearney MC, Gallop-Evans E, Cockcroft JR, Stöhr EJ, Lee E, Backx K, Haykowsky M, Yousef Z, Shave R. Cardiac dysfunction in cancer survivors unmasked during exercise. Eur J Clin Invest 2017; 47:213-220. [PMID: 28036108 DOI: 10.1111/eci.12720] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 12/28/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND The cardiac dysfunction associated with anthracycline-based chemotherapy cancer treatment can exist subclinically for decades before overt presentation. Stress echocardiography, the measurement of left ventricular (LV) deformation and arterial haemodynamic evaluation, has separately been used to identify subclinical cardiovascular (CV) dysfunction in several patient groups including those with hypertension and diabetes. The purpose of the present cross-sectional study was to determine whether the combination of these techniques could be used to improve the characterisation of subclinical CV dysfunction in long-term cancer survivors previously treated with anthracyclines. MATERIALS AND METHODS Thirteen long-term cancer survivors (36 ± 10 years) with prior anthracycline exposure (11 ± 8 years posttreatment) and 13 age-matched controls were recruited. Left ventricular structure, function and deformation were assessed using echocardiography. Augmentation index was used to quantify arterial haemodynamic load and was measured using applanation tonometry. Measurements were taken at rest and during two stages of low-intensity incremental cycling. RESULTS At rest, both groups had comparable global LV systolic, diastolic and arterial function (all P > 0·05); however, longitudinal deformation was significantly lower in cancer survivors (-18 ± 2 vs. -20 ± 2, P < 0·05). During exercise, this difference between groups persisted and further differences were uncovered with significantly lower apical circumferential deformation in the cancer survivors (-24 ± 5 vs. -29 ± 5, -29 ± 5 vs. 35 ± 8 for first and second stage of exercise respectively, both P < 0·05). CONCLUSION In contrast to resting echocardiography, the measurement of LV deformation at rest and during exercise provides a more comprehensive characterisation of subclinical LV dysfunction. Larger studies are required to determine the clinical relevance of these preliminary findings.
Collapse
Affiliation(s)
- Maria C Kearney
- Cardiff School of Sport, Cardiff Metropolitan University, Cardiff, UK
| | | | - John R Cockcroft
- Cardiff School of Sport, Cardiff Metropolitan University, Cardiff, UK.,Wales Heart Research Institute, Cardiff University School of Medicine, Cardiff, UK
| | - Eric J Stöhr
- Cardiff School of Sport, Cardiff Metropolitan University, Cardiff, UK
| | - Eveline Lee
- Cardiff School of Sport, Cardiff Metropolitan University, Cardiff, UK.,University Hospital Wales, Cardiff, UK
| | - Karianne Backx
- Cardiff School of Sport, Cardiff Metropolitan University, Cardiff, UK
| | - Mark Haykowsky
- College of Nursing and Health Innovation, University of Texas at Arlington, Arlington, TX, USA
| | - Zaheer Yousef
- Cardiff School of Sport, Cardiff Metropolitan University, Cardiff, UK.,University Hospital Wales, Cardiff, UK
| | - Rob Shave
- Cardiff School of Sport, Cardiff Metropolitan University, Cardiff, UK.,Wales Heart Research Institute, Cardiff University School of Medicine, Cardiff, UK
| |
Collapse
|
22
|
Chen JJ, Wu PT, Middlekauff HR, Nguyen KL. Aerobic exercise in anthracycline-induced cardiotoxicity: a systematic review of current evidence and future directions. Am J Physiol Heart Circ Physiol 2017; 312:H213-H222. [PMID: 27923793 PMCID: PMC6734062 DOI: 10.1152/ajpheart.00646.2016] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 11/04/2016] [Accepted: 11/18/2016] [Indexed: 01/01/2023]
Abstract
Cancer and cardiovascular disease are major causes of morbidity and mortality worldwide. Older cancer patients often wrestle with underlying heart disease during cancer therapy, whereas childhood cancer survivors are living long enough to face long-term unintended cardiac consequences of cancer therapies, including anthracyclines. Although effective and widely used, particularly in the pediatric population, anthracycline-related side effects including dose-dependent association with cardiac dysfunction limit their usage. Currently, there is only one United States Food and Drug Administration-approved drug, dexrazoxane, available for the prevention and mitigation of cardiotoxicity related to anthracycline therapy. While aerobic exercise has been shown to reduce cardiovascular complications in multiple diseases, its role as a therapeutic approach to mitigate cardiovascular consequences of cancer therapy is in its infancy. This systematic review aims to summarize how aerobic exercise can help to alleviate unintended cardiotoxic side effects and identify gaps in need of further research. While published work supports the benefits of aerobic exercise, additional clinical investigations are warranted to determine the effects of different exercise modalities, timing, and duration to identify optimal aerobic training regimens for reducing cardiovascular complications, particularly late cardiac effects, in cancer survivors exposed to anthracyclines.
Collapse
Affiliation(s)
- Joseph J Chen
- Division of Cardiology, David Geffen School of Medicine at University of California, Los Angeles, California; and
- Division of Cardiology, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Pei-Tzu Wu
- Division of Cardiology, David Geffen School of Medicine at University of California, Los Angeles, California; and
- Division of Cardiology, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Holly R Middlekauff
- Division of Cardiology, David Geffen School of Medicine at University of California, Los Angeles, California; and
| | - Kim-Lien Nguyen
- Division of Cardiology, David Geffen School of Medicine at University of California, Los Angeles, California; and
- Division of Cardiology, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| |
Collapse
|
23
|
Wang F, Gulati R, Lennon RJ, Lewis BR, Park J, Sandhu GS, Wright RS, Lerman A, Herrmann J. Cancer History Portends Worse Acute and Long-term Noncardiac (but Not Cardiac) Mortality After Primary Percutaneous Coronary Intervention for Acute ST-Segment Elevation Myocardial Infarction. Mayo Clin Proc 2016; 91:1680-1692. [PMID: 27916154 DOI: 10.1016/j.mayocp.2016.06.029] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 06/24/2016] [Accepted: 06/27/2016] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To define the effect of a history of cancer on in-hospital and long-term mortality after primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI). PATIENTS AND METHODS In this retrospective cohort study of 2346 patients with STEMI enrolled in the Mayo Clinic PCI registry from November 1, 2000, through October 31, 2010, we identified 261 patients (11.1%) with a history of cancer. The in-hospital and long-term outcomes (median follow-up, 6.2 years; interquartile range=4.3-8.5 years), including cardiac and noncardiac death and heart failure hospitalization, of these patients were compared with those of 1313 cancer-negative patients matched on age, sex, family history of coronary artery disease, and date of STEMI. RESULTS Patients with cancer had higher in-hospital noncardiac (1.9% vs 0.4%; P=.03) but similar cardiac (5.8% vs 4.6%; P=.37) mortality as matched controls. The group at highest acute mortality risk were those diagnosed as having cancer within 6 months before STEMI (hazard ratio [HR]=7.0; 95% CI, 1.4-34.4; P=.02). At 5 years, patients with cancer had similar cardiac mortality (4.2% vs 5.8%; HR=1.27; 95% CI, 0.77-2.10; P=.35) despite more heart failure hospitalizations (15% vs 10%; HR=1.72; 95% CI, 1.18-2.50; P=.01) but faced higher noncardiac mortality (30.0% vs 11.0%; HR=3.01; 95% CI, 2.33-3.88; P<.001) than controls, attributable solely to cancer-related deaths. CONCLUSION One in 10 patients in this contemporary registry of patients undergoing primary PCI for STEMI has a history of cancer. These patients have more than a 3 times higher acute in-hospital and long-term noncardiac mortality risk but no increased acute or long-term cardiac mortality risk with guideline-recommended cardiac care.
Collapse
Affiliation(s)
- Feilong Wang
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Rajiv Gulati
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Ryan J Lennon
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Bradley R Lewis
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Jae Park
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | | | - R Scott Wright
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Amir Lerman
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Joerg Herrmann
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.
| |
Collapse
|
24
|
Jarfelt M, Andersen NH, Hasle H. Is it possible to cure childhood acute myeloid leukaemia without significant cardiotoxicity? Br J Haematol 2016; 175:577-587. [PMID: 27739070 DOI: 10.1111/bjh.14374] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Since cardiotoxicity is a life threatening late effect, a reduction of cardiotoxicity in the treatment of acute myeloid leukaemia (AML) is essential. This review is a compilation of the current knowledge about cardiotoxicity after AML treatment and of how future directions in treatment may affect its incidence. A total of six studies concerning AML and cardiotoxicity were identified. The incidence of late subclinical cardiotoxicity varied between 1·3 and 15·3%, and late clinical cardiotoxicity varied between 1·3 and 9·3%. Cumulative dose of anthracyclines (ACs) and history of relapse were the most common risk factors identified. No conclusions could be drawn about new, potentially less toxic ACs. Differences in treatment data and variations in study populations made comparisons uncertain. The echocardiographic techniques used in the majority of the studies are inferior to more modern echocardiographic methods. This decreases reproducibility and may increase the risk of overestimation of cardiotoxicity. In summary, AML cannot be cured today without ACs. However, some ACs may cause less cardiotoxicity than others. Furthermore there is currently no consensus on equipotent doses of ACs and risk factors for cardiotoxicity. Further research including randomized trials is needed to evaluate whether or not the potentially less cardiotoxic agents fulfil their promise.
Collapse
Affiliation(s)
- Marianne Jarfelt
- Department of Paediatric Oncology and Haematology, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Niels H Andersen
- Department of Cardiology, Aarhus University Hospital, Skejby, Denmark
| | - Henrik Hasle
- Department of Paediatrics, Aarhus University Hospital, Skejby, Denmark
| |
Collapse
|
25
|
Kaneko S, Tham EB, Haykowsky MJ, Spavor M, Khoo NS, Mackie AS, Smallhorn JF, Thompson RB, Nelson MD. Impaired Left Ventricular Reserve in Childhood Cancer Survivors Treated With Anthracycline Therapy. Pediatr Blood Cancer 2016; 63:1086-90. [PMID: 26844944 DOI: 10.1002/pbc.25933] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 12/16/2015] [Accepted: 01/10/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND Childhood cancer survivors show evidence of diffuse myocardial fibrosis that is related to exercise capacity. The mechanism of reduced exercise tolerance in anthracycline cardiotoxicity remains unclear. We explored the determinants of exercise intolerance by evaluating left ventricular (LV) distensibility and functional reserve. METHODS Patients (n = 22) and healthy controls (n = 10) underwent two-dimensional echocardiography while supine, upright, and during cycle exercise. LV distensibility was measured as the change in end-diastolic cavity area (EDCA) from supine to the upright position. LV functional reserve was assessed during peak exercise, and measured as the exercise-induced change in systolic circumferential strain rate (SR) and early-diastolic SR (EDSR). The peak rate of oxygen consumption was measured by indirect calorimetry. RESULTS Median age of patients was 16 years (range 8-19) and controls 14 years (range 8-19). Median time since anthracycline therapy was 6 years (range 2-16). Peak oxygen consumption was significantly lower in patients compared to controls (35 ml/kg/min [28-60] vs. 45 ml/kg/min [44-53], P = 0.005). Transitioning from the supine position to the upright position caused a similar reduction in LV EDCA, suggesting similar LV distensibility between patients (-22% [-46 to -4]) and controls (-20% [-46 to -3], P = 0.3). However, during exercise, both systolic SR and EDSR reserve were significantly impaired in patients (∆SR: 93% [14-308], ∆EDSR: -4.5% [-88 to 121]) compared to controls (∆SR: 128% [54-230], P = 0.046; ∆EDSR: 74% [22-234], P = 0.02). CONCLUSIONS Our findings suggest that impaired LV contractility and functional reserve play a role in the reduced exercise capacity in anthracycline cardiotoxicity rather than LV distensibility.
Collapse
Affiliation(s)
- Sachie Kaneko
- Division of Cardiology, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Edythe B Tham
- Division of Cardiology, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Mark J Haykowsky
- College of Nursing and Health Innovation, University of Texas, Arlington, Texas
| | - Maria Spavor
- Division of Cardiology, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Nee S Khoo
- Division of Cardiology, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Andrew S Mackie
- Division of Cardiology, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Jeffrey F Smallhorn
- Division of Cardiology, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Richard B Thompson
- Department of Biomedical Engineering, University of Alberta, Edmonton, Alberta, Canada
| | - Michael D Nelson
- College of Nursing and Health Innovation, University of Texas, Arlington, Texas
| |
Collapse
|
26
|
Rosa GM, Gigli L, Tagliasacchi MI, Di Iorio C, Carbone F, Nencioni A, Montecucco F, Brunelli C. Update on cardiotoxicity of anti-cancer treatments. Eur J Clin Invest 2016; 46:264-84. [PMID: 26728634 DOI: 10.1111/eci.12589] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 12/30/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS Anti-cancer treatments markedly improved the prognosis of patients, but unfortunately might be hampered by cardiotoxicity. Both symptomatic and asymptomatic clinical forms of heart failure have been reported, which may be reversible or irreversible. The aim of this review is to provide an overview of the antineoplastic agents associated with cardiac toxicity and of the available diagnostic techniques. METHODS AND METHODS This narrative review is based on material from MEDLINE and PUBMED up to November 2015. We looked at the terms antineoplastic drugs and cardiac toxicity in combination with echocardiography, troponins, cardiac magnetic resonance, and positron emission tomography. RESULTS Anthracyclines, monoclonal antibodies, fluoropyrimidines, taxanes, alkylating agents, vinka alkaloids were reported to induce different clinical manifestations of cardioxicity. Chest radiotherapy is also associated with various forms of cardiac damage, which are indistinguishable from those found in patients with heart disease of other aetiologies and that may even appear several years after administration. Among diagnostic techniques, echocardiography is a noninvasive, cost-effective, and widely available imaging tool. Nuclear imaging and cardiac magnetic resonance may be used but are not so widely available and are more difficult to perform. Finally, some biomarkers, such as troponins, may be used to evaluate cardiac damage, but establishing the optimal timing of troponin assessment remains unclear and defining the cut-off point for positivity is still an important goal. CONCLUSIONS Cardiotoxicity of anti-cancer treatments is associated with development of heart failure. Novel diagnostic tools might be relevant to early recognize irreversible forms cardiac diseases.
Collapse
Affiliation(s)
- Gian Marco Rosa
- Division of Cardiology, Department of Internal Medicine, University of Genoa - IRCCS Azienda Ospedaliera Universitaria San Martino - IST Istituto Nazionale per la Ricerca sul Cancro, Genoa, Italy
| | - Lorenzo Gigli
- Division of Cardiology, Department of Internal Medicine, University of Genoa - IRCCS Azienda Ospedaliera Universitaria San Martino - IST Istituto Nazionale per la Ricerca sul Cancro, Genoa, Italy
| | - Maria Isabella Tagliasacchi
- Division of Cardiology, Department of Internal Medicine, University of Genoa - IRCCS Azienda Ospedaliera Universitaria San Martino - IST Istituto Nazionale per la Ricerca sul Cancro, Genoa, Italy
| | - Cecilia Di Iorio
- Division of Cardiology, Department of Internal Medicine, University of Genoa - IRCCS Azienda Ospedaliera Universitaria San Martino - IST Istituto Nazionale per la Ricerca sul Cancro, Genoa, Italy
| | - Federico Carbone
- Division of Cardiology, Foundation for Medical Researches, Department of Medical Specialties, Geneva University, Geneva, Switzerland
| | - Alessio Nencioni
- Department of Internal Medicine, University of Genoa, Genoa, Italy.,IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Istituto Nazionale per la Ricerca Sul Cancro, Genoa, Italy
| | - Fabrizio Montecucco
- Division of Cardiology, Foundation for Medical Researches, Department of Medical Specialties, Geneva University, Geneva, Switzerland.,First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa - IRCCS Azienda Ospedaliera Universitaria San Martino-IST Istituto Nazionale per la Ricerca sul Cancro, Genoa, Italy
| | - Claudio Brunelli
- Division of Cardiology, Department of Internal Medicine, University of Genoa - IRCCS Azienda Ospedaliera Universitaria San Martino - IST Istituto Nazionale per la Ricerca sul Cancro, Genoa, Italy
| |
Collapse
|
27
|
Abstract
OPINION STATEMENT As advancements are made in cancer treatment, there is an increasing recognition of the cardiotoxic potential of chemotherapies and the need to monitor for the development of cardiac dysfunction in survivors. Echocardiography is the cornerstone of cardiac imaging and provides a feasible and non-invasive method to assess cardiac dysfunction in patients with cancer. In recent years, there has been increasing research in echocardiographic techniques to improve diagnosis of cardiotoxicity, including a more accurate assessment of the left ventricular function and the detection of subclinical disease. These specialized techniques include stress and contrast echocardiography, three-dimensional echocardiography, diastolic dysfunction, tissue Doppler imaging, and strain parameters.
Collapse
|
28
|
Molinaro M, Ameri P, Marone G, Petretta M, Abete P, Di Lisa F, De Placido S, Bonaduce D, Tocchetti CG. Recent Advances on Pathophysiology, Diagnostic and Therapeutic Insights in Cardiac Dysfunction Induced by Antineoplastic Drugs. BIOMED RESEARCH INTERNATIONAL 2015; 2015:138148. [PMID: 26583088 PMCID: PMC4637019 DOI: 10.1155/2015/138148] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 07/01/2015] [Indexed: 12/28/2022]
Abstract
Along with the improvement of survival after cancer, cardiotoxicity due to antineoplastic treatments has emerged as a clinically relevant problem. Potential cardiovascular toxicities due to anticancer agents include QT prolongation and arrhythmias, myocardial ischemia and infarction, hypertension and/or thromboembolism, left ventricular (LV) dysfunction, and heart failure (HF). The latter is variable in severity, may be reversible or irreversible, and can occur soon after or as a delayed consequence of anticancer treatments. In the last decade recent advances have emerged in clinical and pathophysiological aspects of LV dysfunction induced by the most widely used anticancer drugs. In particular, early, sensitive markers of cardiac dysfunction that can predict this form of cardiomyopathy before ejection fraction (EF) is reduced are becoming increasingly important, along with novel therapeutic and cardioprotective strategies, in the attempt of protecting cardiooncologic patients from the development of congestive heart failure.
Collapse
Affiliation(s)
- Marilisa Molinaro
- Department of Medicine and Health Sciences, University of Molise, 86100 Campobasso, Italy
| | - Pietro Ameri
- Department of Internal Medicine, University of Genova, 16132 Genova, Italy
| | - Giancarlo Marone
- Department of Clinical Medicine and Surgery, Federico II University, 80131 Naples, Italy
| | - Mario Petretta
- Department of Translational Medical Sciences, Division of Internal Medicine, Federico II University, 80131 Naples, Italy
| | - Pasquale Abete
- Department of Translational Medical Sciences, Division of Internal Medicine, Federico II University, 80131 Naples, Italy
| | - Fabio Di Lisa
- Department of Biomedical Sciences, University of Padova, 35121 Padova, Italy
- National Researches Council, Neuroscience Institute, University of Padova, 35121 Padova, Italy
| | - Sabino De Placido
- Department of Clinical Medicine and Surgery, Federico II University, 80131 Naples, Italy
| | - Domenico Bonaduce
- Department of Translational Medical Sciences, Division of Internal Medicine, Federico II University, 80131 Naples, Italy
| | - Carlo G. Tocchetti
- Department of Translational Medical Sciences, Division of Internal Medicine, Federico II University, 80131 Naples, Italy
| |
Collapse
|
29
|
Jarfelt M, Andersen NH, Glosli H, Jahnukainen K, Jónmundsson GK, Malmros J, Nysom K, Hasle H. Cardiac function in survivors of childhood acute myeloid leukemia treated with chemotherapy only: a NOPHO-AML study. Eur J Haematol 2015; 97:55-62. [PMID: 26383901 DOI: 10.1111/ejh.12683] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2015] [Indexed: 12/24/2022]
Abstract
OBJECTIVES We report cardiac function of patients treated for Childhood acute myeloid leukemia with chemotherapy only according to three consecutive Nordic protocols. METHODS Ninety-eight of 138 eligible patients accepted examination with standardized echocardiography. Results were compared with age- and sex-matched controls. RESULTS The median age was 3 yr at diagnosis (range 0-15), and the median time from diagnosis to study was 11 yr (4-25). All but one patient had received doxorubicin and 90% had received mitoxantrone. The median cumulative dose of daunorubicin equivalents was 300 mg/m(2) (210-525). Left ventricular fractional shortening (LVFS) and ejection fraction (LVEF) were lower in patients than in controls (32.6% (SD 4.0) vs. 35.2% (SD 3.4), P = 0.002 and 59.9% (SD 5.5) vs. 64.2% (SD 4.4), P = 0.001). The myocardial performance index (MPI) was higher in patients than in controls (0.32 (SD 0.081) vs. 0.26 (SD 0.074), P < 0.0001). Cumulative dose of doxorubicin but not mitoxantrone was related to lower LVFS (P = 0.037) and LVEF (P = 0.016). Longer follow-up was associated with lower LVFS (P = 0.034). Higher MPI was associated with young age at diagnosis (P = 0.04) and longer follow-up (P = 0.031). CONCLUSIONS In this study, most patients had cardiac function within normal limits and reported very few cardiac symptoms. However, compared with healthy controls, they had significantly reduced left ventricular function.
Collapse
Affiliation(s)
- Marianne Jarfelt
- Department of Pediatrics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Niels H Andersen
- Department of Internal Medicine, Aarhus University Hospital Skejby, Aarhus, Denmark
| | - Heidi Glosli
- Department of Pediatrics, University Hospital Oslo, Rikshospitalet, Oslo, Norway
| | | | | | - Johan Malmros
- Department of Pediatric Oncology, Karolinska University Hospital, Stockholm, Sweden
| | - Karsten Nysom
- Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Henrik Hasle
- Department of Pediatrics, Aarhus University Hospital Skejby, Aarhus, Denmark
| | | |
Collapse
|
30
|
Multimodality Imaging in Cardiooncology. JOURNAL OF ONCOLOGY 2015; 2015:263950. [PMID: 26300915 PMCID: PMC4537747 DOI: 10.1155/2015/263950] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 10/13/2014] [Accepted: 10/17/2014] [Indexed: 01/06/2023]
Abstract
Cardiotoxicity represents a rising problem influencing prognosis and quality of life of chemotherapy-treated patients. Anthracyclines and trastuzumab are the drugs most commonly associated with development of a cardiotoxic effect. Heart failure, myocardial ischemia, hypertension, myocarditis, and thrombosis are typical manifestation of cardiotoxicity by chemotherapeutic agents. Diagnosis and monitoring of cardiac side-effects of cancer treatment is of paramount importance. Echocardiography and nuclear medicine methods are widely used in clinical practice and left ventricular ejection fraction is the most important parameter to asses myocardial damage secondary to chemotherapy. However, left ventricular ejection decrease is a delayed phenomenon, occurring after a long stage of silent myocardial damage that classic imaging methods are not able to detect. New imaging techniques including three-dimensional echocardiography, speckle tracking echocardiography, and cardiac magnetic resonance have demonstrated high sensitivity in detecting the earliest alteration of left ventricular function associated with future development of chemotherapy-induced cardiomyopathy. Early diagnosis of cardiac involvement in cancer patients can allow for timely and adequate treatment management and the introduction of cardioprotective strategies.
Collapse
|
31
|
Herrmann J, Yang EH. Should the ‘echo guidelines’ be followed in cancer patients? Future Oncol 2015. [DOI: 10.2217/fon.15.109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Joerg Herrmann
- Division of Cardiovascular Disease, Mayo Clinic & College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
| | - Eric H Yang
- Division of Cardiology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| |
Collapse
|
32
|
Ryerson AB, Border WL, Wasilewski-Masker K, Goodman M, Meacham L, Austin H, Mertens AC. Assessing anthracycline-treated childhood cancer survivors with advanced stress echocardiography. Pediatr Blood Cancer 2015; 62:502-8. [PMID: 25393686 DOI: 10.1002/pbc.25328] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 10/01/2014] [Indexed: 01/01/2023]
Abstract
BACKGROUND Surveillance for anthracycline cardiotoxicity in cancer survivors typically utilizes resting M-mode and two-dimensional echocardiography, which are insensitive to detection of subtle myocardial changes. We examined childhood cancer survivors treated with anthracyclines during exercise using various echocardiography techniques to investigate if these tools can better detect subclinical cardiac dysfunction. PROCEDURE We recruited asymptomatic survivors at least five years post treatment. Echocardiography was performed at rest and at termination of exercise utilizing tissue Doppler techniques and strain rate imaging. RESULTS Eighty participants were characterized by cardiotoxicity risk status (high [12], moderate [23], low [24], no risk [21]) as defined by the Children's Oncology Group Long Term Follow-Up Guidelines v3.0. The high-risk group had a higher resting heart rate than controls (100 vs. 88 bpm [P for trend = 0.049]). Peak aerobic capacity in all groups was similar. Compared to controls at rest, the high-risk group had evidence of diastolic dysfunction with lower E/A ratios (1.4 vs. 2.0, P = 0.008) and higher septal early diastolic velocities (E/E') of 11.7 versus 9.9 (P = 0.165). With exercise, this difference resolved and myocardial contractile reserve was preserved. CONCLUSIONS Asymptomatic, pediatric cancer survivors at high-risk for anthracycline cardiotoxicity have some evidence of diastolic filling abnormalities at rest. With exercise, they augment their systolic and diastolic function to achieve normal maximal aerobic capacity suggesting they are able to compensate for mild cardiac dysfunction in the early years after exposure. Additionally, findings suggest that routine exercise echocardiography may not be a useful surveillance tool to assess anthracycline cardiotoxicity.
Collapse
Affiliation(s)
- A Blythe Ryerson
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | | | | | | | | | | |
Collapse
|
33
|
Markman TM, Markman M. Cardiotoxicity of antineoplastic agents: what is the present and future role for imaging? Curr Oncol Rep 2015; 16:396. [PMID: 24992733 DOI: 10.1007/s11912-014-0396-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
As antineoplastic treatment options expand at an increasing rate, both traditional and novel agents continue to be limited by their cardiotoxic effects. While functional decline becomes clinically apparent at late states of toxicity, little is known about early stages during which treatment or prevention may still be an option. Several imaging modalities,including echocardiography, multiple gated acquisition, and cardiac magnetic resonance imaging have the ability to identify cardiac effects before they produce clinical symptoms.Here we discuss the current and future role of cardiac imaging in the assessment of cardiotoxicity of antineoplastic agents. effects on cardiac tissue, resulting in myocardial cellular damage,and ultimately lead to a wide range of effects including electrophysiological abnormalities, symptomatic heart failure(HF), and even death. This represents a limiting factor in the therapy of several otherwise treatable neoplasms [2].The cardiotoxicity of antineoplastic agents raises several important questions regarding the actual prevalence of cardiac toxicity, the ability to effectively treat or prevent such effects with pharmaceutical interventions, and the availability of a means for early diagnosis. Here, we focus on the latter, specifically examining current and potential future imaging strategies to detect the cardiac effects of chemotherapeutic agents.
Collapse
|
34
|
Kirkham AA, Virani SA, Campbell KL. The utility of cardiac stress testing for detection of cardiovascular disease in breast cancer survivors: a systematic review. Int J Womens Health 2015; 7:127-40. [PMID: 25657599 PMCID: PMC4315553 DOI: 10.2147/ijwh.s68745] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Heart function tests performed with myocardial stress, or “cardiac stress tests”, may be beneficial for detection of cardiovascular disease. Women who have been diagnosed with breast cancer are more likely to develop cardiovascular diseases than the general population, in part due to the direct toxic effects of cancer treatment on the cardiovascular system. The aim of this review was to determine the utility of cardiac stress tests for the detection of cardiovascular disease after cardiotoxic breast cancer treatment. Design Systematic review. Methods Medline and Embase were searched for studies utilizing heart function tests in breast cancer survivors. Studies utilizing a cardiac stress test and a heart function test performed at rest were included to determine whether stress provided added benefit to identifying cardiac abnormalities that were undetected at rest within each study. Results Fourteen studies were identified. Overall, there was a benefit to utilizing stress tests over tests at rest in identifying evidence of cardiovascular disease in five studies, a possible benefit in five studies, and no benefit in four studies. The most common type of stress test was myocardial perfusion imaging, where reversible perfusion defects were detected under stress in individuals who had no defects at rest, in five of seven studies of long-term follow-up. Two studies demonstrated the benefit of stress echocardiography over resting echocardiography for detecting left ventricular dysfunction in anthracycline-treated breast cancer survivors. There was no benefit of stress cardiac magnetic resonance imaging in one study. Two studies showed a potential benefit of stress electrocardiography, whereas three others did not. Conclusion The use of cardiac stress with myocardial perfusion imaging and echocardiography may provide added benefit to tests performed at rest for detection of cardiovascular disease in breast cancer survivors, and merits further research.
Collapse
Affiliation(s)
- Amy A Kirkham
- Rehabilitation Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Sean A Virani
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Kristin L Campbell
- Rehabilitation Sciences, University of British Columbia, Vancouver, BC, Canada ; Department of Physical Therapy, University of British Columbia, Vancouver, BC, Canada
| |
Collapse
|
35
|
Plana JC, Galderisi M, Barac A, Ewer MS, Ky B, Scherrer-Crosbie M, Ganame J, Sebag IA, Agler DA, Badano LP, Banchs J, Cardinale D, Carver J, Cerqueira M, DeCara JM, Edvardsen T, Flamm SD, Force T, Griffin BP, Jerusalem G, Liu JE, Magalhães A, Marwick T, Sanchez LY, Sicari R, Villarraga HR, Lancellotti P. Expert consensus for multimodality imaging evaluation of adult patients during and after cancer therapy: a report from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 2014; 15:1063-93. [PMID: 25239940 PMCID: PMC4402366 DOI: 10.1093/ehjci/jeu192] [Citation(s) in RCA: 631] [Impact Index Per Article: 63.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | | | - Ana Barac
- Medstar Washington Hospital Center, Washington, District of Columbia
| | - Michael S Ewer
- MD Anderson Cancer Center, University of Texas, Houston, Texas
| | - Bonnie Ky
- University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | - Igal A Sebag
- Jewish General Hospital and McGill University, Montreal, Quebec, Canada
| | | | | | - Jose Banchs
- MD Anderson Cancer Center, University of Texas, Houston, Texas
| | | | - Joseph Carver
- Abramson Cancer Center at the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | - Thor Edvardsen
- Oslo University Hospital and University of Oslo, Oslo, Norway
| | | | | | | | | | - Jennifer E Liu
- Memorial Sloan-Kettering Cancer Center, New York, New York
| | | | | | - Liza Y Sanchez
- MD Anderson Cancer Center, University of Texas, Houston, Texas
| | - Rosa Sicari
- CNR Institute of Clinical Physiology, Pisa, Italy
| | | | | |
Collapse
|
36
|
Plana JC, Galderisi M, Barac A, Ewer MS, Ky B, Scherrer-Crosbie M, Ganame J, Sebag IA, Agler DA, Badano LP, Banchs J, Cardinale D, Carver J, Cerqueira M, DeCara JM, Edvardsen T, Flamm SD, Force T, Griffin BP, Jerusalem G, Liu JE, Magalhães A, Marwick T, Sanchez LY, Sicari R, Villarraga HR, Lancellotti P. Expert consensus for multimodality imaging evaluation of adult patients during and after cancer therapy: a report from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 2014; 27:911-39. [PMID: 25172399 DOI: 10.1016/j.echo.2014.07.012] [Citation(s) in RCA: 874] [Impact Index Per Article: 87.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
| | | | - Ana Barac
- Medstar Washington Hospital Center, Washington, District of Columbia
| | - Michael S Ewer
- MD Anderson Cancer Center, University of Texas, Houston, Texas
| | - Bonnie Ky
- University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | - Igal A Sebag
- Jewish General Hospital and McGill University, Montreal, Quebec, Canada
| | | | | | - Jose Banchs
- MD Anderson Cancer Center, University of Texas, Houston, Texas
| | | | - Joseph Carver
- Abramson Cancer Center at the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | - Thor Edvardsen
- Oslo University Hospital and University of Oslo, Oslo, Norway
| | | | | | | | | | - Jennifer E Liu
- Memorial Sloan-Kettering Cancer Center, New York, New York
| | | | | | - Liza Y Sanchez
- MD Anderson Cancer Center, University of Texas, Houston, Texas
| | - Rosa Sicari
- CNR Institute of Clinical Physiology, Pisa, Italy
| | | | | |
Collapse
|
37
|
Herrmann J, Lerman A, Sandhu NP, Villarraga HR, Mulvagh SL, Kohli M. Evaluation and management of patients with heart disease and cancer: cardio-oncology. Mayo Clin Proc 2014; 89:1287-306. [PMID: 25192616 PMCID: PMC4258909 DOI: 10.1016/j.mayocp.2014.05.013] [Citation(s) in RCA: 252] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Revised: 04/17/2014] [Accepted: 05/14/2014] [Indexed: 01/17/2023]
Abstract
The care for patients with cancer has advanced greatly over the past decades. A combination of earlier cancer diagnosis and greater use of traditional and new systemic treatments has decreased cancer-related mortality. Effective cancer therapies, however, can result in short- and long-term comorbidities that can decrease the net clinical gain by affecting quality of life and survival. In particular, cardiovascular complications of cancer treatments can have a profound effect on the health of patients with cancer and are more common among those with recognized or unrecognized underlying cardiovascular diseases. A new discipline termed cardio-oncology has thus evolved to address the cardiovascular needs of patients with cancer and optimize their care in a multidisciplinary approach. This review provides a brief introduction and background on this emerging field and then focuses on its practical aspects including cardiovascular risk assessment and prevention before cancer treatment, cardiovascular surveillance and therapy during cancer treatment, and cardiovascular monitoring and management after cancer therapy. The content of this review is based on a literature search of PubMed between January 1, 1960, and February 1, 2014, using the search terms cancer, cardiomyopathy, cardiotoxicity, cardio-oncology, chemotherapy, heart failure, and radiation.
Collapse
Affiliation(s)
- Joerg Herrmann
- Department of Internal Medicine, Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.
| | - Amir Lerman
- Department of Internal Medicine, Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Nicole P Sandhu
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Hector R Villarraga
- Department of Internal Medicine, Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Sharon L Mulvagh
- Department of Internal Medicine, Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Manish Kohli
- Department of Oncology, Mayo Clinic, Rochester, MN
| |
Collapse
|
38
|
Abstract
OPINION STATEMENT New advances in cancer diagnosis and treatment have increased survival rates in patients with cancer. In parallel with this increase in the number of cancer survivors is an increasing prevalence of cardiac complications from cancer treatment. Chemotherapy-induced cardiac dysfunction is a major contributor to adverse morbidity and mortality rates in cancer patients. Evidence suggests that both clinical symptoms and the traditional left ventricular ejection fraction (LVEF) may lack sensitivity as measures of cardiotoxicity. The early identification of subclinical LV dysfunction is becoming increasingly important, as this may allow cancer patients and their physicians to make informed decisions about therapeutic options. The features of echocardiography make it a useful tool in the diagnosis and monitoring of cardiotoxicity. This review will examine the role of cardiac imaging in detecting cardiotoxicity, focusing primarily on the conventional and more recent echocardiographic approaches for assessing subclinical cardiotoxicity.
Collapse
|
39
|
Effects of Exercise Intervention for Children with Acute Lymphoblastic Leukemia: A Systematic Review. REHABILITATION ONCOLOGY 2014. [DOI: 10.1097/01893697-201432030-00006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
|
40
|
Lipshultz SE, Adams MJ, Colan SD, Constine LS, Herman EH, Hsu DT, Hudson MM, Kremer LC, Landy DC, Miller TL, Oeffinger KC, Rosenthal DN, Sable CA, Sallan SE, Singh GK, Steinberger J, Cochran TR, Wilkinson JD. Long-term cardiovascular toxicity in children, adolescents, and young adults who receive cancer therapy: pathophysiology, course, monitoring, management, prevention, and research directions: a scientific statement from the American Heart Association. Circulation 2013; 128:1927-95. [PMID: 24081971 DOI: 10.1161/cir.0b013e3182a88099] [Citation(s) in RCA: 369] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
|
41
|
Miller AM, Lopez-Mitnik G, Somarriba G, Lipsitz SR, Hinkle AS, Constine LS, Lipshultz SE, Miller TL. Exercise capacity in long-term survivors of pediatric cancer: an analysis from the Cardiac Risk Factors in Childhood Cancer Survivors Study. Pediatr Blood Cancer 2013; 60:663-8. [PMID: 23255294 DOI: 10.1002/pbc.24410] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Accepted: 11/01/2012] [Indexed: 01/29/2023]
Abstract
BACKGROUND Childhood cancer survivors may have premature symptomatic cardiovascular and non-cardiovascular diseases that contribute to reduced capacity for physical activity. Studies of exercise capacity and identification of risk factors for reduced capacity in survivors are limited. PROCEDURE We assessed maximal myocardial oxygen consumption (V(O(2)max), a measure of exercise capacity) in survivors at least 4 years after cancer diagnosis and sibling controls. We evaluated associations between V(O(2)max) and age, sex, treatments, cardiac structure and function, biomarkers, endocrine function, and physical activity. RESULTS Of 72 survivors (mean age, 22 years; range, 8.0-40 years) and 32 siblings (mean age, 20.2 years; range, 8-46 years), about half were male. Mean time since diagnosis was 13.4 years (range, 4.5-31.6 years). In age- and sibling-pair adjusted analyses, V(O(2)max) was lower in survivors than siblings (males, 28.53 vs. 30.90 ml/kg/minute, P = 0.08; females, 19.81 vs. 23.40 ml/kg/minute, P = 0.03). In males, older age (P = 0.01), higher percent body fat (P < 0.001) and high or low left ventricular (LV) mass Z-scores (P = 0.03) predicted lower V(O(2)max). In females, older age (P < 0.001), methotrexate exposure (P = 0.01), and higher, but normal, LV load-dependent contractility (P = 0.02) predicted lower V(O(2)max). CONCLUSIONS Fitness for most survivors and controls was poor and generally lower in survivors, particularly females. Older age, higher body fat, methotrexate exposure, and extremes of LV mass/function were associated with lower V(O(2)max) in survivors. Because physical activity can improve nutritional and cardiac conditions, survivors should be encouraged to exercise regularly with close monitoring.
Collapse
Affiliation(s)
- Angela M Miller
- Division of Pediatric Clinical Research, Department of Pediatrics, Sylvester Comprehensive Cancer Center, Leonard M. Miller School of Medicine, University of Miami, Holtz Children's Hospital of the UM/Jackson Memorial Medical Center, Miami, Florida 33101, USA
| | | | | | | | | | | | | | | |
Collapse
|
42
|
Steiner R. Increasing exercise in long-term survivors of pediatric cancer and their siblings: should treatment be a family affair? Pediatr Blood Cancer 2013; 60:529-30. [PMID: 23335365 DOI: 10.1002/pbc.24465] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 12/11/2012] [Indexed: 11/12/2022]
|
43
|
Somarriba G, Lopez-Mitnik G, Ludwig DA, Neri D, Schaefer N, Lipshultz SE, Scott GB, Miller TL. Physical fitness in children infected with the human immunodeficiency virus: associations with highly active antiretroviral therapy. AIDS Res Hum Retroviruses 2013; 29:112-20. [PMID: 22747252 PMCID: PMC3537323 DOI: 10.1089/aid.2012.0047] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Obesity, sedentary lifestyles, and antiretroviral therapies may predispose HIV-infected children to poor physical fitness. Estimated peak oxygen consumption (VO(2) peak), maximal strength and endurance, and flexibility were measured in HIV-infected and uninfected children. Among HIV-infected children, anthropometric and HIV disease-specific factors were evaluated to determine their association with VO(2) peak. Forty-five HIV-infected children (mean age 16.1 years) and 36 uninfected children (mean age 13.5 years) participated in the study. In HIV-infected subjects, median viral load was 980 copies/ml (IQR 200-11,000 copies/ml), CD4% was 28% (IQR 15-35%), and 82% were on highly active antiretroviral therapy (HAART). Compared to uninfected children, after adjusting for age, sex, race, body fat, and siblingship, HIV-infected children had lower VO(2) peak (25.92 vs. 30.90 ml/kg/min, p<0.0001), flexibility (23.71% vs. 46.09%, p=0.0003), and lower-extremity strength-to-weight ratio (0.79 vs. 1.10 kg lifted/kg of body weight, p=0.002). Among the HIV-infected children, a multivariable analysis adjusting for age, sex, race, percent body fat, and viral load showed VO(2) peak was 0.30 ml/kg/min lower per unit increase in percent body fat (p<0.0001) and VO(2) peak (SE) decreased 29.45 (± 1 .62), 28.70 (± 1.87), and 24.09 (± 0.75) ml/kg/min across HAART exposure categories of no exposure, <60, and ≥ 60 months, respectively (p<0.0001). HIV-infected children had, in general, lower measures of fitness compared to uninfected children. Factors negatively associated with VO(2) peak in HIV-infected children include higher body fat and duration of HAART ≥ 60 months. Future studies that elucidate the understanding of these differences and mechanisms of decreased physical fitness should be pursued.
Collapse
Affiliation(s)
- Gabriel Somarriba
- Divisions of Pediatric Clinical Research, University of Miami, Miami, Florida
| | | | - David A. Ludwig
- Divisions of Pediatric Clinical Research, University of Miami, Miami, Florida
| | - Daniela Neri
- Divisions of Pediatric Clinical Research, University of Miami, Miami, Florida
- Pediatric Infectious Diseases, Department of Pediatrics, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Natasha Schaefer
- Divisions of Pediatric Clinical Research, University of Miami, Miami, Florida
| | - Steven E. Lipshultz
- Divisions of Pediatric Clinical Research, University of Miami, Miami, Florida
| | - Gwendolyn B. Scott
- Pediatric Infectious Diseases, Department of Pediatrics, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Tracie L. Miller
- Divisions of Pediatric Clinical Research, University of Miami, Miami, Florida
| |
Collapse
|
44
|
Abstract
Cardiac toxicities from cancer therapy can become evident many years after treatment, and these late cardiac effects can have a profound impact on cancer survivors. There are a myriad of potential cardiovascular complications from cancer therapy, but these can be grouped into three main categories. First, vascular conditions including atherosclerosis, thrombosis, and hypertension predominate. Second, cardiac structural problems, especially valvular degeneration, can have a dramatic impact long term. Lastly, and most importantly, cardiac dysfunction and heart failure are potentially common late cardiac effects and can certainly be prevented or detected early during active cancer therapy to result in optimal outcomes. Future research on late cardiac effects in cancer survivors needs to include advanced cardiac imaging techniques, novel cardiac biomarkers, and genetic determinants of response to cancer treatment.
Collapse
Affiliation(s)
- Daniel J Lenihan
- Division of Cardiovascular Medicine, Vanderbilt Heart and Vascular Institute, Nashville, TN 37232-8802, USA.
| | | |
Collapse
|
45
|
Oreto L, Todaro MC, Umland MM, Kramer C, Qamar R, Carerj S, Khandheria BK, Paterick TE. Use of echocardiography to evaluate the cardiac effects of therapies used in cancer treatment: what do we know? J Am Soc Echocardiogr 2012; 25:1141-52. [PMID: 23000452 DOI: 10.1016/j.echo.2012.09.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Indexed: 01/11/2023]
Abstract
Cardiologists and oncologists today face the daunting challenge of identifying patients at risk for late-onset left ventricular (LV) systolic dysfunction from the use of various chemotherapeutic agents. Currently, the most widely used method in clinical practice for monitoring the potential of chemotherapy-induced cardiotoxicity is calculation of LV ejection fraction. The use of LV ejection fraction to determine whether to continue or discontinue the use of chemotherapeutic agents is limited, because decreases in LV ejection fraction frequently occur late and can be irreversible. These limitations have led to the exploration of diastolic function and newer modalities that assess myocardial mechanics to identify sensitive and specific variables that can predict the occurrence of late systolic function. The cancer therapies associated with cardiotoxicity are reviewed in this report. Additionally, the authors evaluate the role of present-day echocardiographic parameters, complementary noninvasive imaging modalities, and biomarkers in the prediction of cardiotoxicity. The authors address the evolving role of cardioprotective agents and potential therapies to prevent or reverse the progression of LV systolic dysfunction. Finally, they provide some ideas regarding future directions to enhance the knowledge of predicting late-onset LV systolic dysfunction secondary to cancer therapy.
Collapse
Affiliation(s)
- Lilia Oreto
- Clinical and Experimental Department of Medicine and Pharmacology, University of Messina, Messina, Italy
| | | | | | | | | | | | | | | |
Collapse
|
46
|
Guimaraes-Filho FV, Tan DM, Braga JCF, Rodrigues A, Waib PH, Matsubara BB. Ventricular systolic reserve in asymptomatic children previously treated with low doses of anthracyclines: a longitudinal, prospective exercise echocardiography study. Pediatr Blood Cancer 2012; 59:548-52. [PMID: 22970439 DOI: 10.1002/pbc.24000] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The time course of mild cardiotoxicity induced by anthracycline remains unknown. The aim of this study was to evaluate the long-term evolution of decreased myocardial reserve in children previously treated with a cumulative dose of anthracycline up to 100 mg/m(2). PATIENTS AND METHODS Twenty-seven asymptomatic cancer survival patients (25 with lymphoblastic leukemia), in continuous remission and off treatment for >12 months with no alterations in conventional echocardiograms were evaluated by exercise echocardiography at 37 ± 15.4 months (T1) and 101 ± 24 months (T2) after finishing treatment (ADRIA group). This group was compared with 25 healthy individuals (control group) similar to the ADRIA group with respect to age and body surface area (BSA). All individuals underwent treadmill exercise testing according to Bruce protocol. Echocardiograms were performed before and immediately after exercise. RESULTS The groups were similar regarding cardiac structure and left ventricular (LV) systolic function at rest at T1 and T2. The growth of LV posterior wall thickness related to BSA was lower in the ADRIA group at T2. Post exercise, smaller LV ejection indexes and attenuated changes in the afterload in ADRIA group were observed at T1 and T2. CONCLUSION The decreased systolic reserve induced by a low dose of anthracycline in asymptomatic children and adolescents remains unaffected over a 5-year period, suggesting that positive outcomes in chronic cardiotoxicity would be expected in patients with mild impairment after anthracycline treatment.
Collapse
|
47
|
Assessing the Cardiac Toxicity of Chemotherapeutic Agents: Role of Echocardiography. CURRENT CARDIOVASCULAR IMAGING REPORTS 2012; 5:403-409. [PMID: 23227272 DOI: 10.1007/s12410-012-9163-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Advancements in cancer treatment have resulted in sufficient survival length for patients to experience treatment-related cardiac complications. In particular, chemotherapy-induced cardiac dysfunction significantly impacts morbidity and mortality rates in cancer patients. The presence of cardiotoxicity from chemotherapy has been traditionally assessed using clinical symptoms and decreases in left ventricular ejection fraction (LVEF). However, in this indication, LVEF lacks accuracy as a measure of subclinical cardiotoxicity and its prognostic value is controversial. There is an emphasis to identify subclinical and left ventricular dysfunction early, in order to allow cancer patients and their physicians to make informed decisions about therapeutic options. Echocardiography is a readily available noninvasive tool to measure cardiac function and plays a major role in the diagnosis of cardiotoxicity. This review focuses on the role of echocardiography in detecting cardiotoxicity, and will discuss conventional and more recent echocardiographic approaches for assessing subclinical cardiotoxicity.
Collapse
|
48
|
Della Pina P, Vizzardi E, Raddino R, Gavazzoni M, Caretta G, Gorga E, Dei Cas L. Biological Drugs: Classic Adverse Effects and New Clinical Evidences. Cardiovasc Toxicol 2012; 12:285-97. [DOI: 10.1007/s12012-012-9173-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
49
|
Sawaya H, Plana JC, Scherrer-Crosbie M. Newest echocardiographic techniques for the detection of cardiotoxicity and heart failure during chemotherapy. Heart Fail Clin 2011; 7:313-21. [PMID: 21749883 DOI: 10.1016/j.hfc.2011.03.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Chemotherapy-induced cardiotoxicity has become a significant public health issue. Left ventricular ejection fraction is routinely used to monitor cardiotoxicity but fails to detect subtle alterations in cardiac function. Improvements in the measurement of left ventricular ejection fraction, physical or pharmacologic stressors, and novel cardiac functional indices may be useful in the detection of cardiotoxicity. The improvements in the detection and therapy of cancer have led to the emergence of chemotherapy-induced cardiotoxicity. New echocardiographic techniques may be useful in the detection of patients undergoing chemotherapy treatments who could benefit from alternative cancer treatments, therefore decreasing the incidence of cardiotoxicity.
Collapse
Affiliation(s)
- Heloisa Sawaya
- Cardiac Ultrasound Laboratory, Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | | | | |
Collapse
|
50
|
Bonura F, Di Lisi D, Novo S, D’Alessandro N. Timely Recognition of Cardiovascular Toxicity by Anticancer Agents: A Common Objective of the Pharmacologist, Oncologist and Cardiologist. Cardiovasc Toxicol 2011; 12:93-107. [DOI: 10.1007/s12012-011-9141-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|